Diplopia

Last updated
Diplopia
Other namesDouble vision
Diplopia.jpg
One way a person might experience double vision
Specialty Neurology, ophthalmology

Diplopia is the simultaneous perception of two images of a single object that may be displaced horizontally, vertically, diagonally (i.e., both vertically and horizontally), or rotationally in relation to each other. [1] It is usually the result of impaired function of the extraocular muscles, where both eyes are still functional, but they cannot turn to target the desired object. [2] Problems with these muscles may be due to mechanical problems, disorders of the neuromuscular junction, disorders of the cranial nerves (III, IV, and VI) that innervate the muscles, and occasionally disorders involving the supranuclear oculomotor pathways or ingestion of toxins. [3]

Contents

Diplopia can be one of the first signs of a systemic disease, particularly to a muscular or neurological process, [4] and it may disrupt a person's balance, movement, or reading abilities. [2] [5]

Causes

Diplopia has a diverse range of ophthalmologic, infectious, autoimmune, neurological, and neoplastic causes:

Diagnosis

Diplopia is diagnosed mainly by information from the patient. Doctors may use blood tests, physical examinations, computed tomography (CT), or magnetic resonance imaging (MRI) to find the underlying cause. [8]

Classification

One of the first steps in diagnosing diplopia is often to see whether one of two major classifications may be eliminated; both may be present. That involves blocking one eye to see which symptoms are evident in each eye alone. [9]

Binocular

Binocular diplopia is double vision arising as a result of strabismus (in layman's terms "cross-eyed"), the misalignment of the two eyes relative to each other, either esotropia (inward) or exotropia (outward). In such a case while the fovea of one eye is directed at the object of regard, the fovea of the other is directed elsewhere, and the image of the object of regard falls on an extrafoveal area of the retina.

The brain calculates the visual direction of an object based upon the position of its image relative to the fovea. Images falling on the fovea are seen as being directly ahead, while those falling on retina outside the fovea may be seen as above, below, right, or left of straight ahead depending upon the area of retina stimulated. Thus, when the eyes are misaligned, the brain perceives two images of one target object, as the target object simultaneously stimulates different, noncorresponding, retinal areas in either eye, thus producing double vision.

This correlation of particular areas of the retina in one eye with the same areas in the other is known as retinal correspondence. This relationship also gives rise to an associated phenomenon of binocular diplopia, although one that is rarely noted by those experiencing diplopia. Because the fovea of one eye corresponds to the fovea of the other, images falling on the two foveae are projected to the same point in space. Thus, when the eyes are misaligned, two different objects will be perceived as superimposed in the same space. This phenomenon is known as visual confusion'.

The brain naturally guards against double vision. In an attempt to avoid double vision, the brain can sometimes ignore the image from one eye, a process known as suppression. The ability to suppress is to be found particularly in childhood when the brain is still developing. Thus, those with childhood strabismus almost never complain of diplopia, while adults who develop strabismus almost always do. While this ability to suppress might seem an entirely positive adaptation to strabismus, in the developing child, this can prevent the proper development of vision in the affected eye, resulting in amblyopia. Some adults are also able to suppress their diplopia, but their suppression is rarely as deep or as effective and takes much longer to establish, thus they are not at risk of permanently compromising their vision. In some cases, diplopia disappears without medical intervention, but in other cases, the cause of the double vision may still be present.

Certain persons with diplopia who cannot achieve fusion and yet do not suppress may display a certain type of spasm-like irregular movement of the eyes in the vicinity of the fixation point (see: Horror fusionis).

Monocular

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. While serious causes rarely may be behind monocular diplopia symptoms, this is much less often the case than with binocular diplopia. [9] The differential diagnosis of multiple image perception includes the consideration of such conditions as corneal surface keratoconus, subluxation of the lens, a structural defect within the eye, a lesion in the anterior visual cortex, or nonorganic conditions, but diffraction-based (rather than geometrical) optical models have shown that common optical conditions, especially astigmatism, can also produce this symptom. [10]

Temporary

Temporary binocular diplopia can be caused by alcohol intoxication or head injuries, such as concussion (if temporary double vision does not resolve quickly, one should see an optometrist or ophthalmologist immediately). It can also be a side effect of benzodiazepines or opioids, particularly if used in larger doses for recreation, the antiepileptic drugs phenytoin and zonisamide, and the anticonvulsant drug lamotrigine, as well as the hypnotic drug zolpidem and the dissociative drugs ketamine and dextromethorphan. Temporary diplopia can also be caused by tired or strained eye muscles. If diplopia appears with other symptoms such as fatigue and acute or chronic pain, the patient should see an ophthalmologist immediately.

