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Double Vision As a Presenting Symptom in an Ophthalmic Casualty Department

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Double Vision As a Presenting Symptom in an Ophthalmic Casualty Department Eye (1991) 5,124-129 Double Vision as a Presenting Symptom in an Ophthalmic Casualty Department R. J. MORRIS London Summary All patients presenting with double vision as a principal symptom who presented to the Casualty Department of Moorfields Eye Hospital over a nine month period were prospectively investigated. Two hundred and seventy five patients were identified accounting for 1.4% of all casualties. Monocular diplopia was commoner than expected accounting for 69 cases (25.1 %) and was almost always a genuine symptom attributable to uniocular pathology, most commonly lenticular or corneal pathology. Two hundred and six patients (74.9%) had binocular diplopia and in most cases an aetiology was established. Cranial nerve palsies were the commonest cause of bio­ cular diplopia accounting for 81 cases. Other causes were classified as convergence or accommodation problems, decompensating phorias, traumatic, muscular, orbital lesions, supranuclear lesions, and other miscellaneous conditions. In eight cases of monocular and 23 cases of binocular diplopia no cause for the symptoms could be identified. Diplopia is a common and distressing symp­ did not include patients with monocular diplo­ tom which may be the presenting feature of a pia. It has been stated in the literature that wide variety of ocular and neurological condi­ monocular diplopia is rare and that a cause tions. Many patients with double vision pres­ cannot usually be detected.7 Some authors ent directly to an ophthalmic accident and feel that psychogenic factors are the most emergency department and the ophthal­ common cause of this symptom.s However, mologist is the first clinician with the oppor­ there is no epidemiological information on tunity to establish the diagnosis and prevent prevalence of monocular diplopia in the liter­ unnecessary, time consuming and expensive ature to support these statements. investigations. The Casualty Department of Moorfields Previous studies have considered the prob­ Eye Hospital sees patients referred by their lem of diplopia, but only in selected patient general practitioners and opticians as well as populations. These have included a general walk in casualties (self-referrals), and there­ ophthalmic outpatient clinic, 1 orthoptic fore represents a relatively un selected patient departments2-4 and a paralytic squint c1inic.5 population. In order to investigate the inci­ However, these studies represent specific dence of diplopia as a presenting symptom, groups of patients and would exclude some of the proportion of patients with monoc(Jlar the common causes of diplopia. One study has and binocular diplopia and the aetiology of considered patients presenting with diplopia the symptom, a prospective study of consec­ to an ophthalmic emergency department,6 but utive patients with double vision as a principal From: Moorfields Eye Hospital, City Road, London ECIV 2PD Correspondence to: R. J. Morris, FRCS, FCOphth. Southampton Eye Hospital, Wilton Avenue, Southampton S09 4XW. DOUBLE VISION AS A PRESENTING SYMPTOM 125 complaint who presented to the Casualty symptoms were related to optical aberrations Department over a nine month period was from the edge of the lens and in two from the conducted. dialling hole. Seventeen patients (24.6%) had corneal pathology resulting in corneal scar­ Methods and Materials ring, epithelial irregularity or irregular astig­ All patients who presented with double vision matism. In addition three patients had as a principal complaint to the Casualty irregular corneal astigmatism induced by cen­ Department, Moorfields Eye Hospital, City tral lid chalazion. Road between April and November 1987 Four patients had monocular diplopia as a were included in the study. Patients referred r�sult of macular pathology. Two patients by other ophthalmologists for a second opin­ developed transient diplopia following ion were excluded from the study. The trauma but ocular examination was within majority of patients were examined by the normal limits. author at presentation, but when this was not In eight (11.6%) patients no cause for the possible, the notes were reviewed and dis­ complaint of monocular diplopia could be cussed with the examining ophthalmologist. established. Four of these patients were lost All patients with binocular diplopia were also to follow up and in four the symptoms sponta­ assessed by an orthoptist. When necessary neously resolved within six weeks. patients were referred to specialist ophthal­ mic and neuro-ophthalmic clinics for further Binocular Diplopia investigation. In some cases the patients were The causes of binocular diplopia are summar­ admitted for neurological