REVIEW

C URRENT
OPINION Nonsurgical treatment of diplopia
Michael J. Bartiss

Purpose of review
As the population ages, the number of patients presenting to ophthalmologists with complaints of double
vision is increasing.
Recent findings
Diplopia is known to occur for optical, neuroophthalmological, strabismological and even iatrogenic
reasons following various ophthalmic surgical procedures. The mainstays of the nonsurgical treatment of
diplopia including no treatment, partial or total occlusion, press-on or ground in prisms and vergence
exercises (to increase fusional vergence amplitudes) have been utilized for some time. Although a review of
the literature demonstrates that very little has been published on this topic in recent years , subtle treatment
variations have evolved.
Summary
The ability to successfully manage patients’ diplopia symptoms remains important to decrease the risk of
patient injuries, as well as maximize their independence and quality of life. These concerns are es pecially
important as patients age.
Keywords
diplopia, prisms, vergence exercises

INTRODUCTION through a pinhole. If the double vision disappears,

The symptoms of diplopia are becoming an increas-
ingly common patient complaint to ophthalmolo-
gists. It is important to understand how to utilize
nonsurgical approaches in the management of both
monocular and binocular diplopia.
MONOCULAR DIPLOPIA
Subjective complaints of diplopia can arise from
monocular causes. Monocular diplopia can often
be confused with refractive blur from the patient’s
perspective. This is especially true if the doubled
images are not completely separated. This often
occurs in cases of uncorrected or inaccurate optical
correction of astigmatism. The presence of monoc-
ular diplopia is readily determined during assess-
ment of monocular visual acuity by asking the
patient if they are seeing a doubled image when
viewing a single letter ‘E’ on the Snellen chart. Each
eye should be assessed individually.
then it is likely that there is something in the visual
pathway from the level of the cornea to the retina
that is degrading the image. Cataracts (even mild
ones) or opacification of the posterior capsule in
pseudophakic patients are frequent causes, but cor-
neal irregularities, vitreous or retinal abnormalities
may cause these same symptoms.
REFRACTIVE ABNORMALITIES
If an uncorrected or inaccurately compensated astig-
matic refractive error is present, the spherocylindri-
cal results of a careful subjective refraction should be
placed in a trial frame and the diplopia reassessed.
The patient should view distant objects (e.g. looking
out a window) with the distance prescription and
then at reading distance with proper near vision
lenses in the trial frame. If the proper spectacle lens
Family Eye Care of the Carolinas, Aberdeen, North Carolina, USA

DETERMINING CAUSE OF MONOCULAR
DIPLOPIA
Addressing the underlying cause of monocular dip-
lopia should typically be the initial diagnostic effort.
The patient should be asked to view the acuity chart
Correspondence to Michael J. Bartiss, OD, MD, FAAO, FAAP, FACS,
Pediatric Ophthalmologist in Private Practice, Family Eye Care of the
Carolinas, 1902 North Sandhills Blvd. Ste. A, Aberdeen, NC 28315,
USA. Tel: +1 910 692 2020; e-mail: kidseyes11@gmail.com
Curr Opin Ophthalmol 2018, 29:381–384
DOI:10.1097/ICU.0000000000000513

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Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