Voluntary

Some people are able to consciously uncouple their eyes, either by overfocusing closely (i.e. going cross-eyed) or unfocusing. Also, while looking at one object behind another object, the foremost object's image is doubled (for example, placing one's finger in front of one's face while reading text on a computer monitor). In this sense, double vision is neither dangerous nor harmful, and may even be enjoyable. It makes viewing stereograms possible. [11]

Monocular diplopia may be induced in many individuals, even those with normal eyesight, with simple defocusing experiments involving fine, high-contrast lines. [10]

Treatment

The appropriate treatment for binocular diplopia depends upon the cause of the condition producing the symptoms. Efforts must first be made to identify and treat the underlying cause of the problem. Treatment options include eye exercises, [2] wearing an eye patch on alternative eyes, [2] prism correction, [12] and in more extreme situations, surgery [5] or botulinum toxin. [13]

If diplopia turns out to be intractable, it can be managed as last resort by obscuring part of the patient's field of view. This approach is outlined in the article on diplopia occurring in association with a condition called horror fusionis.

It is possible to cure it with glasses

See also

Related Research Articles

Esotropia Esotropia is a strabismus in which the eye turns inward toward the nose

Esotropia is a form of strabismus in which one or both eyes turns inward. The condition can be constantly present, or occur intermittently, and can give the affected individual a "cross-eyed" appearance. It is the opposite of exotropia and usually involves more severe axis deviation than esophoria. Esotropia is sometimes erroneously called "lazy eye", which describes the condition of amblyopia—a reduction in vision of one or both eyes that is not the result of any pathology of the eye and cannot be resolved by the use of corrective lenses. Amblyopia can, however, arise as a result of esotropia occurring in childhood: In order to relieve symptoms of diplopia or double vision, the child's brain will ignore or "suppress" the image from the esotropic eye, which when allowed to continue untreated will lead to the development of amblyopia. Treatment options for esotropia include glasses to correct refractive errors, the use of prisms and/or orthoptic exercises and/or eye muscle surgery. The term is from Greek eso meaning "inward" and trope meaning "a turning".

Binocular vision type of vision in which an animal having two eyes is able to perceive a single three-dimensional image of its surroundings

In biology, binocular vision is a type of vision in which an animal having two eyes is able to perceive a single three-dimensional image of its surroundings. Neurological researcher Manfred Fahle has stated six specific advantages of having two eyes rather than just one:

  1. It gives a creature a spare eye in case one is damaged.
  2. It gives a wider field of view. For example, humans have a maximum horizontal field of view of approximately 190 degrees with two eyes, approximately 120 degrees of which makes up the binocular field of view flanked by two uniocular fields of approximately 40 degrees.
  3. It can give stereopsis in which binocular disparity provided by the two eyes' different positions on the head gives precise depth perception. This also allows a creature to break the camouflage of another creature.
  4. It allows the angles of the eyes' lines of sight, relative to each other (vergence), and those lines relative to a particular object to be determined from the images in the two eyes. These properties are necessary for the third advantage.
  5. It allows a creature to see more of, or all of, an object behind an obstacle. This advantage was pointed out by Leonardo da Vinci, who noted that a vertical column closer to the eyes than an object at which a creature is looking might block some of the object from the left eye but that part of the object might be visible to the right eye.
  6. It gives binocular summation in which the ability to detect faint objects is enhanced.
Far-sightedness condition of the eye

Far-sightedness, also known as hypermetropia, is a condition of the eye in which light is focused behind, instead of on, the retina. This results in close objects appearing blurry, while far objects may appear normal. As the condition worsens, objects at all distances may be blurry. Other symptoms may include headaches and eye strain. People may also experience accommodative dysfunction, binocular dysfunction, amblyopia, and strabismus.

Strabismus Visual impairment

Strabismus is a condition in which the eyes do not properly align with each other when looking at an object. The eye that is focused on an object can alternate. The condition may be present occasionally or constantly. If present during a large part of childhood, it may result in amblyopia or loss of depth perception. If onset is during adulthood, it is more likely to result in double vision.

