Diplopia – Double Vision
Diplopia, also known as double vision, occurs in one of two ways. The double
vision is either present with one eye open (monocular diplopia) or only with
both eyes open (binocular diplopia). Monocular diplopia is almost always
attributable to the focusing elements of the eye. Binocular diplopia occurs
when there is misalignment of the eyes. Examples of binocular diplopia include
esotropia (crossing of the eyes) or exotropia (one eye “wanders” away
to the side).
Symptoms of diplopia include seeing a single object as two images.
The two images may appear to be seen horizontally, vertically or
Treatment for diplopia depends on the underlying cause. Options
include glasses with prism lenses, vision therapy, Botox therapy,
Anisocoria – Unequal Pupils
Unequal pupil sizes, called anisocoria, is a common vision condition. While
it is normal for pupils to be slightly different size, large or new anisocria
should be evaluated. Unequal pupil size can be related to a completely benign
condition or a life-threatening illness.
Medications, either eye drops or oral, are a common cause of a harmless change
in pupil size. More serious causes of unequal pupil size may be due to aneurysm,
bleeding inside the skull, brain tumor, excess pressure on an eye due to glaucoma,
meningitis, encephalitis, migraines, or seizures.
It is important to see a doctor when there is a persistent, sudden
or unexplained change in the size of pupils. It is also important
to seek immediate medical attention for a head or eye injury.Also
seek medical attention if pupil sizes differ and are paired with
blurry vision, double vision, sensitivity to light, a fever, headache,
loss of vision, nausea, vomiting, a stiff neck and severe eye pain.
To make a proper diagnosis, a doctor may run blood tests, cerebrospinal
fluid tests, CT scans, EEGs, MRI, tonometry to screen for glaucoma
and X-rays of the neck and skull. Recommendations vary from simple
observation to medical or surgical treatment depending on the underlying
cause of the condition.
Many neurological disorders present with visual symptoms. However, these symptoms
are often difficult to describe. Any visual disturbances associated with
other neurologic symptoms such as numbness, weakness, loss of coordination,
difficulty speaking or swallowing, trouble walking, or loss of bowel or bladder
control should be assessed by a Neuro-ophthalmologist.
Visual disturbances are often associated with neurological disorders
such as double vision, nystagmus, reduced visual field and acuity,
a full or total loss of vision due to papilledema or a swollen
optic disc. Visual disturbances can be symptoms of other conditions,
including neurological disorders, muscular disorders, vascular
disease, cancers or trauma. Patients with diabetes or hyperthyroidism
may experience visual disturbances. In some cases, patients with
hereditary congenital conditions also may have visual disturbances.
Migraine syndromes often include a number of visual symptoms. The most common
of these are visual auras. Visual Auras are a wide range of visual phenomenon
including flashes of light, spots, moving colors, or kaleidoscopic patterns.
Other symptoms include sensitivity to light, sensation of being overwhelmed
by complex patterns, or eye pain. Hormonal changes, medications, chemicals
in foods and even flashing lights can cause migraines. The migraine episode
may only last a few minutes, but typically lasts about 20 to 30 minutes.
Usually an ocular migraine does not require treatment and does not cause
permanent brain or visual damage. However, it is recommended that you stay
still during the migraine episode for safety reasons. If there are lingering
visual symptoms, the migraines occur regularly or are increasing in frequency,
see a doctor. Medications may be prescribed to help control the frequency
or severity of these migraines.
Eyelid and Facial spasm
Eyelid spasms are small muscle spasms that may occur in the upper or lower
eyelid. Typically, these twitches are harmless spasms in the muscles around
the eye. They can be felt by the patient and sometimes seen by others. Although
the spasms can be disturbing, they typically last no more than a few hours
and are sporadic in nature.
However, in some more serious cases, the spasms can last for several
weeks. A patient who is experiencing deep spasms in the face or
eyelid should contact a doctor immediately.
Some causes of an eyelid spasm can include the following:
- Eye strain from computer use, reading in improper light or
from handwork like sewing
- Squinting due to being in the sun or reading
- Drinking too much caffeine
- Short-term stress, nervousness or anxiety
Additional types of spasms include:
This is an extreme form of eyelid spasm. Blepharospasm affects both the upper
and lower eyelids, on both sides, and may include the eyebrows. The eyes
close involuntarily and may difficult to reopen. This may be particularly
dangerous while driving.
This is another extreme form of eyelid spasm. In this condition one side of
face will spasm including the eyelids as well as the cheek and lower face.
Treatments: Most minor eyelid spasms do not require special treatment.
In some cases removing the stressor will help with the spasms.
Some doctors recommend reducing the amount of caffeine and/or artificial
sweeteners being consumed.
Patients with blepharospasm and hemifacial spasm may require more
involved treatment, including medications, botulinum injections
(commonly known as Botox) or even surgery.
Myasthenia gravis is a neuromuscular disorder causing weakness of voluntary
muscles, particularly those which control eye movement and eye opening. Ocular
symptoms often include double vision and eyelid drooping. Muscle function
often improves with rest. While visual symptoms are very common, other muscles
throughout the body may be affected causing symptoms of fatigue, weakness,
facial paralysis, and even difficulty with breathing or swallowing.
