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Diplopia: binocular, monocular

 
, medical expert
Last reviewed: 12.03.2022
 
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Visual impairment, in which a person looks at one object, but sees two (in a vertical or horizontal plane), is defined as diplopia (from the Greek diploos - double and ops - eye). [1]

Epidemiology

According to clinical studies, in 89% of cases, diplopia is binocular. Giant cell arteritis is the main cause of diplopia in 3-15% of cases.

Diplopia is observed in 50-60% of patients with miasthenia gravis and progressive supranuclear palsy.

With double vision in only one eye, up to 11% of cases are caused by facial trauma, thyroid disease, or age-related eye problems. And in almost the same number of patients, this visual disorder occurs due to a violation of the functions of higher mechanisms for controlling eye movements.

Causes of the diplopia

Experts call such main causes of this visual disorder  [2]as:

  • ophthalmic problems in the form of clouding of the lens (cataract) or vitreous, damage to the retina or iris, corneal abnormalities -  keratoconus , refractive errors (in particular, uncorrected  astigmatism ), sometimes - dry eyes and tear film deficiency, as well as idiopathic inflammation or swelling of the orbit of the eye;
  • restriction of the movement of one or more extraocular (oculomotor) muscles, which provide the mobility of the eyeballs and fix their position - due to their weakness in  myasthenia gravis  (miasthenia gravis), as well as due to paresis / paralysis.

Damage to the cranial nerves, brain stem and demyelinating diseases (myelitis, multiple sclerosis, Guillain-Barré syndrome) can cause diplopia when the cranial nerves  [3] innervating the muscles of the eye are damaged. Diplopia is one of the manifestations of degenerative changes in the central nervous system - the brain stem and basal ganglia - with  progressive supranuclear palsy , Parkinson's disease, as well as lesions of the structures of the autonomic nervous system, as in  Parino's syndrome .

Post-traumatic diplopia - in most cases after a blow to the face, as well as a fracture of the orbit (orbital floor) - is associated with damage to the III cranial nerve, which leads to denervation of the lower rectus oculomotor muscle (m. Rectus inferior).

Due to impaired cerebral circulation, diplopia appears after a stroke - hemorrhagic (intracerebral hemorrhage) or ischemic (cerebral infarction). Diplopia of vascular origin develops in cases of granulomatous inflammation of the aorta and its branches -  giant cell arteritis , as well as intracranial aneurysm.

Double vision in diabetes or thyroid problems, such as  autoimmune chronic thyroiditis , is considered to be diplopia in endocrine ophthalmopathy. In the first case, the cause is incomplete paralysis of the oculomotor nerve - diabetic  ophthalmoplegia (ophthalmoparesis) . And with thyroiditis, there is hyperplasia of the tissue of the muscular funnel of the orbit of the eye with  exophthalmos .

Deformation of the intervertebral discs in the cervical spine and compression of the vertebral artery with a narrowing of its lumen and deterioration in the trophism of nerve tissues explains diplopia in cervical steochondrosis .

Alcoholic diplopia is considered part  of alcoholic polyneuropathy  ; a critical lack of thiamine (vitamin B1) in the body of people with chronic alcohol dependence leads to the so-called Wernicke's encephalopathy, in which the brain stem and III pair of cerebral nerves suffer.

Diplopia may develop after eye surgery for cataracts, glaucoma, strabismus, or retinal detachment due to damage to the extraocular muscles.

Why can there be diplopia in children? First of all, due to latent  strabismus  -  heterophoria , although the mismatch of gaze at birth or in the first years of life may not be accompanied by doubling, since the developing CNS of the child is able to suppress the image perceived by the deviating eye. In this case, there is a risk of loss of vision in this eye.

About when and why strabismus and diplopia are combined, read in the publications:

Diplopia is noted in many genetically determined syndromes in children, for example,  Arnold-Chiari syndrome, Duane syndrome, Brown syndrome, etc.

In addition, the occurrence of diplopia may be due to damage to brain tissues (subcortical neurons) by the measles virus (Measles morbillivirus), which leads to the development of  subacute sclerosing panencephalitis .