Pediatrics and strabismus
KEY POINTS
● Diplopia symptoms can often be managed with
nonsurgical therapy.
● Monocular diplopia must be identified early in the
diplopia workup.
● Appropriate prism therapy is accomplished through
careful evaluation of eye alignment and binocular
fusional ranges.
prescription eliminates the diplopia, new glasses
should be prescribed.
ANATOMIC ABNORMALITIES
If an anatomic abnormality is the cause of the
double vision symptoms, then this abnormality
should be addressed whenever possible. Irregular
astigmatism can often be managed with a gas per-
meable contact lens, or corneal resurfacing. Cataract
extraction or posterior capsulotomy should be per-
formed if that is the location of the optical media
problem. If there are no abnormalities at these loca-
tions, the retina should be carefully assessed, utiliz-
ing an Amsler grid, Optical Coherence Tomography
and Fluorescein Angiography as needed.
If no treatable anatomical abnormality is iden-
tified, then treating the symptoms becomes the best
approach. This can involve increasing the blur of the
eye, or the partial or total occlusion of the involved
eye. This can be accomplished with something as
simple as a ‘pirate’ or amblyopia patch (total occlu-
sion), a simple clip-on spectacle patch (which spares
peripheral vision allowing better patient navigation
ability), Bangerter occlusion foils or inexpensive
commercially available ‘satin’ cellophane tape.
The ultimate decision of which treatment to use
is obviously what works best for the individual
patient. I have found that if the increased blur
caused by the satin tape or Bangerter foil is sufficient
to eliminate the perception of the doubled image,
this tends to be the most readily acceptable treat-
ment for most patients, as it preserves peripheral
vision and is the most cosmetically acceptable. The
tape or foil can be trimmed to cover the entire
concave surface of the lens in front of the involved
eye or trimmed in a circle sufficient to cover the
pupil in the dark-adapted state. Allow the patient to
view themselves in a mirror to see how the glasses
appear with the tape or foil in place.
If the patient does not wear distance vision spec-
tacles (as occurs with many pseudophakic patients),
inexpensive bifocal glasses can be obtained from
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numerous vendors with plano lenses in the top
and a reading add on the bottom. This will provide
the ‘carrier’ for the occlusion device of choice.
BINOCULAR DIPLOPIA
Binocular diplopia is known to occur for optical,
neuroophthalmological, strabismological and even
iatrogenic reasons following various ophthalmic
surgical procedures [1 ]. The therapeutic goal should
&
be to help the patient regain clear, comfortable,
single binocular vision. In cases of true binocular
diplopia, nonsurgical treatment options include, as
previously discussed, image blur, partial or total
occlusion, vergence exercises to increase fusional
amplitudes as well as the use of prisms.
However, for patients with intractable diplopia
(e.g. Horror fusionis) or in patients who are capable
of binocular fusion but demonstrate severely limited
binocular fields when they fuse, blur, partial or total
occlusion tend to work best to treat their symptoms
NO TREATMENT
No treatment is a viable option when the diplopia is
not particularly troublesome, and the patient can
compensate with a small face turn, chin elevation or
depression, or head tilt.
FUSIONAL VERGENCE EXERCISES
Fusional vergence exercises usually work best in
cases in which increased fusional convergence
amplitudes are needed to maintain binocular
fusion. I have found that computer-based programs
or orthoptic treatment regimens can work well
when the patient demonstrates 15 or less prism
diopters of intermittent exotropia at distance,
and/or a true convergence insufficiency. Compli-
ance with this treatment regimen is usually the
key to success.
PRISM THERAPY
Most people have a small underlying heterophoria. It
is important to remember, however, that most people
also possess horizontal, vertical and cyclotorsional
fusional ranges that allow the eyes to remain aligned,
thus preventing binocular diplopia symptoms. When
a neurological event occurs that effects eye move-
ments (such as a cranial nerve paresis or palsy), or the
natural aging process degrades the fusional ranges
(e.g. age-related distance esotropia), the fusional
ranges decrease, and patients can no longer sustain
stable binocular fusion. If patients demonstrate dip-
lopia with a small vertical misalignment, an esotropic
Volume 29 ● Number 5 ● September 2018