investigation. All ised in Table II. Infranuclear cranial nerve patients without an aetiological diagnosis palsies were the commonest cause and were followed until their symptoms resolved. accounted for 81 cases (29.5% of all cases and 39.3% of binocular cases). No patient had Results more than one oculomotor nerve involved. Nineteen thousand six hundred and sixty four Cranial nerve palsies were most commonly patients attended the casualty department due to diabetes or microvascular disease (32 during the nine month period of the study. patients), although superior oblique palsies Two hundred and seventy five patients pre­ were most frequently due to longstanding sented with diplopia as a principal symptom congenital palsies (14 patients). Two patients accounting for 1.4% of all patients. Two hun­ with 3rd nerve palsies had orbital pseudo­ dred and six patients (74.0%) had binocular tumours, one also had involvement of the diplopia and 69 (25.1 % ) monocular diplopia. ophthalmic nerve, and the other had an iso­ lated palsy of the superior division of the 3rd Monocular Diplopia nerve. One patient developed an isolated The causes of monocular diplopia are sum­ inferior rectus palsy following ophthalmic marised in Table 1. Extra-ocular optical herpes zoster. Three patients had intracere­ causes accounted for seven patients' symp­ bral tumours, one a pituitary tumour invading toms. Spectacle induced diplopia resulted the cavernous sinus and two metastatic from the bifocal segment ledge in four tumours. Eight patients in this group were lost patients and refractive correction of myopia to follow up. in one. Contact lens induced monocular dip­ The next most common group of patients lopia occurred in two patients due to lens with binocular diplopia was that classified as decentration and lens spoilage. muscular. This included nine patients with Ocular abnormalities were the commonest squint, five with diplopia following cataract group of conditions causing monocular diplo­ surgery, two adults with Duane's syndrome, pia. Lens abnormalities accounted for 27 two with long standing tropias who had dis­ patients (39.1%) and included cortical, nucle­ ruption of suppression. ar and posterior subcapsular cataracts. Four Twenty seven patients had a history of patients in this group had decentred posterior trauma. Fifteen had a blow out fracture and chamber intraocular lens implants, in two the fivesustained blunt orbital trauma but a frac- 126 R. J. MORRIS Table I. Causes of Monocular Diplopia OPTICAL Extra-ocular Bifocal Spectacles 4 Contact lenses (soft) 2 Myopic spectacles 1 OClllar Lids Chalazion 3 Cornea Infections -Herpes simplex 2 -Adenovirus 1 -Thygesons 1 Trauma -Healing abrasions 3 -Trichiasis 1 -Toxic epitheliopathy 2 -Scarring 4 -Contact lens induced microcysts 1 Dystrophy -Keratoconus 2 Iris Pharmacological mydriasis 1 Holmes Adie pupil 1 Lens Lens opacities 23 Intraocular lens 4 Retinal Parafoveal neovascular membrane I Pigment epithelial detachment I Macular pucker 1 Central retinal vein occlusion I TRAUMA 1 NO CAUSE ESTABLISHED 8 ture could not be demonstrated radiologically sents the first study to investigate patients despite the presence of diplopia in vertical presenting to an ophthalmic emergency gaze positions. Two presented some days after department with monocular and binocular penetrating orbital trauma and one patient diplopia. It has been suggested that monocu­ developed post concussion syndrome follow­ lar diplopia is a rare complaint/ but this is not ing a closed head injury. Four patients pre­ borne out by these figures. It was commoner sented following non-strabismus surgery, than expected accounting for 25.1% of all three had symptoms-following successful ret­ patients presenting with diplopia and 0.35% inal detachment surgery and one following of all new casualties. Monocular diplopia repeated pterygium surgery which had arises when two images of the same object are resulted in a mechanical limitation of seen by one eye. Typically the secondary abduction of the involved eye. image is fainter than the primary image and Fifteen patients had diplopia associated may be continuous with it or separated from with supranuclear lesions. Six patients with it.9 In some cases triplopia or polyopia may be internuclear ophthalmoplegia were sub­ experienced by the patient. The second image sequently diagnosed as having multiple scler­ may be vertically or horizontally separated osis, four patients had transient diplopia from the primary image, and when due to len­ associated with brain stem ischaemia, three ticular causes the diplopia is typically had skew deviations related t6 cerebral vertical. uo ischaemia, one had migraine and one Wer­ There is no concensus in the literature as to nicke's encephalopathy. One patient with a the commonest cause of monocular diplopia. large pituitary tumour and bitemporal field Despite
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