Practice 10-Minute Consultation

Double vision

BMJ 2015; 351 doi: https://doi.org/10.1136/bmj.h5385 (Published 18 November 2015) Cite this as: BMJ 2015;351:h5385

This article has a correction. Please see:

  1. Liying Low, academic clinical fellow in ophthalmology1,
  2. Waqaar Shah, general practitioner and RCGP clinical champion in eye health2,
  3. Caroline J MacEwen, professor of ophthalmology3
  1. 1Academic Unit of Ophthalmology, University of Birmingham, Birmingham B18 7QH, UK
  2. 2Clinical Innovation and Research Centre, Royal College of General Practitioners, London, UK
  3. 3Ophthalmology Department, University of Dundee, UK
  1. Correspondence to: L Low l.low{at}bham.ac.uk
  • Accepted 26 August 2015

What you need to know

  • Binocular diplopia may indicate a life threatening condition, and a stepwise approach is needed to distinguish this sort of diplopia from benign monocular diplopia

  • Red flags for urgent referral: new headache or ocular pain, unilateral pupil dilation, neurological features or fatigability, ptosis, facial trauma, papilloedema

  • Advise all patients with diplopia to stop driving

A 70 year old woman presents with a three day history of painless double vision.

What you should cover

Double vision, or diplopia, may be the first sign of life threatening pathology, or it may be completely benign. A rapid and systematic assessment is, therefore, crucial.1

Assessment

  • Is the diplopia is monocular or binocular? The latter may indicate a life threatening cause1

    • Monocular—Diplopia persists when one eye is covered. “What does the extra image look like?” The extra image typically appears as a ghost or shadow. Generally indicates abnormalities of the eye itself, including dry eyes, corneal pathology or scarring, cataracts, and non-organic causes.

    • Binocular—Diplopia occurs with both eyes open and disappears when either eye is covered.

      • Are the images separated vertically (on top of each other), or horizontally (side by side)? Vertical diplopia indicates impaired elevation or depression of the eye (such as decompensated squints, thyroid eye disease, fourth nerve palsies (figure

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