misalignment or intermittent exotropia less than 15
prism diopters, prism therapy becomes the best non-
surgical option to restore binocular vision. Although
patients often demonstrate a unidirectional eye mis-
alignment, many will present with a combination of
vertical and horizontal (and sometimes cyclotor-
sional) eye misalignment.
DETERMINING CORRECTIVE PRISM
MAGNITUDE AND ORIENTATION
Determining the amount and orientation of the
proper prismatic correction is dependent on the
findings of a careful, comprehensive eye examina-
tion (including refraction), as well as a detailed
sensorimotor examination and binocular visual
field assessment. After ductions and versions are
assessed, and cover testing performed, the next
step in the sensorimotor examination is to assess
the patient’s subjective ‘ocular position at rest’
(associated phoria) and measure their fusional
vergence ranges.
MEASURING-ASSOCIATED PHORIAS
Measuring associated phorias is done by having the
patient view a distant letter ‘E’ that is sufficiently
dissociated by the examiner both horizontally and
vertically such that the patient appreciates two sep-
arate images. To further clarify, the vertical associ-
ated phoria is determined by presenting vertical
prism in front of the patient (most easily done with
a prism bar) until the images appear horizontally
aligned, ‘like the headlights on a car’. The amount of
prism needed is recorded. The horizontal associated
phoria is determined by presenting horizontal prism
in front of the patient until the images appear
straight up and down, ‘like stacked blocks.’ Again,
the needed amount of prism is recorded. Once these
values are determined, these prisms are placed on
the patient’s spectacles with a Janelli or Halberg clip
or in a trial frame along with the appropriate spher-
ocylindrical correction. The patient is asked if the
images remain doubled. If there is residual subjec-
tive misalignment, additional horizontal and/or
vertical prism is placed in front of the patient until
fusion is obtained.
MEASURING FUSIONAL RANGES
Using the prism amount determined by the associ-
ated phoria testing as a starting point, the fusional
vergence ranges are then measured, with the break
and recovery points recorded. A vertical prism bar is
placed base down in front of one eye, and the prism
increased until the patient breaks fusion. This is
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Nonsurgical treatment of diplopia Bartiss
called the ‘break point.’ The prism is then decreased
until fusion is regained. This is called the ‘recovery
point’. The prism amount is then further decreased
(flipping the prism bar if needed to the base up
position) until the patient again breaks fusion. This
is the second ‘break point’. The prism amount is
then increased until fusion is regained. This is the
second ‘recovery point’. The amount of prism half
way between the two recovery points is then used to
replace the vertical prism in the clip or trial frame.
This same process is then utilized with a hori-
zontal prism bar, measuring the break and recovery
points discussed above. The prism amount half way
between the two recovery points is then used to
replace the horizontal prism in the clip or trial
frame.
The patient is then again asked if the ‘E’ appears
single. If so, the patient is asked to move his/her
eyes left, right, up and down to determine the
extent of the binocular visual field with this pris-
matic correction.
It is important to know how the patients use
their eyes in their activities of daily living. For most
people, maintaining a binocular visual field from 10
to 15 degrees above the midline and as far into
downgaze as possible proves maximally beneficial.
This however is not true if the patient is a carpenter,
plumber or bicyclist for example, where upgaze is
extremely important. The prescribed prismatic cor-
rection must take this into account and may need to
be adjusted accordingly.
DETERMINING TYPE OF PRISM THERAPY
Once the optimal prismatic correction is deter-
mined, the type of prism therapy is determined. I
typically advocate the use of press-on prisms as an
initial treatment unless the patient is an excellent
historian and the magnitude (separation of the dip-
lopic images) has been stable for several months. I
recommend this for two reasons. First, because it
allows the patient to try the prismatic correction for
a longer period and during various activities to
determine if this amount of prism correction will
adequately address the diplopia symptoms. The sec-
ond reason involves the cost of grinding in prisms
into spectacle lenses when compared with the costs
of press-on prisms.
I will recommend ground-in prism for patients if
the prismatic correction is not so large that it creates
