Screening Adult Double Vision Michele Harn, M.S., C.O., C.O.M.T Orthoptist UW Health Diplopia

u Binocularly, the patient sees two images simultaneously due to images falling on non-corresponding retinal areas.

u Tw o Pa r t s :

u I Phone triage

u II In clinic history and workup Triage Questions

u When possible speak to patient rather than family member. u How and when did you first notice double vision? u Sudden or gradual onset? u Constant or intermittent? u Frequency? u What caused this? Triage Questions

u Worse/better in up, down, right, or left gaze, images tilted? u Images vertical, horizontal, or a little of both? u Gone with EITHER eye covered? u Can you make it go away?

Medical Questions

Cardiovascular Neurologic High Cholesterol Cancer Hypertension Multiple sclerosis History of stroke Parkinson’s Aneurysm Brain shunt

Arteriosclerosis, Vasculitis

Temporal arteritis

Medical Questions

Eye Disease Other Lenticular changes Recent illness Retinal disease Thyroid disease Keratoconus Medications Myasthenia gravis Diabetes

Further Questions

u Recent change in activity – more computer time, reading, night driving u Change in glasses, contacts – monovision u Change in vision u Head/face trauma u Decreased depth perception u Exercise or fatigue related Further Questions

u Severe headache, vertigo, nausea, numbness, tingling, slurred speech, weakness u Lid droop u Recent surgery u Pupils unequal What is an Emergency?

u Sudden onset u Constant or gaze specific u Medical history – HTN, CVA, high cholesterol, diabetes, shunt, cancer, severe headache, trauma* u Same day appointment What is Urgent?

u Sudden or rapid onset u Medical history – Parkinson’s, MS, recent illness u Appointment within a few days What is Next Available?

u Changes in use of eyes u Changes in glasses/contacts u History of cataracts, keratoconus, retinal disease, thyroid disease u Monocular double vision u Childhood strabismus, eye exercises u Appointment within 6-8 weeks Which Eye Doctor? MD or OD

u Clinic preference in some cases u Establish a protocol for Emergent and Urgent cases Monocular Causes

u Ocular

u Macular disease

u Cataract

u Displaced IOL

u PI

u Keratoconus

u Corneal scar

u Dry eye Monocular Causes

u Refractive

u Astigmatism uncorrected

u Progressive bifocal

u Incorrect refraction

u Bent glasses especially with flat top bifocal Binocular Causes

u Neurologic – Parkinson’s, MS, skew, midbrain lesion u Neuromuscular – myasthenia, CPEO u Restrictive – thyroid eye disease, blow out fracture, acquired Brown’s syndrome (dog bite, sinus surgery) u Paretic – CN III, IV, VI Binocular Causes

u Dragged fovea – small epiretinal membrane (lights on-off test) u Cataract surgery – IR paresis, aniseikonia, prior controlled strabismus u Retina surgery – scleral buckle, inferior rectus paresis u Glaucoma surgery – Baerveldt, Ahmed valves Binocular Causes

u Sensory – ARC, post EOM surgery u Refractive – mono vision, aniseikonia, lenses switched u Fixation switch u Visual field loss leading to hemi-field slide u Convergence insufficiency u Divergence insufficiency

Case #1

u 55 year old male referred by VA for vertical double vision u Gradual onset over 1+ years u Wears OTC readers u Referring Dx: Convergence Insufficiency u Appointment: not urgent. u Exam: Good vision, stereo, ortho at distance with 10^ Exo at near. Monocular diplopia resolved with pinhole. u DX: severe dry eye Case #2

u 65 year old with poorly controlled diabetes. Woke up with double vision. u Appointment: Same or next day u DX: CN VI palsy Case #3

u For two months patient notes intermittent vertical double vision and blurred “weird” vision in right eye only. Gone with OD occluded, but not with OS occluded. u History of “retina problems” u Appointment: If negative for retinal detachment then 1-2 weeks. u DX: Epiretinal membrane Case #4

u 55 year woman notes occasional double vision especially when tired or reading a lot. Started wearing monovision contact lenses recently. u Appointment: Not urgent u DX: Intermittent exotropia previously well controlled. u Plan: Discontinued monovision and resolved. u Monovision can be intentionally or accidentally induced by cataract and refractive surgery Case #5

u 10 year old boy with recent history of fever and illness notes constant double vision since yesterday. u Appointment: Same day u DX: CN VI palsy post-viral in a child. u Have to rule out cranial mass as cause Questions