How to Diagnose Double Vision Amrita Kaur, OD

All conditions marked in red with * are potential emergencies

that require prompt workup and referral

Blurred vision
or loss of
vision
-Stroke
Double Vision -GCA
Is it Monocular -Thyroid Eye
or Binocular? Disease
-Orbital
Monocular Binocular
lesions/
How are the
inflammation
images
*Loss of vision
displaced?
in the context
of any of these
No Improvement
is an
with Pinhole
emergency
-Cortical
Abnormality/lesions
-Macular Pathology
-Retinal
Improvement Detachment
With Pinhole Anisocoria
-OSD YES -*CN 3 Palsy
-Lens Opacity or -*Concurrent
Displacement Horner?s
-Spectacle Syndrome
Vertical or NO
Misalignemnt
diagonal (or Are there
-Refractive Error
Horizontal torsional) associated
-Corneal Defect Proptosis or
Is diplopia Does Patient ocular
-Iris Defects limitation on Ptosis and/or
worse in a present with symptoms? Causes of CN
-Vitreous Opacity Forced facial pain
particular head tilt that palsies
Ductions -*CN 3 Palsy
gaze? alleviates (unilateral or -MG
symptoms? bilateral) -*Concurrent
Not Evident
-Thyroid Eye Horner’s
What does
Disease Syndrome
Cover Test or
-*Orbital lesion -*GCA
Maddox Rod
(mass, trauma, -*Stroke
testing show?
inflammation) Pons Lesion
Present at Not notably Worse at Near Worse in left YES
Distance only worse in any -Convergence or right gaze -Skew
-CN 6 Palsy direction/gaze Insufficiency Limitation on Deviation Not followng
CN 6 Palsy Trauma
-Divergence or intermittent -Decomp forced duction -CN 4 Palsy pattern of CN
Eso deviation
Insufficiency -MG Phoria testing? Palsy
*Note: not all patients
largest in
-Decomp
with these conditions will -Skew
present with head tilt ipsilateral gaze
Phoria Deviation
-MG
Cavernous
Sinus Lesion
Torsion
CN 4 Palsy
Follows
NO Pt often
Pattern of CN
-CN 6 Palsy presents with Subarachnoid
Nerve Palsy
Disclaimer: This chart serves -MG head tilt to Space
(often
merely as a guide for common -INO (MS) contalateral Infection/
non-comitant)
diagnoses associated with YES side. Hyper Inflammation
diplopia. There may be -Thyroid Eye deviation
additional conditions Disease largest in
associated with the symptoms -Muscle Paresis contralateral
mentioned. Additionally, any of -*Orbital Lesion gaze. Vasculopathy
the conditions listed may (mass, trauma,
present with atypical or inflammation)
symptoms not listed. When *Consider further
using this guide, be sure to use Midbrain
workup with *CN 3 Palsy
your best clinical judgment on Lesion
a case-by-case basis.
these symptoms Reversing hyper with
exo deviation largest
on contralateral gaze
of vertically inhibited Aneurysm
eye