Double vision in adults

To determine the patient characteristics, patterns in presentation and incidences of the various etiologies in adult patients with the chief complaint of double vision.

Retrospective review.

All persons greater than 18 years of age who presented to a single provider (DG) in a nonacademic private practice over a 2-year period, from 2011 to 2013, with the chief complaint of double vision. The provider is part of a multispecialty eye care group practice with both ophthalmologists and optometrists. This group practice provides a large adult referral base.

Examination for each patient included refraction, versions, alignment in different positions of gaze at distance and at near, binocular sensory testing, neuro-ophthalmologic examination, and dilated fundus examination if not recently documented. Alignment was measured with cover-uncover testing and alternate cover testing with prism bars or free prisms, using Snellen letters for fixation. Appropriate refractive correction was ensured. Alignment was measured in the primary position at distance and in gaze directed 20 degrees L, R, up, and down. The near deviation was measured in the reading position with the large letters on a near card for fixation. Sensory testing was performed with the Worth 4-dot at distance and near and with the Titmus stereopsis test. Vectograph testing was also performed at distance on many patients, particularly those with small-angle deviations. The prismatic correction necessary to correct diplopia subjectively at distance in the primary position and at near in the reading position was also recorded.

Ocular alignment and etiology of diplopia. Management, response to treatment, and outcome were also recorded.

A total of 125 patients were included in the analysis. Subjects ranged from 18 to 93 years of age. Most cases of idiopathic strabismus were in the elderly, but the age range varied with category of underlying strabismus. Small-angle HT was the most common type of strabismus, comprising 21% of all subjects. ET, usually of the divergence insufficiency type (20%); XT (14%); and palsies not including trochlear palsy (12%) and trochlear palsy (8%) were the next most common etiologies. No strabismus was found in 11% of subjects.

Most cases of diplopia in adults presenting as an outpatient can be classified into a few categories based on their type of strabismus. These categories of strabismus share typical age ranges and features. While diplopia in adults is usually idiopathic, diplopia can be the presenting sign of serious underlying pathology. Thus, a thorough history; examination; and, in some cases, diagnostic testing is necessary.