Eyes Opened: Double Vision IDs Neurological Ills

February 26, 2014
Mark L. Fuerst

An emergency medicine expert opens doctors’ eyes about what to do when patients present with vision disorders.

When a patient comes to a primary care physician with complaints of double vision, first identify the tempo of the problem, recommends an emergency medicine expert.

“Ask if the double vision has appeared abruptly. This is more likely to be serious than if it has been intermittent for weeks or months. Next, ask are there any associated signs or symptoms, or is the double vision an isolated issue,” J. Stephen Huff, MD, Professor of Emergency Medicine and Neurology at the University of Virginia, Charlottesville, told ConsultantLive.

Dr Huff presented a talk on double vision to more than 200 attendees at the American Academy of Emergency Medicine’s 20th Annual Scientific Assembly in New York.

“If double vision has an abrupt symptom onset with associated symptoms of headache, altered mental status, or additional neurologic findings on physical examination, send the patient to the emergency room,” he says.

One exception is a patient who has diabetes mellitus and hypertension with double vision from an isolated third cranial nerve palsy that has preserved pupillary response to light. This likely is not a serious problem and can be simply observed for several weeks.

If a patient has intermittent double vision, has no additional findings or symptoms, and has had the symptoms for some time, refer the patient to an ophthalmologist for further workup.

In general, Dr Huff recommends: “Take a history looking for additional symptoms. Do a careful examination looking for additional signs on physical examination, paying particular attention to cranial nerves and pupillary reactivity.”

“Top 10” Double Vision To Do List

Taking a page out of “Late Show” host David Letterman’s book, Dr Huff presented his own “Top 10 List” for dealing with patients who present with double vision:

#10. Diplopia. Clarify the chief complaint. What makes it worse? What does the patient mean by double vision?

#9. Monocular diplopia. Cover and uncover 1 eye. If there is refractive error in 1 eye, then send the patient to an ophthalmologist.

#8. Is the chief complaint an isolated symptom? If the patient has nausea, vomiting, ataxia, fever, headache, or pain in the globe, this is not isolated diplopia. Address these chief complaints.

#7. Is this a restrictive problem? If the patient has limited motion in 1 globe, this could be the result of mechanical restriction. Send the patient to an ophthalmologist if there is no proptosis. This often is thyroid myopathy.

#6. Cranial nerve issue? A single cranial nerve pattern may be the result of increased intracranial pressure, which needs a workup. If the eye is deviated out and pulled down and pupillary reactivity is intact, this is unlikely to be an aneurysm. More likely this is the result of diabetic, hypertensive, microvascular disease.

#5. Fatigable? Does it get worse at certain times of the day? Is it intermittent? Myasthenia gravis is a possibility.

#4. Other exam abnormalities. Are multiple cranial nerves involved? Is there facial weakness and corneal reflex? This patient needs emergency evaluation.

#3. Don’t forget Wernicke disease. This disease is not just for chronic inebriates any more. It is found among patients with malabsorption syndromes and  after gastric bypass surgery. Also think about other unusual causes of diplopia, such as cavernous sinus thrombosis and orbital apex syndrome. Generalized weakness with diplopia can be a presentation of Guillain-Barré and similar syndromes.

#2. Pain is a red flag. A patient with headache and diplopia may have an aneurysm.


#1. Don’t panic! Clarify the chief complaint. What are the associated symptoms? Do a thorough, focused examination. The chance of a secondary, serious cause of diplopia is only about 5%.

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