Also read -  Impaired eye movements with double vision

Risk factors

Risk factors include:

  • craniocerebral injury with paralysis of the trochlear nerve, increased cerebral pressure, the formation of a  carotid-cavernous fistula ;
  • bruises and wounds of the eyes ;
  • inflammation of the meninges (meningitis);
  • chronic arterial hypertension (threatening the development of a stroke);
  • diabetes;
  • elevated levels of thyroid hormones with thyrotoxicosis or  diffuse toxic goiter (Graves' disease) ;
  • herpes zoster (herpes zoster with damage to the ganglia of the cerebral nerves Varicella zoster virus);
  • intracerebral and maxillofacial neoplasms (including cystic);
  • anatomical anomalies of the facial skull in congenital (syndromal) dysostoses and  ocular manifestations of craniosynostosis .

Pathogenesis

Eye movements move visual stimuli to the central fovea (fovea centralis) of the macula or macula (macula lutea) of the retina, and also maintain the fixation of the fovea centralis on a moving object or during head movements. These movements are provided by the ocular motor system: ocular motor nerves and nuclei in the brainstem, vestibular structures, extraocular muscles.

Considering the mechanism of development of diplopia, one should take into account the possibility of nuclear and infranuclear eye movement disorders in lesions of any nerve that provides the functions of extraocular muscles:

All of them pass from the brain stem or bridge into the subarachnoid space, then converge in the cavernous sinuses (cavernous sinuses) filled with venous blood (cavernous sinuses) on the sides of the pituitary gland. And these sinuses, the nerves next to each other follow into the superior orbital fissure, and from it each of them passes to “its own” muscle, forming a neuromuscular junction.

Thus, lesions that cause double vision may be present throughout these nerves, including surrounding structures, as well as extraocular muscle pathology and neuromuscular junction dysfunction (characteristic of myasthenia gravis). [6]

A key role in the pathogenesis of diplopia is also played by supranuclear (supranuclear) eye movement disorders that occur when lesions are above the level of the nuclei of the oculomotor nerve - in the cerebral cortex, anterior section and superior tubercle of the midbrain, in the cerebellum. These include tonic gaze deviation, saccadic (rapid) and fluent pursuit disorders (simultaneous movement of both eyes between gaze fixation phases). Impaired focusing of vision with diplopia; there is a lack of convergence (information of the visual axes); insufficiency of divergence (breeding of visual axes); anomalies of fusion (bifoveal fusion) - combining visual excitations from the corresponding images of the retina into a single visual perception.

The pathogenesis of diplopia is discussed in more detail in the publication -  Why double vision and what to do?

Forms

There are different types of diplopia. With a shift in the visual axes, double vision disappears when one of the eyes is closed, but in the presence of ophthalmic problems (pathologies of the lens, cornea or retina), monocular diplopia is noted - double vision that occurs when looking with one eye. But when patients with monocular diplopia of any etiology close the affected eye, they see one image.

Double vision in both eyes - binocular diplopia - occurs when the images received by the two eyes do not completely match, shifting relative to each other. Such a displacement can occur suddenly as a result of vascular damage during a stroke, and the gradual progression of the pathology is characteristic of a compression lesion of any of the cranial oculomotor nerves. At the same time, the image ceases to double if a person closes one eye.

Depending on the plane of displacement, diplopia can be vertical, horizontal and inclined (oblique and torsion).

Double vision in the vertical plane - vertical diplopia / diplopia when looking down - is the result of paralysis or  damage to the trochlear (IV) nerve , which innervates the superior oblique muscle of the eye (m.obliquus superior). Often it is observed with myasthenia gravis, hyperthyroidism, a neoplasm localized in the orbit of the eye, and supranuclear lesions. And in the case of trauma to the orbit of the eye, negative pressure in the paranasal sinuses can exert a compressive effect on the lower wall of the orbit, trapping the inferior rectus muscle of the eye, which leads to vertical diplopia with an inability to lift the affected eye up - that is, when looking down. But damage to the abducens (VI) cranial nerve causes diplopia when viewed from the side.

