Diplopia causes

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief:  Farman Khan, MD, MRCP [2]

## Overview

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Diplopia is the perception of two images from a single object. The images may be horizontal, vertical, or diagonal.

## Causes[1][2]

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### Common Causes

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* Alcohol

* Cataract

* Diabetes

* Dry eyes

* Misalignment of the eyes

* Multiple sclerosis

* Myasthenia gravis

* Refractive error

* Strabismus

### Causes by Organ System

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Cardiovascular | Subclavian Artery Disease

|

Chemical / poisoning | No underlying causes
Dermatologic | No underlying causes
Drug Side Effect | Abciximab, Acute anticholinergic syndrome, Aztreonam, Botulinum toxin, Citalopram, Clobazam, Conjugated estrogens/bazedoxifene, Cytarabine, Eslicarbazepine acetate, Ezogabine, Gabapentin, Lacosamide, Latanoprost, Methocarbamol, Mitotane, Oxcarbazepine, Pralidoxime, Ropinirole, Rufinamide, Temozolomide, Topiramate, Trazodone, Trimethadione, Vigabatrin
Ear Nose Throat | Pansinusitis, Trochleitis
Endocrine | Diabetes mellitus type 2, Diabetic neuropathy, Graves' disease, Hypoglycemia, Insulinoma
Environmental | No underlying causes
Gastroenterologic | No underlying causes
Genetic | No underlying causes
Hematologic | No underlying causes
Iatrogenic | No underlying causes
Infectious Disease | Orbital cellulitis, Treponema pallidum
Musculoskeletal / Ortho | Frontal sinus osteoma, Myositis, Tenosynovitis
Neurologic | 3rd cranial nerve disorder, Acquired Brown's syndrome associated with underaction of the ipsilateral superior oblique muscle, Berry aneurysm, Brain Stem Gliomas, Brain tumor, Brown's superior oblique tendon sheath syndrome, Chiasmal syndrome, Colloid cyst, Congenital fourth nerve palsy, Episodic ataxia, Miller Fisher syndrome, Fourth cranial nerve palsy, Guillain-Barré syndrome, Idiopathic intracranial hypertension, Internuclear ophthalmoplegia, Intracranial berry aneurysm, Lateral medullary syndrome, Medulloblastoma, Midbrain pseudo-sixth nerve palsy, Millard-Gubler syndrome, Multiple sclerosis, Myasthenia gravis, One-and-a-half syndrome,Peribulbar anesthesia, Poliomyelitis, Progressive external ophthalmoplegia syndromes, Raised intracranial pressure, Rising eye syndrome, Silent sinus syndrome, Sixth cranial nerve palsy, Sphenoid wing meningioma, Stroke, Supranuclear monocular elevation paresis, Thalamic esotropia, Third cranial nerve palsy, Transient ischemic attack, Vertebrobasilar insufficiency, Vertical one-and-a-half syndrome, Vertigo, Wernicke's syndrome
Nutritional / Metabolic | No underlying causes
Obstetric/Gynecologic | No underlying causes
Oncologic | Maxillary sinus carcinoma, Metastasis to the superior oblique muscle, Metastatic infiltration of extraocular muscles, Nasopharyngeal carcinoma
Opthalmologic | Acquired motor fusion deficiency, Acute acquired comitant esotropia, Amblyopia, Aniseikonia, Anisometropia, Asthenopia, Blepharoplasty, Cataracts, Change of angle of preexisting childhood strabismus or loss of suppression scotoma, Childhood strabismus syndromes, Chronic Progressive External Ophthalmoplegia, Congenital "double elevator"palsy, Congenital inferior rectus fibrosis, Congenital strabismus syndromes, Consecutive esotropia, Consecutive exotropia, Convergence insufficiency, Convergence micropsia, Corectopia, Cyclic esotropia, Decompensation of a long-standing esophoria, Decompensation of a long-standing exophoria, Decompensation of a long-standing phoria, Dissociated vertical deviation, Divergence insufficiency or paralysis, Double depressor paralysis, Dry eyes, Dystonia, Esophoria, Esotropia, Exophoria, Exopthalmos, Exotropia, Fictitious vertical diplopia, Fixation disparity, Foveal displacement syndrome, Hemifield slide phenomena, Hemifield slip phenomenon resulting from dense bitemporal hemianopsia or heteronymous altitudinal field defects, Hemifield slip, retinal disease, and fictitious diplopia, Hypertropia, Iridodialysis, Isolated paresis of a vertical-acting extraocular muscle, superior oblique, inferior oblique, superior rectus, or inferior rectus, Isolated weakness of lateral rectus muscle, Isolated weakness of medial rectus muscle, Keratoconus, Lens dislocation, Misalignment of the eyes, Nystagmus, Ocular myasthenia, Ocular neuromyotonia, Ophthalmoplegia, Ophthalmoplegic migraine, Optic neuritis, Orbital inflammation and pseudotumor, Orbital mass, Orbital myositis, Orbital tumors Fallen eye syndrome, Paroxysmal superior rectus and levator palpebrae spasm with multiple sclerosis, Periodic alternating esotropia, Physiologic hyperdeviation on lateral gaze, Polycoria, Proptosis, Refractive error, Sensory esotropia, Sensory exotropia, Skew deviation, Spasm of the near reflex, Strabismus, Strabismus fixus, Superior oblique myokymia, Superior oblique tendon sheath syndrome, Superior oblique tuck, Superior orbital fissure syndrome
Overdose / Toxicity | Alcohol intoxication, Botulism, Toxidrome
Psychiatric | No underlying causes
Pulmonary | No underlying causes
Renal / Electrolyte |

