Diplopia - profiles.uonbi.ac.ke
Transcript of Diplopia - profiles.uonbi.ac.ke
Diplopia
Dr. Njambi Ombaba, Paediatric ophthalmologist
University of Nairobi
Objectives
To understand types of diplopia
To be able to identify the various causes of diplopia
To outline the approach to diplopia management
Definition of diplopia Seeing two images instead
of one
The images can be side by side, on top of each other or both
Loss of simultaneous use of both eyes with bifoveal fixation
Conditions for Bifoveal fixation
Perfect (or near perfect) alignment of retinal receptors
Perfect (or near perfect )retinal correspondence
Perfect (or near perfect) alignment of the visual axes
Perfect(or near perfect)optics for clear images
Perfect central(or paracentral) fusional capability
Types of diplopia
Binocular diplopia
Monocular diplopia
Monocular diplopia
• Abnormalities of refractive media
• Typically improves with a pinhole
Persistent double vision when one eye is occluded
Monocular diplopia
Binocular diplopia
Present when the two eyes are open
Results from misalignment of visual axis
Relieves by closing either eye
The extraocular muscles
Nerve supply All by CN3 except LR6SO4
Actions of the extraocular muscles
Actions of the extraocular muscles
Vertical Recti- Primary action abducted 23 degreesOblique's: Primary action adducted 51degrees
Yoke muscles combinations
Causes of Binocular diplopia
Cranial nerve palsies – stroke, DM, HTN, neoplasms, aneurysms
Convergence / accommodation- insufficiency spasms
Trauma- orbital, intracranial
Muscle / Neuromuscular junction- Thyroid, Myasthenia
Decompensating phoria
Previous cataract surgery
Idiopathic / physiological
Localization of cranial nerve palsies
Parks-Bielschowsky three-step test for vertical deviations
R-G- B
Approach to a Patient with Diplopia
Key questions during evaluation
Monocular or binocular diplopia
Horizontal ,vertical, angular diplopia
Worse for near or distance
Change in head position- turn / tilt
Gaze where images are more separated
Evaluation?
Monocular
Ocular
media
Cortical polyopia
Psychogenic
Binocular
Comitant eye deviation
Non Comitant deviation
Key clues in binocular diplopia
Abnormal head position
Vision better at certain gazes
Obvious misalignment of eyes
Proptosis
Ptosis
Nystagmus
Clues for Restrictive causes
•Proptosis
•Graves disease
•Orbital trauma
•Retrobulbar injections
•Enophthalmos
Differentiating clues
Restrictive
• Mechanical restriction on FDT
• Increase IOP at eccentric gaze
• Normal saccades
• Ductions equal to versions
Paretic
• Free EOMM on FDT
• No change in IOP
• Slower saccades
• Ductions greater than versions
Versions and Ductions
Versions
Ductions
Institute appropriate management
Relief of diplopia Specific to pathology
Classify the Diplopia
Monocular Binocular ( Restrictive / Paretic)
Recognise the diplopia and accompanying features
History Examination / Tests
Examination guide
Monocular
Slit lamp examination
Fundoscopy
Brain pathology
Binocular
Strabismus / orthoptic assessment
Extraocular motility
Diplopia charting
Associated features; AHP proptosis, ptosis
Diplopia charting
Additional assessment
Relief of diplopia
Eye Patch
Glasses with filters or prisms
Contact lenses
Botox injections
Strabismus surgery
Treatment of specific cause