Diplopia is double vision, viz., seeing two images of a single object. The spatial and temporal characteristics of the diplopia may help to ascertain its cause.
Diplopia may be monocular, in which case ocular causes are most likely (although monocular diplopia may be cortical or functional in origin), or binocular, implying a divergence of the visual axes of the two eyes. With binocular diplopia, it is of great importance to ask the patient whether the images are separated horizontally, vertically, or obliquely (tilted), since this may indicate the extraocular muscle(s) most likely to be affected. Whether the two images are separate or overlapping is important when trying to ascertain the direction of maximum diplopia.
The experience of diplopia may be confined to, or particularly noticeable during, the performance of particular activities, reflecting the effect of gaze direction; for example, diplopia experienced on coming downstairs may reflect a trochlear (IV) nerve palsy; or only on looking to the left may reflect a left abducens (VI) nerve palsy. Double vision experienced on looking at a distant object after looking down (e.g., reading) may occur with bilateral abducens (VI) nerve palsies. The effect of gaze direction on diplopia should always be sought, since images are most separated when looking in the direction of a paretic muscle. Conversely, diplopia resulting from the breakdown of a latent tendency for the visual axes to deviate (latent strabismus, squint) results in diplopia in all directions of gaze.
Examination of the eye movements should include asking the patient to look at a target, such as a pen, in the various directions of gaze (versions) to ascertain where diplopia is maximum. Ductions are tested monocularly with the opposite eye covered. Then, each eye may be alternately covered to try to demonstrate which of the two images is the false one, namely that from the nonfixing eye. The false image is also the most peripheral image. Thus in a left abducens (VI) nerve palsy, diplopia is maximum on left lateral gaze; when the normal right eye is covered the inner image disappears; the nonfixing left eye is responsible for the remaining false image, which is the more peripheral and which disappears when the left eye is covered.
Other clues to the cause of diplopia include ptosis (unilateral: Oculomotor (III) nerve palsy; bilateral: myasthenia gravis), and head tilt or turn (e.g., turn to the right suggests a weak right lateral rectus muscle suggesting a right abducens (VI) nerve palsy; tilt to the left shoulder suggests a right trochlear (IV) nerve palsy, = Bielschowsky’s sign).
Manifest squints (heterotropia) are obvious but seldom a cause of diplopia if long-standing. Latent squints may be detected using the cover-uncover test, when the shift in fixation of the eyes indicates an imbalance in the visual axes; this may account for diplopia if the normal compensation breaks down. This produces diplopia in all directions of gaze (comitant). Patients may with an effort be able to fuse the two images. Transient diplopia (minutes to hours) suggests the possibility of myasthenia gravis. There are many causes of persistent diplopia, including the breakdown of a latent strabismus, development of oculomotor (III), trochlear (IV) or abducens (VI) nerve palsy (singly or in combination), orbital myopathy (thyroid), and mass lesions of the orbit (tumor, pseudotumor).
Divergence of the visual axes or ophthalmoplegia without diplopia suggests a long-standing problem, such as amblyopia or chronic progressive external ophthalmoplegia. Some eye movement disorders are striking for the lack of associated diplopia, e.g., internuclear ophthalmoplegia.
Danchaivijitr C, Kennard C. Diplopia and eye movement disorders. Journal of Neurology, Neurosurgery and Psychiatry 2004; 75(supplIV): iv24-iv31
Yee RD. Approach to the patient with diplopia. In: Biller J (ed.). Practical neurology (2nd edition). Philadelphia: Lippincott Williams & Wilkins, 2002: 147-161