Treatments: There is no a cure for the condition but treatments
often include medications and various visual aids.
Eye Movement Disorders – Cranial Nerve Palsies
Eye movement disorders are frequently the result of paralysis of a cranial
nerve. Three cranial nerves (on each side) are responsible for controlling
eye movements. They include third (oculomotor) nerve palsy, forth (trochlear)
nerve palsy and sixth (abducens) nerve palsy.
Third Cranial Nerve (Oculomotor Nerve) Palsy
Third cranial nerve palsy, also known as oculomotor nerve palsy, can result
from head injuries, aneurysms, hemorrhages, tumors, or diabetes.
The symptoms include one eye turning outward while the other is
oriented normally, causing double vision. The affected eye is unable
to move past the middle when looking inward and is unable to move
up and down. There also maybe problems with eyelid drooping and
and dilation of the pupil on the affected side. In some cases the
condition causing the palsy may worsen, for example, when a sudden,
severe headache occurs due to a ruptured aneurysm.
Treatment will be determined after a neurological exam and testing.
Emergency treatment may be required if a life-threatening condition
is causing the palsy.
Fourth Cranial Nerve (Trochlear Nerve) Palsy
The cause of a fourth cranial nerve palsy, or a trochlear nerve palsy, is not
always easy to identify. The majority of cases are due to head trauma and
stroke; however there are many other causes. Urgent evaluation should be
obtained for any patient experience new double vision.
The most common symptom is vertical double vision. The two images
will appear to be misaligned up and down. Often people will experience
some horizontal displacement as well resulting two images diagonal
from one another.
Treatment for this type of palsy may include patching, prisms,
or even surgery if necessary.
Sixth Cranial Nerve (Abducens Nerve) Palsy
Sixth cranial nerve palsy, also referred to at Abducens nerve palsy, can be
caused by a head injury, brain tumors, infections, aneurysms, or multiple
sclerosis. Depending on the condition, there may be increased pressure on
the affected nerve or a decrease in blood flow to the nerve.
Symptoms include horizontal double vision where the two images
are side by side. The affected eye is unable to move fully outward
and may also move inward when the patient is trying to look straight
ahead. Additional symptoms may occur depending on the underlying
condition however headaches are quite common.
Treatment of sixth nerve palsy depends on the cause. Once the
underlying cause is determined the palsy typically resolves itself.
Optic Neuritis is an inflammatory condition of the optic nerve which leads
to sudden vision loss and often pain with eye movement on the affected side.
The vast majority of cases are idiopathic (meaning medical science has yet
to find the cause). In a small minority of patients optic neuritis might
be the first symptom of Multiple Sclerosis (MS). The vision loss in optic
neuritis returns to normal, or near normal, in most cases without any medical
intervention. However, some medications can be used to hasten the recovery
Optic neuropathy is defined as damage to the optic nerve often due to ischemia,
toxins, vascular or blood pressure issues, or pressure within the eye.The
most common cause of optic neuropathy is anterior ischemic optic neuropathy.
Anterior ischemic optic neuropathy is caused by blood flow interruption to
the optic nerve as it enters the back of the eye.
Symptoms include a severe loss of vision either suddenly or over
many days, or visual field deficiencies. At the time of vision
loss there will be swelling inside the eye which can be detected
by an eye care professional. The condition often occurs in the
middle-aged or elderly.
There are numerous causes of optic nerve damage. When visual symptoms
are attributed to damage of the optic nerve a search begins to
find the cause. Usually damage to the optic nerve is irreversible.
It is important find out what damaged the optic nerve so that the
other eye doesn’t become involved as well.
Temporal arteritis occurs when blood vessels on the scalp and in the head become
inflamed and damaged. If the blood vessels going to the eye are affected
then vision loss can result.
Symptoms of temporal arteritis include fever, excessive perspiration,
feeling ill, intermittent jaw pain, achy muscles, headaches on
the side or back of the head, a sensitive scalp, reduced, blurred
or double vision.
Treatment of temporal arteritis focuses on reducing the amount
of tissue damage that has occurred due to restricted or lack of
blood flow. Medication may be recommended to reduce inflammation
or suppress the immune system.
Brain Tumors Causing Vision Loss
Brain tumors can cause vision loss through inflammation or pressure on areas
of the brain that control vision. Not all brain tumors are malignant (cancerous),
in fact most are not. Unfortunately, that doesn’t mean that they can’t
cause problems by just being there and placing pressure on the brain.
There are several symptoms associated with brain tumors depending
on the areas of the brain affected by the tumor. Visual symptoms
can often be the first sign of a brain tumor. Sudden vision problems
including blurry vision, double vision or a loss of side or peripheral
vision often occur. New or suddenly different headaches may often
occur.Treatment of brain tumors depends on the type of tumor and
the age of the patient. Options may include surgery, drug therapies,
radiation therapy, chemotherapy, or any combination of these treatments.
A multidisciplinary approach is critical to the successful management
of brain tumors. A team of neuro-oncologists, neurosurgeons, radiation
oncologists, and neuro-ophthalmologists need to work together on
these complicated cases.
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