Hypophosphatemia

Rheum / Immune / Allergy |

Temporal arteritis

Sexual | No underlying causes
Trauma | Blowout fracture, Brain or head injury, Direct trauma to the extraocular muscles, Injury to the eye, Medial orbital wall fracture, Orbital floor blow-out fracture,Orbital fracture, Post-concussion syndrome, Superomedial orbital trauma, Traumatic brain injury
Urologic | No underlying causes
Dental | No underlying causes
Miscellaneous | Adhesions, Decompression sickness, Maxillofacial or sinus surgery, Postoperative sequelae, Postsurgical esotropia, Postsurgical exotropia, Snakebites, Vitamin E deficiency

### Causes in Alphabetical Order

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* 3rd cranial nerve disorder
* Abciximab
* Acquired Brown's syndrome associated with underaction of the ipsilateral superior oblique muscle
* Acquired motor fusion deficiency
* Acute acquired comitant esotropia
* Acute anticholinergic syndrome
* Adhesions
* Alcohol intoxication
* Amblyopia
* Aneisokonia
* Aniseikonia
* Anisometropia
* Asthenopia
* Aztreonam
* Berry aneurysm
* Blepharoplasty
* Blowout fracture
* Botulinum toxin
* Botulism
* Brain or head injury
* Brain Stem Gliomas
* Brain tumor
* Brown's superior oblique tendon sheath syndrome
* Cataracts
* Change of angle of preexisting childhood strabismus or loss of suppression scotoma
* Chiasmal syndrome
* Childhood strabismus syndromes
* Chronic Progressive External Ophthalmoplegia
* Citalopram
* Clobazam
* Colloid cyst
* Congenital "double elevator"palsy
* Congenital fourth nerve palsy
* Congenital inferior rectus fibrosis
* Congenital strabismus syndromes
* Consecutive esotropia
* Consecutive exotropia
* Convergence insufficiency
* Convergence micropsia
* Corectopia
* Cyclic esotropia
* Cytarabine
* Decompensation of a long-standing esophoria
* Decompensation of a long-standing exophoria
* Decompensation of a long-standing phoria
* Decompression sickness
* Diabetes mellitus type 2
* Diabetic neuropathy
* Direct trauma to the extraocular muscles
* Dissociated vertical deviation
* Divergence insufficiency or paralysis
* Double depressor paralysis
* Dry eyes
* Dystonia
* Episodic ataxia
* Eslicarbazepine acetate
* Esophoria
* Esotropia
* Exophoria
* Exopthalmos