Amblyopia Failure of the brain to process input from one eye

Amblyopia, also called lazy eye, is a disorder of sight in which the brain fails to process inputs from one eye and over time favors the other eye. It results in decreased vision in an eye that otherwise typically appears normal. Amblyopia is the most common cause of decreased vision in a single eye among children and younger adults.

Eye examination a series of tests assessing vision and pertaining to the eyes

An eye examination is a series of tests performed by an ophthalmologist, optometrist, or orthoptist, optician, assessing vision and ability to focus on and discern objects, as well as other tests and examinations pertaining to the eyes. Health care professionals often recommend that all people should have periodic and thorough eye examinations as part of routine primary care, especially since many eye diseases are asymptomatic.

Ocular dominance, sometimes called eye preference or eyedness, is the tendency to prefer visual input from one eye to the other. It is somewhat analogous to the laterality of right- or left-handedness; however, the side of the dominant eye and the dominant hand do not always match. This is because both hemispheres control both eyes, but each one takes charge of a different half of the field of vision, and therefore a different half of both retinas. There is thus no direct analogy between "handedness" and "eyedness" as lateral phenomena, which can be a considerable factor to unusual outstanding sports performance, such as cricket or tennis, where athletes may take some physical advantages from the space-time relation and the significant quickness of the moving object as well as the usual brief remaining space of time, or short windows lots, for tagging the projectile with the opponent's movement. Aside from physical advantages, it might be some functional or visuospatial processing advantages when the left eye is preponderant on the scene's information intake.

Stereopsis is a term that is most often used to refer to the perception of depth and 3-dimensional structure obtained on the basis of visual information deriving from two eyes by individuals with normally developed binocular vision. Because the eyes of humans, and many animals, are located at different lateral positions on the head, binocular vision results in two slightly different images projected to the retinas of the eyes. The differences are mainly in the relative horizontal position of objects in the two images. These positional differences are referred to as horizontal disparities or, more generally, binocular disparities. Disparities are processed in the visual cortex of the brain to yield depth perception. While binocular disparities are naturally present when viewing a real 3-dimensional scene with two eyes, they can also be simulated by artificially presenting two different images separately to each eye using a method called stereoscopy. The perception of depth in such cases is also referred to as "stereoscopic depth".

Eye movement voluntary or involuntary movement of the eyes, helping in acquiring, fixating and tracking visual stimuli

Eye movement includes the voluntary or involuntary movement of the eyes, helping in acquiring, fixating and tracking visual stimuli. A special type of eye movement, rapid eye movement, occurs during REM sleep.

Vergence

A vergence is the simultaneous movement of both eyes in opposite directions to obtain or maintain single binocular vision.

Exotropia Visual disorder where eyes work independently

Exotropia is a form of strabismus where the eyes are deviated outward. It is the opposite of esotropia and usually involves more severe axis deviation than exophoria. People with exotropia often experience crossed diplopia. Intermittent exotropia is a fairly common condition. "Sensory exotropia" occurs in the presence of poor vision. Infantile exotropia is seen during the first year of life, and is less common than "essential exotropia" which usually becomes apparent several years later.

Sixth nerve palsy non-neoplastic or neoplastic disorder affecting the abducens nerve (sixth cranial nerve)

Sixth nerve palsy, or abducens nerve palsy, is a disorder associated with dysfunction of cranial nerve VI, which is responsible for causing contraction of the lateral rectus muscle to abduct the eye. The inability of an eye to turn outward and results in a convergent strabismus or esotropia of which the primary symptom is diplopia in which the two images appear side-by-side. Thus the diplopia is horizontal and worse in the distance. Diplopia is also increased on looking to the affected side and is partly caused by overaction if the medial rectus on the unaffected side as it tries to provide the extra innervation to the affected lateral rectus. These two muscles are synergists or "yoke muscles" as both attempt to move the eye over to the left or right. The condition is commonly unilateral but can also occur bilaterally.

Congenital fourth nerve palsy human disease

Congenital fourth nerve palsy is a condition present at birth characterized by a vertical misalignment of the eyes due to a weakness or paralysis of the superior oblique muscle.

Suppression of an eye is a subconscious adaptation by a person's brain to eliminate the symptoms of disorders of binocular vision such as strabismus, convergence insufficiency and aniseikonia. The brain can eliminate double vision by ignoring all or part of the image of one of the eyes. The area of a person's visual field that is suppressed is called the suppression scotoma. Suppression can lead to amblyopia.

