BMJ 2015;351:h5385 doi: 10.1136/bmj.

h5385 (Published 18 November 2015)

Page 1 of 3

Practice

PRACTICE
10-MINUTE CONSULTATION

Double vision
1

Liying Low academic clinical fellow in ophthalmology , Waqaar Shah general practitioner and RCGP
2
3
clinical champion in eye health , Caroline J MacEwen professor of ophthalmology
Academic Unit of Ophthalmology, University of Birmingham, Birmingham B18 7QH, UK; 2Clinical Innovation and Research Centre, Royal College
of General Practitioners, London, UK; 3Ophthalmology Department, University of Dundee, UK
1

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
MonocularDiplopia 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.
BinocularDiplopia 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), orbital trauma), whereas horizontal
diplopia suggests impaired adduction or abduction of the
eye (such as decompensated squints, sixth nerve palsies
(figure), multiple sclerosis).
Is the double vision constant, intermittent, or variable?
Patients with intermittent diplopia should be asked about
timing, duration, and frequency of symptoms, and
exacerbating and relieving factors. Intermittent diplopia
worse in the evenings or with fatigue suggests myasthenia
gravis or decompensating squint. Diplopia worse with
spectacle prescription change suggests an accommodative
or spectacle induced cause (both benign).

Is the double vision worse with any particular direction

of gaze? (see figure)
Onset of symptomsSudden onset of diplopia usually
indicates acute aetiology, such as ischaemia or vascular
compression. Gradual or intermittent onset may indicate
decompensation of a latent or longstanding squint. Vague
onset may be seen in thyroid eye disease.
Associated featuresAre there any associated headaches
or pain around the eyes? May indicate ischaemia,
inflammation, infection, raised intracranial pressure, or
aneurysm.

Weakness or fatigueIs there any associated weakness or

fatigue, particularly in the evenings, droopy eyelids, or
difficulty swallowing? Possible myasthenia gravis.
TraumaIs there any recent head or facial trauma?
Blow-out orbital fractures may cause extraocular muscle
entrapment or damage.
Other featuresIs there any new onset headache, scalp
tenderness, unexplained weight loss, or pain when
chewing? Possible giant cell arteritis.

Ocular historyChildhood squint or amblyopia, eye

muscle surgery, or new glasses may suggest a longer term
aetiology.

Medical historyDiabetes, hypertension, and

vasculopathic risk factors are associated with cranial nerve
microvascular ischaemia. Include history of thyroid disease,
cancer, and multiple sclerosis.
Drug historyDrugs such as lamotrigine, topiramate,
gabapentin, fluroquinolones, and citalopram have been
associated with diplopia, but it is a rare adverse effect.

Correspondence to: L Low l.low@bham.ac.uk

This is part of a series of occasional articles on common problems in primary care. The BMJ welcomes contributions from GPs.
For personal use only: See rights and reprints http://www.bmj.com/permissions

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BMJ 2015;351:h5385 doi: 10.1136/bmj.h5385 (Published 18 November 2015)

Page 2 of 3

PRACTICE

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

Examination

Urgent, same day referral

Observe any abnormal head position (tilt or face turn) and

compare with old photographs, which would support a
longstanding problem.

Painful third nerve palsy with ipsilateral dilated pupil or

sixth nerve palsy with papilloedemaRefer to either acute
medical or neurosurgical team for same day neuroimaging.

Observe the eyelid positionPtosis of the upper eyelid

may indicate third nerve palsy or myasthenia gravis, lid
retraction may indicate thyroid eye disease.

Suspected giant cell arteritisRefer to either the

rheumatology or acute medical team or the ophthalmology
team for urgent tests (including erythrocyte sedimentation
rate and C reactive protein) and high dose corticosteroid
treatment.

Inspect for strabismus (misalignment of the eyes)For

example, in third nerve palsy the affected eye turns down
and out (figure).

Acute onset diplopia associated with facial traumaRefer

to the maxillofacial or ophthalmology team.

Inspect for proptosis (protrusion of the eyeball)Suggests

orbital cellulitis, orbital tumours, thyroid eye disease, or
carotid cavernous fistula.
Is the diplopia is monocular or binocular?Cover each
eye in turn and ask if the diplopia persists with either eye
covered.
Assess visual acuity in each eyeLongstanding reduced
vision in one eye suggests amblyopia, while new onset
reduced vision suggests orbital or neurological lesion.

Pupil size and responsesA unilateral dilated pupil in

association with headache and diplopia highly suggests an
intracranial aneurysm (third nerve palsy), a neurosurgical
emergency. Unilateral lid ptosis with pupillary miosis and
unilateral cranial nerve palsies suggests Horners syndrome
secondary to cavernous sinus pathology. These are red flag
signs.
Examine eye movements in nine positions of gazeAsk
if double vision worsens with different positions of gaze
(figure).

Cranial nerve and peripheral nervous system examination

should be completed in all cases of suspected extraocular
muscle weakness. Multiple cranial nerve palsies indicate
intracranial or meningeal based tumours, meningitis,
polyneuropathy, multiple sclerosis, or cavernous sinus
lesion.

Papilloedema must be excluded in all cases of sixth nerve

palsy (reduced abduction) as it can be a false localising
sign of increased intracranial pressure.

Red flag symptoms need referral to the acute medicine or

ophthalmology team.

Routine referral to ophthalmology department

Patients with:
Any painless monocular diplopia or longstanding diplopia.

Isolated fourth and sixth cranial nerve palsies. They should

have cardiovascular risk factor work up.3
Suspected thyroid eye disease. They should have thyroid
function tests performed and be advised to stop smoking.

We thank Caitlin Monney for the illustration provided in this article.

Contributors: LL conceived and designed the manuscript. LL and CJM
wrote the first draft. All authors revised and critically appraised the
manuscript and gave final approval for publication.
Competing interests: We have read and understood BMJ policy on
declaration of interests and have no relevant interests to declare.
1
2
3

OColmain U, Gilmour C, MacEwen CJ. Acute-onset diplopia. Acta Ophthalmol

2014;92:382-6.
Drivers Medical Group. For medical practitioners: at a glance guide to the current medical
standards of fitness to drive . DVLA, 2014.
Tamhankar MA, Biousse V, Ying GS, et al. Isolated third, fourth, and sixth cranial nerve
palsies from presumed microvascular versus other causes: a prospective study.
Ophthalmology 2013;120:2264-9.

Accepted: 26 Aug 2015

Cite this as: BMJ 2015;351:h5385
BMJ Publishing Group Ltd 2015

What you should do

Advise patients with diplopia not to drive.2

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BMJ 2015;351:h5385 doi: 10.1136/bmj.h5385 (Published 18 November 2015)

Page 3 of 3

PRACTICE

Red flags. Signs of serious causes of binocular diplopia that require urgent, same day referral
New onset of headache or ocular pain
Unilateral pupil dilation
Associated neurological features or fatigability
Ptosis
Facial trauma
Papilloedema

Further reading
Lee MS. Diplopia: diagnosis and management. focal points. Vol 25. American Academy of Ophthalmology, 2007A detailed description
of diagnosis and management of diplopia
Rucker JC, Tomsak RL. Binocular diplopia. A practical approach. Neurologist 2005;11:98-110A logical stepwise approach to
assessing patients with diplopia

Figure

Interpretation of incomitance (that is, angle of squint varies with direction of gaze)

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