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Diplopia



Diplopia is the simultaneous perception of two images of a single object that may be displaced horizontally or vertically in relation to each other.[1] Also called double vision, it is a loss of visual focus under regular conditions, and is often voluntary. However, when occurring involuntarily, it results in impaired function of the extraocular muscles, where both eyes are still functional, but they cannot turn to target the desired object.[2] Problems with these muscles may be due to mechanical problems, disorders of the neuromuscular junction, disorders of the cranial nerves (III, IV, and VI) that innervate the muscles, and occasionally disorders involving the supranuclear oculomotor pathways or ingestion of toxins.[3]

Diplopia
Other namesDouble vision
One way a person might experience double vision
SpecialtyNeurology, ophthalmology

Diplopia can be one of the first signs of a systemic disease, particularly to a muscular or neurological process,[4] and it may disrupt a person's balance, movement, or reading abilities.[2][5]

Contents


Clasification

Monocular

Binocular


Causes

Monocular

Diplopia can occur when viewing with only one eye; this is called monocular diplopia, or where the patient perceives more than two images, monocular polyopia. Some of the causes of momocular diplopia may be:

  • [6] The differential diagnosis of multiple image perception includes the consideration of such conditions as corneal surface keratoconus, subluxation of the lens, a structural defect within the eye, a lesion in the anterior visual cortex, or nonorganic conditions, but diffraction-based (rather than geometrical) optical models have shown that common optical conditions, especially astigmatism, can also produce this symptom.[7]

Binocular


Diagnosis

Diplopia is diagnosed mainly by information from the patient. Doctors may use blood tests, physical examinations, computed tomography (CT), or magnetic resonance imaging (MRI) to find the underlying cause.[8]

Classification

One of the first steps in diagnosing diplopia is often to see whether one of two major classifications may be eliminated. That involves blocking one eye to see which symptoms are evident in each eye alone.[6]

Binocular

Binocular diplopia is double vision arising as a result of strabismus (in layman's terms "cross-eyed"), the misalignment of the two eyes relative to each other, either esotropia (inward) or exotropia (outward). In such a case while the fovea of one eye is directed at the object of regard, the fovea of the other is directed elsewhere, and the image of the object of regard falls on an extrafoveal area of the retina.

The brain calculates the visual direction of an object based upon the position of its image relative to the fovea. Images falling on the fovea are seen as being directly ahead, while those falling on retina outside the fovea may be seen as above, below, right, or left of straight ahead depending upon the area of retina stimulated. Thus, when the eyes are misaligned, the brain perceives two images of one target object, as the target object simultaneously stimulates different, noncorresponding, retinal areas in either eye, thus producing double vision.

This correlation of particular areas of the retina in one eye with the same areas in the other is known as retinal correspondence. This relationship also gives rise to an associated phenomenon of binocular diplopia, although one that is rarely noted by those experiencing diplopia. Because the fovea of one eye corresponds to the fovea of the other, images falling on the two foveae are projected to the same point in space. Thus, when the eyes are misaligned, two different objects will be perceived as superimposed in the same space. This phenomenon is known as visual confusion'.

The brain naturally guards against double vision. In an attempt to avoid double vision, the brain can sometimes ignore the image from one eye, a process known as suppression. The ability to suppress is to be found particularly in childhood when the brain is still developing. Thus, those with childhood strabismus almost never complain of diplopia, while adults who develop strabismus almost always do. While this ability to suppress might seem an entirely positive adaptation to strabismus, in the developing child, this can prevent the proper development of vision in the affected eye, resulting in amblyopia. Some adults are also able to suppress their diplopia, but their suppression is rarely as deep or as effective and takes much longer to establish, thus they are not at risk of permanently compromising their vision. In some cases, diplopia disappears without medical intervention, but in other cases, the cause of the double vision may still be present.

Certain people with diplopia who cannot achieve fusion and yet do not suppress may display a certain type of spasm-like irregular movement of the eyes in the vicinity of the fixation point (see: Horror fusionis).

Monocular

Diplopia can also occur when viewing with only one eye; this is called monocular diplopia, or where the patient perceives more than two images, monocular polyopia. While serious causes rarely may be behind monocular diplopia symptoms, this is much less often the case than with binocular diplopia.[6] The differential diagnosis of multiple image perception includes the consideration of such conditions as corneal surface keratoconus, subluxation of the lens, a structural defect within the eye, a lesion in the anterior visual cortex, or nonorganic conditions, but diffraction-based (rather than geometrical) optical models have shown that common optical conditions, especially astigmatism, can also produce this symptom.[7]


Treatment

The appropriate treatment for binocular diplopia depends upon the cause of the condition producing the symptoms. Efforts must first be made to identify and treat the underlying cause of the problem. Treatment options include eye exercises,[2] wearing an eye patch on alternative eyes,[2] prism correction,[9] and in more extreme situations, surgery[5] or botulinum toxin.[10]

If diplopia turns out to be intractable, it can be managed as last resort by obscuring part of the patient's field of view. This approach is outlined in the article on diplopia occurring in association with a condition called horror fusionis.


Clinical Pearls

  • Diplopia is almost always binocular
  • CN VI palsy is a red flag for intracranial masses
  • Look for ptosis with CN III palsy
  • Examine both eyes to determine which is the affected one.
  • Neurologic symptoms suggest a mass as the cause
  • Myasthenia Gravis is fatiguable
  • Migrane is a diagnosis of exclusion.

See also


References

  1. ^ Najem K, Margolin E. Diplopia. [Updated 2020 Nov 20]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441905/
  2. ^ a b c d O'Sullivan, S.B & Schmitz, T.J. (2007). Physical Rehabilitation. Philadelphia, PA: Davis. ISBN 978-0-8036-1247-1.
  3. ^ Blumenfeld, Hal (2010). Neuroanatomy through Clinical Cases. Sunderland MA: Sinauer. ISBN 978-0-87893-058-6.
  4. ^ Rucker, JC. (2007). "Oculomotor disorders". Semin Neurol. 27 (3): 244–56. doi:10.1055/s-2007-979682 . PMID 17577866 .
  5. ^ a b Kernich, C.A. (2006). "Diplopia". The Neurologist. 12 (4): 229–230. doi:10.1097/01.nrl.0000231927.93645.34 . PMID 16832242 .
  6. ^ a b c Karmel, Miriam (November 2009), "Deciphering Diplopia" , EyeNet, archived from the original on March 16, 2016
  7. ^ a b Steven M. Archer, MD (December 2007), "Monocular Diplopia Due To Spherocylindrical Refractive Errors", Trans Am Ophthalmol Soc., 105: 252–271, PMC 2258122 , PMID 18427616
  8. ^ "An Overview of Double Vision" . WebMD. Retrieved 2018-09-23.
  9. ^ Phillips PH. (2007). "Treatment of diplopia". Semin Neurol. 27 (3): 288–98. doi:10.1055/s-2007-979680 . PMID 17577869 .
  10. ^ Taub, M.B. (2008). "Botulinum toxin represents a new approach to managing diplopia cases that do not resolve". Journal of the American Optometric Association. 79 (4): 174–175. doi:10.1016/j.optm.2008.01.003 .

Further reading


External links

Classification
External resources




Source


Information as of: 22.08.2021 07:13:26 CEST

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