DOUBLE TROUBLE
ACQUIRED DIPLOPIA IN ADULTS
2020
Clinical Optometry
Update and Review
Matthew Mahek, OD
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DOUBLE TROUBLE
ACQUIRED DIPLOPIA IN ADULTS
Clinical Optometry Update and Review Matthew Mahek, OD
DOUBLE TROUBLE
No financial disclosures
DOUBLE TROUBLE
WHERE TO START
CC: Double vision1st Question: Does it go away with one eye covered?
Yes: Binocular diplopia
No: Monocular diplopia
DOUBLE TROUBLE
WHERE TO START
Monocular Diplopia
Refractive
Optical
Retinal
Binocular Diplopia
Optical
CNS
Orbital
Systemic
Binocular Vision Disorders
MONOCULAR DIPLOPIA
CC: Double vision
Does it go away when you coverone eye? •
No (monocular)
Right, Left, both eyes?
Constant or intermittent?
MONOCULAR DIPLOPIA
REFRACTIVE
Uncorrected refractive error
Regular astigmatism
Anisometropia
Irregular astigmatism
Diagnostic RGP
Exam
Refraction
Topography
MONOCULAR DIPLOPIA
Retina
Macular Edema
Central Serous
Exudative ARMD
DOUBLE TROUBLE
CC: Double vision 1
st
Question: Does it go away with one eye covered?
Yes: Binocular diplopia
No: Monocular diplopia
BINOCULAR DIPLOPIA
WHERE TO START
History
the double vision up-and-down or side-by-side?
Is the diplopia greater at distance or near?
Is the event variable?
Has this happened before?
Is there associated pain?
Associated symptoms
Headache
GCA symptoms
Numbness/tingling
Motor deficits
Systemic History
Vascular disease: HTN, HLD, DM
Graves Disease
Multiple sclerosis
Myasthenia gravis
BINOCULAR DIPLOPIA
WHERE TO START
Motility Grading
-1 completes 75% of movement-2 completes 50% of movement-3 completes 25% of movement-4 does not move from primary
BINOCULAR DIPLOPIA
WHERE TO START
https://www.researchgate.net/figure/Drawing-and-designation-in-different-grades-of-abduction-deficit-No-abduction-deficit_fig1_
Binocular Function
Cover Test
Cover-Uncover and Alternating
Distance and Near
Primary and cardinal positions of gaze
Hirschberg
Krimsky
Stereo
BINOCULAR DIPLOPIA
WHERE TO START
BINOCULAR DIPLOPIA
Optical
Induced or unwanted prism
THIRD NERVE PALSY
SIGNS AND SYMPTOMS
Binocular Diplopia
Ptosis
Exotropia and hypotropia
Down and out
Limitation of all fields of gazeexcept temporally
Pupil sparing/involved
With or without pain
Complete and partial
https://eyerounds.org/cases-i/case156/1-partial-eyelid-ptosis-adduction-supraduction-infraduction.jpg