BMJ 2015;351:h5385 doi: 10.1136/bmj.
h5385 (Published 18 November 2015)
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
1
Academic 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
This is part of a series of occasional articles on common problems in
primary care. The BMJ welcomes contributions from GPs.
A 70 year old woman presents with a three day history of
painless double vision.
What you should cover
Double vision, or diplopia, may be the first sign of life
threatening pathology, or it may be completely benign. A rapid
and systematic assessment is, therefore, crucial.1
Assessment
• Is the diplopia is monocular or binocular? The latter may
indicate a life threatening cause1
Monocular—Diplopia persists when one eye is covered.
“What does the extra image look like?” The extra image
typically appears as a ghost or shadow. Generally indicates
abnormalities of the eye itself, including dry eyes, corneal
pathology or scarring, cataracts, and non-organic causes.
Binocular—Diplopia occurs with both eyes open and
disappears when either eye is covered.
– Are the images separated vertically (on top of each other),
or horizontally (side by side)? Vertical diplopia indicates
impaired elevation or depression of the eye (such as
decompensated squints, thyroid eye disease, fourth nerve
palsies (figure⇓), orbital trauma), whereas horizontal
diplopia suggests impaired adduction or abduction of the
eye (such as decompensated squints, sixth nerve palsies
(figure⇓), multiple sclerosis).
– Is the double vision constant, intermittent, or variable?
Patients with intermittent diplopia should be asked about
timing, duration, and frequency of symptoms, and
exacerbating and relieving factors. Intermittent diplopia
worse in the evenings or with fatigue suggests myasthenia
gravis or decompensating squint. Diplopia worse with
spectacle prescription change suggests an accommodative
or spectacle induced cause (both benign).
Correspondence to: L Low l.low@bham.ac.uk
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PRACTICE
– Is the double vision worse with any particular direction
of gaze? (see figure⇓)
• Onset of symptoms—Sudden onset of diplopia usually
indicates acute aetiology, such as ischaemia or vascular
compression. Gradual or intermittent onset may indicate
decompensation of a latent or longstanding squint. Vague
onset may be seen in thyroid eye disease.
• Associated features—Are there any associated headaches
or pain around the eyes? May indicate ischaemia,
inflammation, infection, raised intracranial pressure, or
aneurysm.
• Weakness or fatigue—Is there any associated weakness or
fatigue, particularly in the evenings, droopy eyelids, or
difficulty swallowing? Possible myasthenia gravis.
• Trauma—Is there any recent head or facial trauma?
Blow-out orbital fractures may cause extraocular muscle
entrapment or damage.
• Other features—Is there any new onset headache, scalp
tenderness, unexplained weight loss, or pain when
chewing? Possible giant cell arteritis.
• Ocular history—Childhood squint or amblyopia, eye
muscle surgery, or new glasses may suggest a longer term
aetiology.
• Medical history—Diabetes, hypertension, and
vasculopathic risk factors are associated with cranial nerve
microvascular ischaemia. Include history of thyroid disease,
cancer, and multiple sclerosis.
• Drug history—Drugs such as lamotrigine, topiramate,
gabapentin, fluroquinolones, and citalopram have been
associated with diplopia, but it is a rare adverse effect.
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BMJ 2015;351:h5385 doi: 10.1136/bmj.h5385 (Published 18 November 2015)
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
• Observe any abnormal head position (tilt or face turn) and
compare with old photographs, which would support a
longstanding problem.
• Observe the eyelid position—Ptosis of the upper eyelid
may indicate third nerve palsy or myasthenia gravis, lid
retraction may indicate thyroid eye disease.
• Inspect for strabismus (misalignment of the eyes)—For
example, in third nerve palsy the affected eye turns “down
and out” (figure⇓).
• Inspect for proptosis (protrusion of the eyeball)—Suggests
orbital cellulitis, orbital tumours, thyroid eye disease, or
carotid cavernous fistula.
• Is the diplopia is monocular or binocular?—Cover each
eye in turn and ask if the diplopia persists with either eye
covered.
• Assess visual acuity in each eye—Longstanding reduced
vision in one eye suggests amblyopia, while new onset
reduced vision suggests orbital or neurological lesion.
• Pupil size and responses—A unilateral dilated pupil in
association with headache and diplopia highly suggests an
intracranial aneurysm (third nerve palsy), a neurosurgical
emergency. Unilateral lid ptosis with pupillary miosis and
unilateral cranial nerve palsies suggests Horner’s syndrome
secondary to cavernous sinus pathology. These are red flag
signs.
• Examine eye movements in nine positions of gaze—Ask
if double vision worsens with different positions of gaze
(figure⇓).
• Cranial nerve and peripheral nervous system examination
should be completed in all cases of suspected extraocular
muscle weakness. Multiple cranial nerve palsies indicate
intracranial or meningeal based tumours, meningitis,
polyneuropathy, multiple sclerosis, or cavernous sinus
lesion.
• Papilloedema must be excluded in all cases of sixth nerve
palsy (reduced abduction) as it can be a false localising
sign of increased intracranial pressure.
What you should do
Advise patients with diplopia not to drive.2
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PRACTICE
Urgent, same day referral
• Painful third nerve palsy with ipsilateral dilated pupil or
sixth nerve palsy with papilloedema—Refer to either acute
medical or neurosurgical team for same day neuroimaging.
• Suspected giant cell arteritis—Refer to either the
rheumatology or acute medical team or the ophthalmology
team for urgent tests (including erythrocyte sedimentation
rate and C reactive protein) and high dose corticosteroid
treatment.
• Acute onset diplopia associated with facial trauma—Refer
to the maxillofacial or ophthalmology team.
• Red flag symptoms need referral to the acute medicine or
ophthalmology team.
Routine referral to ophthalmology department
Patients with:
• Any painless monocular diplopia or longstanding diplopia.
• Isolated fourth and sixth cranial nerve palsies. They should
have cardiovascular risk factor work up.3
• Suspected thyroid eye disease. They should have thyroid
function tests performed and be advised to stop smoking.
We thank Caitlin Monney for the illustration provided in this article.
Contributors: LL conceived and designed the manuscript. LL and CJM
wrote the first draft. All authors revised and critically appraised the
manuscript and gave final approval for publication.
Competing interests: We have read and understood BMJ policy on
declaration of interests and have no relevant interests to declare.
1 O’Colmain U, Gilmour C, MacEwen CJ. Acute-onset diplopia. Acta Ophthalmol
2014;92:382-6.
2 Drivers Medical Group. For medical practitioners: at a glance guide to the current medical
standards of fitness to drive . DVLA, 2014.
3 Tamhankar MA, Biousse V, Ying GS, et al. Isolated third, fourth, and sixth cranial nerve
palsies from presumed microvascular versus other causes: a prospective study.
Ophthalmology 2013;120:2264-9.
Accepted: 26 Aug 2015
Cite this as: BMJ 2015;351:h5385
© BMJ Publishing Group Ltd 2015
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BMJ 2015;351:h5385 doi: 10.1136/bmj.h5385 (Published 18 November 2015) Page 3 of 3

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

Further reading
• Lee MS. Diplopia: diagnosis and management. focal points. Vol 25. American Academy of Ophthalmology, 2007—A detailed description
of diagnosis and management of diplopia
• Rucker JC, Tomsak RL. Binocular diplopia. A practical approach. Neurologist 2005;11:98-110—A logical stepwise approach to
assessing patients with diplopia

Figure

Interpretation of incomitance (that is, angle of squint varies with direction of gaze)

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