Monocular vision is vision in which both eyes are used separately. By using the eyes in this way the field of view is increased, while depth perception is limited. The eyes of an horse with monocular vision are usually positioned on opposite sides of the animal's head, giving it the ability to see two objects at once. The word monocular comes from the Greek root, mono for single, and the Latin root, oculus for eye.

Hypertropia Human disease

Hypertropia is a condition of misalignment of the eyes (strabismus), whereby the visual axis of one eye is higher than the fellow fixating eye. Hypotropia is the similar condition, focus being on the eye with the visual axis lower than the fellow fixating eye. Dissociated vertical deviation is a special type of hypertropia leading to slow upward drift of one or rarely both eyes, usually when the patient is inattentive.

The health effects of 3D are the aspects in which the human body is altered after the exposure of three-dimensional (3D) graphics. The viewing of 3D stereoscopic stimuli can cause symptoms related to vision disorders that the individual already had, as a person with a healthy binocular vision shouldn’t experience any side effects under three-dimensional exposure.

In ophthalmology, horror fusionis is a condition in which the eyes have an unsteady deviation, with the extraocular muscles performing spasm-like movements that continuously shift the eyes away from the position in which they would be directed to the same point in space, giving rise to diplopia. Even when the double vision images are made to nearly overlap using optical means such as prisms, the irregular movements prevent binocular fusion. The name horror fusionis arises from the notion that the brain is, or at least appears to be, actively preventing binocular fusion.

The FourPrism Dioptre Reflex Test, is an objective, non-dissociative test used to prove the alignment of both eyes by assessing motor fusion. Through the use of a 4 dioptre base out prism, diplopia is induced which is the driving force for the eyes to change fixation and therefore re-gain bifoveal fixation meaning, they overcome that amount of power.

The management of strabismus may include the use of drugs or surgery to correct the strabismus. Strabismus is a misalignment of the eyes and may also result in amblyopia or impairments of binocular vision.

References

  1. Cassin, B. & Solomon, S. (1990) Dictionary of Eye Terminology. Gainesville, Florida: Triad Publishing Company
  2. 1 2 3 4 O'Sullivan, S.B & Schmitz, T.J. (2007). Physical Rehabilitation. Philadelphia, PA: Davis. ISBN   978-0-8036-1247-1.
  3. Blumenfeld, Hal (2010). Neuroanatomy through Clinical Cases. Sunderland MA: Sinauer. ISBN   978-0-87893-058-6.
  4. Rucker, JC. (2007). "Oculomotor disorders". Semin Neurol. 27 (3): 244–56. doi:10.1055/s-2007-979682. PMID   17577866.
  5. 1 2 Kernich, C.A. (2006). "Diplopia". The Neurologist. 12 (4): 229–230. doi:10.1097/01.nrl.0000231927.93645.34. PMID   16832242.
  6. Fraunfelder FW, Fraunfelder FT (September 2009). "Diplopia and fluoroquinolones". Ophthalmology. 116 (9): 1814–7. doi:10.1016/j.ophtha.2009.06.027. PMID   19643481.
  7. "Diplopia - Eye Disorders - Merck Manuals Professional Edition". merck.com. Retrieved 27 March 2018.
  8. "An Overview of Double Vision". WebMD. Retrieved 2018-09-23.
  9. 1 2 Karmel, Miriam (November 2009), "Deciphering Diplopia", EyeNet, archived from the original on March 16, 2016
  10. 1 2 Steven M. Archer, MD (December 2007), "Monocular Diplopia Due To Spherocylindrical Refractive Errors", Trans Am Ophthalmol Soc., 105: 252–271, PMC   2258122 , PMID   18427616
  11. http://www.focusillusion.com/Instructions/ Instructions on how to view stereograms such as magic eye
  12. Phillips PH. (2007). "Treatment of diplopia". Semin Neurol. 27 (3): 288–98. doi:10.1055/s-2007-979680. PMID   17577869.
  13. Taub, M.B. (2008). "Botulinum toxin represents a new approach to managing diplopia cases that do not resolve". Journal of the American Optometric Association. 79 (4): 174–175. doi:10.1016/j.optm.2008.01.003.

Further reading

Classification
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External resources