A feature of horizontal diplopia, which many patients with Parkinson's disease and multiple sclerosis suffer from, is a manifestation only after prolonged observation of closely spaced objects. The origin of this type of double vision is also most often associated with paralysis of the VI nerve and impaired innervation of the lateral rectus muscle (m. Rectus lateralis), leading to esotropia (converging strabismus); with insufficiency of divergence in old age, an idiopathic inability to align the eyes when focusing on close objects (convergence insufficiency) in children and adults; with lateral medullary syndrome - a lesion of the middle nerve bundle located in the brainstem (responsible for coordinating eye movement) and with an associated violation of lateral gaze -  internuclear ophthalmoplegia .

Oblique and torsion diplopia (with oblique doubling) is associated with paresis of the upper and lower rectus muscles and lateral medullary syndrome, primary orbital tumor, neuropathy of the oculomotor (III) nerve, Parino or Miller-Fischer syndrome. Patients with such diplopia have a tilt of the head in the opposite direction.

Transient diplopia (intermittent) occurs in patients in a state of  cataplexy , with alcohol intoxication, the use of certain drugs; with head injuries, such as concussion. And persistent diplopia (binocular) develops when the macula or fovea centralis is displaced, in patients with an isolated lesion of the III cranial nerve or decompensated congenital paralysis of the IV nerve.

Double vision associated with a disorder of fusion - the process of central and peripheral sensory fusion, that is, the combination of images from each eye into one - is defined as sensory diplopia.

In cases where the horizontal axes of the eyes do not match, the images of the left and right eyes may "swap" in places, and this is binocular cross-diplopia.

Complications and consequences

The main complication of diplopia itself is the discomfort that the patient experiences and the inability to perform many actions (for example, drive a car, perform actions that require precision). Of course, the pathologies that cause diplopia have their own complications and consequences.

Diplopia and disability. Severe, uncorrectable double vision in both eyes seriously reduces the ability to work and can lead to disability.

Diagnostics of the diplopia

To diagnose diplopia, a thorough history and clinical examination of the patient are necessary. An examination of the eye  and testing of ocular motility is  carried out  - a study of eye movements  with a Hess screen test, which allows you to objectively assess the internal and external range of rotation of each eye.

With monocular diplopia, refractometry and an occluder test are mandatory.

Other instrumental diagnostics are also used, in particular,  ophthalmoscopy , refractometry, radiography of the orbital area,  magnetic resonance imaging (MRI) of the brain .

Tests are given: a general blood test, for C-reactive protein, for the level of thyroid hormones, for various autoantibodies, etc. An analysis of the cerebrospinal fluid and bakposev of the lacrimal fluid and conjunctival smear is carried out. [7]

For patients with diplopia, differential diagnosis means looking for a specific cause of this visual disorder.

Who to contact?

Treatment of the diplopia

Treatment for diplopia always depends on its cause. For example, with transient binocular double vision associated with convergence deficiency, diplopia is corrected with glasses; prismatic glasses are used for diplopia: the so-called Fresnel prism is attached to the lens of the glasses - a thin transparent plastic sheet with angular grooves that create a prismatic effect (change the direction of the image entering the eye).  [8], [9

An eye patch or glasses with an occlusive lens are used.

Botox (botulinum toxin) may be injected into the stronger eye muscle to repair a weakened extraocular muscle. [10

Orthoptic exercises according to Kashchenko are prescribed for diplopia, which contribute to the restoration of the fusion reflex of the eyes; they are described in detail in the publication -  Strabismus - Treatment

Appropriate eye drops for diplopia are used for dry eyes. And containing methylethylpyridinol hydrochloride drops Oftalek or Emoksipin with diplopia can be prescribed in case of post-traumatic intraocular hemorrhage or acute cerebral circulatory disorders in stroke.

Surgical treatment is used to remove cataracts, with advanced keratoconus, retinal damage, macular fibrosis; surgery for diplopia is performed to remove a tumor of the orbit of the eye or brain, with a fracture of the orbit, with problems with the thyroid gland. [11]

More information in the material -  Treatment of double vision

Prevention

Given the wide range of causes and risk factors, it is difficult to prevent diplopia, and in many cases its prevention is simply impossible. But timely treatment of diseases that lead to this vision problem can give good results.

Forecast

The prognosis of diplopia is individual and depends entirely on the underlying condition that causes it.

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