* Exotropia
* Fallen eye syndrome
* Fictitious vertical diplopia
* Miller Fisher syndrome
* Fixation disparity
* Fourth cranial nerve palsy
* Foveal displacement syndrome
* Frontal sinus osteoma
* Gabapentin
* Graves' disease
* Guillain-Barré syndrome
* Hemifield slide phenomena
* Hemifield slip phenomenon resulting from dense bitemporal hemianopsia or heteronymous altitudinal field defects
* Hemifield slip, retinal disease, and fictitious diplopia
* Hypertropia
* Hypoglycemia
* Hypophosphatemia
* Idiopathic intracranial hypertension
* Injury to the eye
* Insulinoma
* Internuclear ophthalmoplegia
* Intracranial berry aneurysm
* Iridodialysis
* Isolated paresis of a vertical-acting extraocular muscle, superior oblique, inferior oblique, superior rectus, or inferior rectus
* Isolated weakness of lateral rectus muscle
* Isolated weakness of medial rectus muscle
* Keratoconus
* Lacosamide
* Lateral medullary syndrome
* Lens dislocation
* Maxillary sinus carcinoma
* Maxillofacial or sinus surgery
* Medial orbital wall fracture
* Medulloblastoma
* Metastasis to the superior oblique muscle
* Metastatic infiltration of extraocular muscles
* Midbrain pseudo-sixth nerve palsy
* Millard-Gubler syndrome
* Misalignment of the eyes
* Multiple sclerosis
* Myasthenia gravis
* Myositis
* Nasopharyngeal carcinoma
* Nystagmus
* Ocular myasthenia
* Ocular neuromyotonia
* One-and-a-half syndrome
* Ophthalmoplegia
* Ophthalmoplegic migraine
* Optic neuritis
* Orbital cellulitis
* Orbital floor blow-out fracture
* Orbital fracture
* Orbital inflammation and pseudotumor
* Orbital mass

* Orbital myositis
* Orbital tumors
* Oxcarbazepine
* Pansinusitis
* Paroxysmal superior rectus and levator palpebrae spasm with multiple sclerosis
* Peribulbar anesthesia
* Periodic alternating esotropia
* Physiologic hyperdeviation on lateral gaze
* Poliomyelitis
* Polycoria
* Post-concussion syndrome
* Postoperative sequelae
* Postsurgical esotropia
* Postsurgical exotropia
* Pralidoxime
* Progressive external ophthalmoplegia syndromes
* Proptosis
* Raised intracranial pressure
* Refractive error
* Rising eye syndrome
* Rufinamide
* Sensory esotropia
* Sensory exotropia
* Silent sinus syndrome
* Sixth cranial nerve palsy
* Skew deviation
* Snakebites
* Spasm of the near reflex
* Sphenoid wing meningioma
* Strabismus
* Strabismus fixus
* Stroke
* Subclavian Artery Disease
* Superior oblique myokymia
* Superior oblique tendon sheath syndrome
* Superior oblique tuck
* Superior orbital fissure syndrome
* Superomedial orbital trauma
* Supranuclear monocular elevation paresis
* Temozolomide
* Temporal arteritis
* Tenosynovitis
* Thalamic esotropia
* Third cranial nerve palsy
* Topiramate
* Toxidrome
* Transient ischemic attack
* Traumatic brain injury
* Trazodone
* Treponema pallidum
* Trochleitis
* Vertebrobasilar insufficiency
* Vertical one-and-a-half syndrome
* Vertigo
* Vigabatrin
* Vitamin E deficiency
* Wernicke's syndrome

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#### Binocular Diplopia

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* Abducent nerve palsy
* Anisocoria
* Botulism
* Brown's Syndrome
* Cavernous sinus thrombosis
* Cerebrovascular accident
* Chronic progressive external ophthalmoplegia
* Decompensated phoria
* Eclampsia
* Encephalitis
* Giant Cell Arteritis
* Grave's Disease
* Insulinoma
* Internuclear ophthalmoplegia
* Meningitis
* Multiple Sclerosis
* Myasthenia gravis
* Myositis of the eye muscles
* Oculomotor nerve palsy
* Orbital disease
* Orbital trauma
* Orbital tumors
* Polio
* Polyneuropathy
* Postocular surgery
* Pseudotumor cerebri
* Subarachnoid hemorrhage
* Superior orbital fissure syndrome
* Syphilis
* Trauma
* Trochlear nerve palsy
* Vascular disorders
* Vertebrobasilar insufficiency
* Wernicke's Encephalopathy

