Double Vision

BMJ 2015;351:h5385 doi: 10.1136/bmj.h5385 (Published 18 November 2015) Page 1 of 3

Practice

PRACTICE

10-MINUTE CONSULTATION

Double vision

1 Liying Low academic clinical fellow in ophthalmology , Waqaar Shah general practitioner and RCGP 2 3 clinical champion in eye health , Caroline J MacEwen professor of ophthalmology

1Academic Unit of Ophthalmology, University of Birmingham, Birmingham B18 7QH, UK; 2Clinical Innovation and Research Centre, Royal College of General Practitioners, London, UK; 3Ophthalmology Department, University of Dundee, UK

A 70 year old woman presents with a three day history of – Is the double vision worse with any particular direction painless double vision. of gaze? (see figure⇓) What you should cover • Onset of symptoms—Sudden onset of diplopia usually indicates acute aetiology, such as ischaemia or vascular Double vision, or diplopia, may be the first sign of life compression. Gradual or intermittent onset may indicate threatening pathology, or it may be completely benign. A rapid 1 decompensation of a latent or longstanding squint. Vague and systematic assessment is, therefore, crucial. onset may be seen in thyroid eye disease. Assessment • Associated features—Are there any associated headaches or pain around the eyes? May indicate ischaemia, Is the diplopia is monocular or binocular? The latter may • inflammation, infection, raised intracranial pressure, or indicate a life threatening cause1 aneurysm. Monocular—Diplopia persists when one eye is covered. “What does the extra image look like?” The extra image • Weakness or fatigue—Is there any associated weakness or typically appears as a ghost or shadow. Generally indicates fatigue, particularly in the evenings, droopy eyelids, or abnormalities of the eye itself, including dry eyes, corneal difficulty swallowing? Possible myasthenia gravis. pathology or scarring, cataracts, and non-organic causes. • Trauma—Is there any recent head or facial trauma? Binocular—Diplopia occurs with both eyes open and Blow-out orbital fractures may cause extraocular muscle disappears when either eye is covered. entrapment or damage. – Are the images separated vertically (on top of each other), • Other features—Is there any new onset headache, scalp or horizontally (side by side)? Vertical diplopia indicates tenderness, unexplained weight loss, or pain when impaired elevation or depression of the eye (such as chewing? Possible giant cell arteritis. decompensated squints, thyroid eye disease, fourth nerve • Ocular history—Childhood squint or amblyopia, eye palsies (figure⇓), orbital trauma), whereas horizontal muscle surgery, or new glasses may suggest a longer term diplopia suggests impaired adduction or abduction of the aetiology. eye (such as decompensated squints, sixth nerve palsies (figure⇓), multiple sclerosis). • Medical history—Diabetes, hypertension, and vasculopathic risk factors are associated with cranial nerve – Is the double vision constant, intermittent, or variable? microvascular ischaemia. Include history of thyroid disease, Patients with intermittent diplopia should be asked about cancer, and multiple sclerosis. timing, duration, and frequency of symptoms, and exacerbating and relieving factors. Intermittent diplopia • Drug history—Drugs such as lamotrigine, topiramate, worse in the evenings or with fatigue suggests myasthenia gabapentin, fluroquinolones, and citalopram have been gravis or decompensating squint. Diplopia worse with associated with diplopia, but it is a rare adverse effect. spectacle prescription change suggests an accommodative or spectacle induced cause (both benign).

Correspondence to: L Low [email protected]

This is part of a series of occasional articles on common problems in primary care. The BMJ welcomes contributions from GPs.

