Dr. Huntley's
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Diplopia is the clinical term for double vision, or seeing one object as two. This symptom results when extraocular muscles fail to work together, causing images to fall on noncorresponding parts of the retinas. Orbital lesions, the effects of surgery, or impaired function of cranial nerves (CNs) that supply extraocular muscles (oculomotor, CN III; trochlear, CN IV; abducens, CN VI) may be responsible. (See Testing extraocular muscles, page 214.)
Diplopia usually begins intermittently and affects near or far vision exclusively. It can be classified as monocular or binocular. More common binocular diplopia may result from ocular deviation or displacement, extraocular muscle palsies, or psychoneurosis, or it may occur after retinal surgery. Monocular diplopia may result from an early cataract, retinal edema or scarring, iridodialysis, a subluxated lens, a poorly fitting contact lens, or an uncorrected refractive error such as astigmatism. Diplopia may also occur in hysteria or malingering.
Briefly ask about associated symptoms, especially a severe headache. Find out about associated neurologic symptoms first because diplopia can accompany serious disorders. Find out when the patient first noticed diplopia. Are the images side-by-side (horizontal), one above the other (vertical), or a combination? Does diplopia affect near or far vision? Does it affect certain directions of gaze? Ask if diplopia has worsened, remained the same, or subsided. Does its severity change throughout the day? Diplopia that worsens or appears in the evening may indicate myasthenia gravis. Find out if the patient can correct diplopia by tilting his head. If so, ask him to show you. (If the patient has a fourth nerve lesion, tilting of the head toward the opposite shoulder causes compensatory tilting of the unaffected eye. If he has incomplete sixth nerve palsy, tilting of the head toward the side of the paralyzed muscle may relax the affected lateral rectus muscle.)
Explore associated symptoms such as eye pain. Ask about hypertension, diabetes mellitus, allergies, and thyroid, neurologic, or muscular disorders. Also, note a history of extraocular muscle disorders, trauma, or eye surgery.
Perform a neurologic examination. Evaluate the patient’s level of consciousness (LOC); pupil size, equality, and response to light; and motor and sensory function. Then take his vital signs.
Observe the patient for ocular deviation, ptosis, proptosis, lid edema, and conjunctival injection. Distinguish monocular from binocular diplopia by asking the patient to occlude one eye at a time. If he still sees double out of one eye, he has monocular diplopia. Test visual acuity and extraocular muscles.
Diplopia may be an early symptom of a brain tumor. Accompanying signs and symptoms vary with the tumor’s size and location but may include eye deviation, emotional lability, decreased LOC, headache, vomiting, absence or generalized tonic-clonic seizures, hearing loss, visual field deficits, abnormal pupillary responses, nystagmus, motor weakness, and paralysis.
Diplopia due to isolated third cranial nerve palsy may be among the long-term effects of diabetes mellitus. It typically begins suddenly and may be accompanied by intense periorbital or head pain. The patient may display the typical signs and symptoms of diabetes to varying degrees.
Initially, encephalitis may cause a brief episode of diplopia and eye deviation. However, it usually begins with sudden onset of high fever, severe headache, and vomiting. As the inflammation progresses, the patient may display signs of meningeal irritation, decreased LOC, seizures, ataxia, and paralysis.
Potentially life-threatening head injuries may cause diplopia, depending on the site and extent of the injury. Associated signs and symptoms include eye deviation, pupillary changes, headache, decreased LOC, altered vital signs, nausea, vomiting, and motor weakness or paralysis.
Intracranial aneurysm is a life-threatening disorder that initially produces diplopia and eye deviation, perhaps accompanied by ptosis and a dilated pupil on the affected side. The patient complains of a recurrent, severe, unilateral, frontal headache. After the aneurysm ruptures, the headache becomes violent. Associated signs and symptoms include neck and spinal pain and rigidity, decreased LOC, tinnitus, dizziness, nausea, vomiting, and unilateral muscle weakness or paralysis.
Diplopia, a common early symptom in multiple sclerosis (MS), is usually accompanied by blurred vision and paresthesia. As MS progresses, signs and symptoms may include nystagmus, constipation, muscle weakness, paralysis, spasticity, hyperreflexia, intention tremor, gait ataxia, dysphagia, dysarthria, impotence, emotional lability, and urinary frequency, urgency, and incontinence.
Myasthenia gravis initially produces diplopia and ptosis, which worsen throughout the day. It then progressively involves other muscles, resulting in blank facial expression; nasal voice; difficulty chewing, swallowing, and making fine hand movements; and possibly signs of life-threatening respiratory muscle weakness.
Most common in young adults, ophthalmologic migraine results in diplopia that persists for days after the headache. Accompanying signs and symptoms include severe, unilateral pain; ptosis; and extraocular muscle palsies. Irritability, depression, or slight confusion may also occur.
An orbital blowout fracture usually causes monocular diplopia affecting the upward gaze. However, with marked periorbital edema, diplopia may affect other directions of gaze. This fracture commonly causes periorbital ecchymosis but doesn’t affect visual acuity, although eyelid edema may prevent accurate testing. Subcutaneous crepitation of the eyelid and orbit is typical. Occasionally, the patient’s pupil is dilated and unreactive, and he may have a hyphema.
Orbital cellulitis (inflammation of the orbital tissues and eyelids) causes sudden diplopia. Other findings are eye deviation and pain, purulent drainage, lid edema, chemosis and redness, proptosis, nausea, and fever.
Orbital tumors can cause diplopia. Proptosis and possibly blurred vision may also occur. One or both eyes may appear prominent. The patient may also report pain and redness and swelling of the lid of the affected eye.
Diplopia characterizes stroke when it affects the vertebrobasilar artery. Other signs and symptoms of this life-threatening disorder include unilateral motor weakness or paralysis, ataxia, decreased LOC, dizziness, aphasia, visual field deficits, circumoral numbness, slurred speech, dysphagia, and amnesia.
Diplopia accompanies exophthalmos in patients with thyrotoxicosis. It usually begins in the upper field of gaze because of infiltrative myopathy involving the inferior rectus muscle. It’s accompanied by impaired eye movement, excessive tearing, lid edema and, possibly, inability to close the lids. Other cardinal findings include tachycardia, palpitations, weight loss, diarrhea, tremors, an enlarged thyroid, dyspnea, nervousness, diaphoresis, and heat intolerance.
Transient ischemic attack is generally accompanied by diplopia, dizziness, tinnitus, hearing loss, and numbness. It can last for a few seconds or up to 24 hours and may be a warning sign for a future stroke.
Continue to monitor the patient’s vital signs and neurologic status if you suspect an acute neurologic disorder. Prepare him for neurologic tests such as a computed tomography scan. Provide a safe environment. If the patient has severe diplopia, remove sharp obstacles and assist him with ambulation. Also, institute seizure precautions if indicated.
Strabismus, which can be congenital or acquired at an early age, produces diplopia; however, in young children, the brain rapidly compensates for double vision by suppressing one image, so diplopia is a rare complaint. School-age children who complain of double vision require a careful examination to rule out serious disorders such as a brain tumor.
Discuss safety measures with the patient and his family. Stress the importance of ambulating with assistance. Explain all diagnostic tests and procedures to the patient. Encourage the patient to express his concerns regarding diplopia. If necessary, orient the patient to his room and his meal tray.
Read excerpts from these other book chapters related to Eye symptoms:
Copyright Details: Signs & Symptoms: A 2-in-1 Reference for Nurses, Copyright © 2008 Williams & Wilkins.
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More About This Book:
Title: Signs & Symptoms: A 2-in-1 Reference for Nurses Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 1-58255-318-1 
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