#### Monocular Diplopia

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* Cataract
* Corneal opacity or irregularity
* Dislocated lens or lens implant
* Extrapupillary openings
* Macular degeneration
* Nonphysiologic
* Refractive error
* Retinal detachment

## Diagnosis

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### Binocular Diplopia

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Double vision can occur when the two eyes are not correctly aligned while aiming at an object, such as in esotropia and exotropia \- these result in uncrossed diplopia and crossed diplopia, respectively (i.e. "crossed eyes", in esotropia, result in uncrossed diplopia). When the eyes are misaligned and aimed at different targets, two non-matching images are sent to the viewer's brain. When the viewer's brain accepts and uses two non-matching images simultaneously, double vision results.

Double vision is dangerous to survival, therefore, the brain naturally guards against its occurrence. In an attempt to avoid double vision, the brain can ignore one eye (suppression). Due to the brain's ability to suppress one eye, double vision can appear to go away without medical evaluation or treatment. The causes of the double vision are very likely still present and loss of vision in one eye can occur due to lack of treatment. The loss of vision in one eye can be temporary or permanent depending on detection and treatment. It is in this way, that diplopia contributes to loss of depth perception and binocular vision, amblyopia (lazy eye), and/or strabismus (deviating eye).

### Monocular Diplopia

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Diplopia can also occur when viewing with only one eye; this is called monocular diplopia, or where the patient perceives more than two images, monocular polyopia. In this case, the multiple vision can be caused by a structural defect in the vision system, such as cataracts, subluxation of the crystalline lens or Keratoconus causing irregularities in the refraction of light within the eye.

### Temporary Diplopia

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Temporary diplopia can also be caused by intoxication from alcohol or head injuries, such as concussion. If temporary double vision does not resolve quickly, one should see an eye doctor immediately. It can also be a side effect of the anti-epileptic drugs Phenytoin and Zonisamide, and the anti-convulsant drug Lamotrigine, as well as the hypnotic drug Zolpidem.

### Treatment for Binocular Diplopia

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Treatment for binocular diplopia includes prism lenses and/or vision therapy. Daily wear of prism lenses is the passive compensatory treatment. Vision therapy is an active treatment which retrains the visual and vestibular systems (brain, eye muscles, and body). Vision therapy may eliminate the need for daily wear of prism lenses.

### Voluntary Diplopia

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Some people are able to consciously uncouple their eyes, inducing double vision on purpose. These people do not consider their double vision dangerous or harmful, and may even consider it enjoyable.

## References

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1. ↑ Kahan, Scott, Smith, Ellen G. In A Page: Signs and Symptoms. Malden, Massachusetts: Blackwell Publishing, 2004:68 ISBN 140510368X
2. ↑ Sailer, Christian, Wasner, Susanne. Differential Diagnosis Pocket. Hermosa Beach, CA: Borm Bruckmeir Publishing LLC, 2002:77 ISBN 1591032016

## Related Chapters

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* Amblyopia
* Binocular vision
* Orthoptics
* Strabismus
* Vision therapy

* v
* t
* e

* Diseases of the human eye (H00–H59
* 360–379)

Adnexa

| Eyelid|

| Inflammation|

* Stye
* Chalazion
* Blepharitis

|

* Entropion
* Ectropion
* Lagophthalmos
* Blepharochalasis
* Ptosis
* Blepharophimosis
* Xanthelasma

Eyelash|

* Trichiasis
* Madarosis

Lacrimal apparatus|

* Dacryoadenitis
* Epiphora
* Dacryocystitis
* Xerophthalmia

Orbit|

* Exophthalmos
* Enophthalmos
* Orbital cellulitis
* Orbital lymphoma
* Periorbital cellulitis

Conjunctiva|

* Conjunctivitis
* allergic
* Pterygium
* Pinguecula
* Subconjunctival hemorrhage