For personal use only: See rights and reprints http://www.bmj.com/permissions Subscribe: http://www.bmj.com/subscribe BMJ 2015;351:h5385 doi: 10.1136/bmj.h5385 (Published 18 November 2015) Page 2 of 3

PRACTICE

What you need to know

• Binocular diplopia may indicate a life threatening condition, and a stepwise approach is needed to distinguish this sort of diplopia from benign monocular diplopia • Red flags for urgent referral: new headache or ocular pain, unilateral pupil dilation, neurological features or fatigability, ptosis, facial trauma, papilloedema • Advise all patients with diplopia to stop driving

Examination Urgent, same day referral • Observe any abnormal head position (tilt or face turn) and • Painful third nerve palsy with ipsilateral dilated pupil or compare with old photographs, which would support a sixth nerve palsy with papilloedema—Refer to either acute longstanding problem. medical or neurosurgical team for same day neuroimaging. • Observe the eyelid position—Ptosis of the upper eyelid • Suspected giant cell arteritis—Refer to either the may indicate third nerve palsy or myasthenia gravis, lid rheumatology or acute medical team or the ophthalmology retraction may indicate thyroid eye disease. team for urgent tests (including erythrocyte sedimentation • Inspect for strabismus (misalignment of the eyes)—For rate and C reactive protein) and high dose corticosteroid example, in third nerve palsy the affected eye turns “down treatment. and out” (figure⇓). • Acute onset diplopia associated with facial trauma—Refer • Inspect for proptosis (protrusion of the eyeball)—Suggests to the maxillofacial or ophthalmology team. orbital cellulitis, orbital tumours, thyroid eye disease, or • Red flag symptoms need referral to the acute medicine or carotid cavernous fistula. ophthalmology team. • Is the diplopia is monocular or binocular?—Cover each eye in turn and ask if the diplopia persists with either eye Routine referral to ophthalmology department covered. Patients with: • Assess visual acuity in each eye—Longstanding reduced • Any painless monocular diplopia or longstanding diplopia. vision in one eye suggests amblyopia, while new onset • Isolated fourth and sixth cranial nerve palsies. They should reduced vision suggests orbital or neurological lesion. 3 have cardiovascular risk factor work up. • Pupil size and responses—A unilateral dilated pupil in • Suspected thyroid eye disease. They should have thyroid association with headache and diplopia highly suggests an function tests performed and be advised to stop smoking. intracranial aneurysm (third nerve palsy), a neurosurgical emergency. Unilateral lid ptosis with pupillary miosis and unilateral cranial nerve palsies suggests Horner’s syndrome We thank Caitlin Monney for the illustration provided in this article. secondary to cavernous sinus pathology. These are red flag Contributors: LL conceived and designed the manuscript. LL and CJM signs. wrote the first draft. All authors revised and critically appraised the manuscript and gave final approval for publication. • Examine eye movements in nine positions of gaze—Ask if double vision worsens with different positions of gaze Competing interests: We have read and understood BMJ policy on (figure⇓). declaration of interests and have no relevant interests to declare.

• Cranial nerve and peripheral nervous system examination 1 O’Colmain U, Gilmour C, MacEwen CJ. Acute-onset diplopia. Acta Ophthalmol should be completed in all cases of suspected extraocular 2014;92:382-6. 2 Drivers Medical Group. For medical practitioners: at a glance guide to the current medical muscle weakness. Multiple cranial nerve palsies indicate standards of fitness to drive . DVLA, 2014. intracranial or meningeal based tumours, meningitis, 3 Tamhankar MA, Biousse V, Ying GS, et al. Isolated third, fourth, and sixth cranial nerve polyneuropathy, multiple sclerosis, or cavernous sinus palsies from presumed microvascular versus other causes: a prospective study. Ophthalmology 2013;120:2264-9. lesion. Accepted: 26 Aug 2015 • Papilloedema must be excluded in all cases of sixth nerve palsy (reduced abduction) as it can be a false localising Cite this as: BMJ 2015;351:h5385 sign of increased intracranial pressure. © BMJ Publishing Group Ltd 2015

What you should do Advise patients with diplopia not to drive.2

PRACTICE

Red flags. Signs of serious causes of binocular diplopia that require urgent, same day referral

• New onset of headache or ocular pain • Unilateral pupil dilation • Associated neurological features or fatigability • Ptosis • Facial trauma • Papilloedema