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Functional diplopia — Clinical Guidelines

Overview

Functional diplopia refers to the perception of double vision without an organic cause, often implicating neurological or muscular dysfunction. It can arise from various conditions including ocular misalignment, neurological disorders, and even iatrogenic factors like medication side effects 4 5 6.

Diagnosis

History and Physical Examination: Detailed history focusing on onset, progression, and associated symptoms; physical exam includes assessment of ocular alignment and motility 4.

Specific Tests:

- Bielschowsky Head Tilt Test: Useful in distinguishing between sagging eye syndrome and trochlear nerve palsy by measuring vertical deviations 1. - Maddox Rod and Risley's Prism: Aid in identifying misalignment in primary position 7. - Red Glass Test: Evaluates muscle function in various gaze positions 7. - Imaging: MRI may be indicated, especially in emergency settings to rule out serious underlying causes 2.

Management

Identify and Treat Underlying Cause: Address specific etiologies such as refractive errors, muscle imbalances, or neurological conditions 4.

Medication Review: Evaluate and potentially discontinue fluoroquinolones if suspected as a cause 5.

Conservative Measures: For benign causes, observation and reassurance may suffice 4.

Orthoptic and Prism Therapy: Utilize for managing residual symptoms in cases of ocular misalignment 4.

Special Populations

Elderly: More prone to conditions like sagging eye syndrome; careful differentiation from neurological causes is crucial 1.

Comorbidities: Neurological conditions may complicate diagnosis and require thorough evaluation 4.

Key Recommendations

Conduct a thorough history and physical examination, including specific ocular motility tests, to differentiate functional from organic diplopia (Evidence: Moderate 4 7).

Consider imaging studies like MRI in emergency settings to rule out serious underlying pathologies (Evidence: Moderate 2).

Evaluate and manage potential drug-induced causes, particularly fluoroquinolones, in patients presenting with diplopia (Evidence: Weak 5).

Tailor management based on identified etiology, ranging from conservative approaches to targeted therapies (Evidence: Expert opinion).

References

1 Yamadera K, Kimura A, Okita Y, Mochizuki Y, Gomi F. Comparison of head tilt test between sagging eye syndrome and acquired unilateral trochlear nerve palsy. Graefe's archive for clinical and experimental ophthalmology = Albrecht von Graefes Archiv fur klinische und experimentelle Ophthalmologie 2024. link 2 Stoessel M, Lersy FO, Moris MN, Bierry G, Anheim M, Kremer SP et al.. Implementation of a Magnetic Resonance Imaging scanner dedicated to emergencies in cases of binocular diplopia: Impact on patient management. Journal of neuroradiology = Journal de neuroradiologie 2023. link 3 Feng Y, Commiskey PW, Deveney TK, De Lott LB, Trobe JD. Evaluation of Diplopia by Emergency Medicine Physicians and Consulting Neurologists. Journal of neuro-ophthalmology : the official journal of the North American Neuro-Ophthalmology Society 2022. link 4 Iliescu DA, Timaru CM, Alexe N, Gosav E, De Simone A, Batras M et al.. Management of diplopia. Romanian journal of ophthalmology 2017. link 5 Fraunfelder FW, Fraunfelder FT. Diplopia and fluoroquinolones. Ophthalmology 2009. link 6 Plaut GS. Diplopia in a swimmer due to badly fitting goggles. Postgraduate medical journal 1998. link 7 Garber N. Evaluating diplopia with the Maddox rod, Risley's prism, and red glass. Journal of ophthalmic nursing & technology 1995. link 8 Fraser H. Diagnosis of double vision in adults. Australian family physician 1995. link 9 Spector RH. Vertical diplopia. Survey of ophthalmology 1993. link90054-b) 10 Carney LG, Liubinas J, Bowman KJ. The role of corneal distortion in the occurrence of monocular diplopia. Acta ophthalmologica 1981. link

Functional diplopia