Globe

| Fibrous tunic|

| Sclera|

* Scleritis
* Episcleritis

|

Cornea|

* Keratitis
* herpetic
* acanthamoebic
* fungal
* Corneal ulcer
* Photokeratitis
* Thygeson's superficial punctate keratopathy
* Corneal dystrophy
* Fuchs'
* Meesmann
* Corneal ectasia
* Keratoconus
* Pellucid marginal degeneration
* Keratoglobus
* Terrien's marginal degeneration
* Post-LASIK ectasia
* Keratoconjunctivitis
* sicca
* Corneal neovascularization
* Kayser–Fleischer ring
* Haab's striae
* Arcus senilis
* Band keratopathy

Vascular tunic|

* Iris
* Ciliary body

* Uveitis
* Intermediate uveitis
* Hyphema
* Rubeosis iridis
* Persistent pupillary membrane
* Iridodialysis
* Synechia

|

Choroid|

* Choroideremia
* Choroiditis
* Chorioretinitis

Lens|

* Cataract
* Congenital cataract
* Childhood cataract
* Aphakia
* Ectopia lentis

Retina|

* Retinitis
* Chorioretinitis
* Cytomegalovirus retinitis
* Retinal detachment
* Retinoschisis
* Ocular ischemic syndrome / Central retinal vein occlusion
* Central retinal artery occlusion
* Branch retinal artery occlusion
* Retinopathy
* diabetic
* hypertensive
* Purtscher's
* of prematurity
* Bietti's crystalline dystrophy
* Coats' disease
* Macular degeneration
* Retinitis pigmentosa
* Retinal haemorrhage
* Central serous retinopathy
* Macular edema
* Epiretinal membrane (Macular pucker)
* Vitelliform macular dystrophy
* Leber's congenital amaurosis
* Birdshot chorioretinopathy

Other|

* Glaucoma / Ocular hypertension / Primary juvenile glaucoma
* Floater
* Leber's hereditary optic neuropathy
* Red eye
* Globe rupture
* Keratomycosis
* Phthisis bulbi
* Persistent fetal vasculature / Persistent hyperplastic primary vitreous
* Persistent tunica vasculosa lentis
* Familial exudative vitreoretinopathy

Pathways

| Optic nerve
Optic disc|

* Optic neuritis
* optic papillitis
* Papilledema
* Foster Kennedy syndrome
* Optic atrophy
* Optic disc drusen

Optic neuropathy|

* Ischemic
* anterior (AION)
* posterior (PION)
* Kjer's
* Leber's hereditary
* Toxic and nutritional

Strabismus
Extraocular muscles
Binocular vision
Accommodation|

| Paralytic strabismus|

* Ophthalmoparesis
* Chronic progressive external ophthalmoplegia
* Kearns–Sayre syndrome

palsies|

* Oculomotor (III)
* Fourth-nerve (IV)
* Sixth-nerve (VI)

Other strabismus|

* Esotropia / Exotropia
* Hypertropia
* Heterophoria
* Esophoria
* Exophoria
* Cyclotropia
* Brown's syndrome
* Duane syndrome

Other binocular|

* Conjugate gaze palsy
* Convergence insufficiency
* Internuclear ophthalmoplegia
* One and a half syndrome

Refraction|

* Refractive error
* Hyperopia
* Myopia
* Astigmatism
* Anisometropia / Aniseikonia
* Presbyopia

Vision disorders
Blindness|

* Amblyopia
* Leber's congenital amaurosis
* Diplopia
* Scotoma
* Color blindness
* Achromatopsia
* Dichromacy
* Monochromacy
* Nyctalopia
* Oguchi disease
* Blindness / Vision loss / Visual impairment

Anopsia|

* Hemianopsia
* binasal
* bitemporal
* homonymous
* Quadrantanopia

subjective|

* Asthenopia
* Hemeralopia
* Photophobia
* Scintillating scotoma

Pupil|

* Anisocoria
* Argyll Robertson pupil
* Marcus Gunn pupil
* Adie syndrome
* Miosis
* Mydriasis
* Cycloplegia
* Parinaud's syndrome

Other|

* Nystagmus
* Childhood blindness

Infections

* Trachoma
* Onchocerciasis

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