significant lens edge thickness issues and the press-
on prism trial has been successful in controlling the
diplopia. The patient also has the option of continu-
ing the use of the press-on prism, if the one to two-
line degradation in visual acuity caused by the prism
is not problematic.
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Pediatrics and strabismus
CALCULATING RESULTANT PRISM
In patients with both a vertical and horizontal mis-
alignment, vertical prism can be placed on one lens
and horizontal prism on the other, but I prefer to
dispense a single obliquely oriented prism in front of
the nondominant eye, thereby not blurring both
eyes with the prism. The amount of ‘resultant’ prism
can be determined in several different ways. Ven-
dors who provide press-on prisms often provide a
graph that allows the determination of the power
and orientation of the resultant prism. The power of
the resultant prism can also be determined graphi-
cally. The Tanganelli Vector method [2 ] can also be
&
used with some patients. It can also be easily calcu-
lated using basic math and trigonometry with a
scientific calculator.
For example, let’s say that a patient-centered
his/her fusional ranges with 4 pd base-up in and
3 pd base-up and front of the right eye. Since the
vectors are 90 degrees apart they create a right
triangle with respect to the resultant prism vector.
Pythagorean theorem can be utilized to calculate the
power of the resulting prism.
c2 ¼pa2 þ b2 ¼ 9 þ 16
c ¼ 25 ¼ 5 prism diopters
To determine the orientation of the prism:
opposite
TanQ ¼ adjacent ¼ 43 ¼ 0:75
Q ¼ tan—10:75 ¼ 37 degrees
Therefore, the resultant prism should be:
5 pd base-in and base up @ 37 degrees
The lines on the press-on prism will be 90 degrees
away from the base and therefore should line up at
127 degrees. Using the lines on the press-on prisms
to determine the proper orientation is much easier
than ‘guessing’ the actual orientation of the prism
base when applying to the spectacle lens. A protrac-
tor or the astigmatic dial on the trial frame can help
orient the lines on the press on prism, which will
determine the direction of the prism base.
PATIENTS UNABLE TO FUSE
Sometimes stable binocular fusion cannot be
established with prisms. This can result from a
number of causes including significant cyclotro-
pia, fixation switch following strabismus surgery,
aniseikonia and horror fusionis. Cyclotropia can
be surgically addressed by a number of strabismus
surgery approaches. Aniseikonia can sometimes be
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addressed with the prescription of eiseikonic
lenses with the help of an optician in determining
the required base curves and lens thicknesses. The
amount of aniseikonia can be determined with the
use of either a space eikonometer, or more simply
with the commercially available Awaya Aniseiko-
nia Test in the examination lane, where the
patient views pairs of calibrated half-moon targets
through red/green glasses which separate the right
and left eye images for comparison. Encouraging
ocular dominance in one eye by blurring the con-
tralateral eye, creating a monovision scenario, is
sometimes effective with aniseikonia or fixation
switch. Horror fusionis, however, remains a diffi-
cult condition to treat, other than with occlusion
techniques.
CONCLUSION
Although such cases as these can be challenging for
the ophthalmologist and frustrating for the patient,
most patients presenting to your office with diplo-
pia complaints can be greatly helped with proper
evaluation and the appropriately prescribed treat-
ment regimen. The best treatment for many patients
is a nonsurgical one. This sort of evaluation takes
time, but patients suffering from diplopia are typi-
cally extremely grateful and will sing your praises to
everyone they know for helping them.
Acknowledgements
None.
Financial support and sponsorship
None.
Conflicts of interest
There are no conflicts of interest.
REFERENCES AND RECOMMENDED
READING
Papers of particular interest, published within the annual period of review, have
been highlighted as:
& of special interest
&& of outstanding interest
1. Sobol EK, Rosenberg JB. Strabismus after ocular surgery. J Pediatr Ophthal-
& mol Strabismus 2017; 54:272–281.
The review discusses the incidence, mechanisms and treatments of patients
experiencing diplopia following various ocular surgeries.
2. Kushner BJ. Diplopia. In: Hoyt C, editor. Strabismus-practical pearls you
& won’t find in textbooks, 1st ed. Cham, Switzerland: Springer International
Publishing; 2017. pp. 149– 150.
The chapter on diplopia presents applicable information on the calculation of
resultant prism in a clear and understandable manner.
Volume 29 ● Number 5 ● September 2018