Approach to Diplopia

Diplopia is a frequently encountered neurologic symptom that can lead to apprehension in patients and clinicians. Some causes of double vision are benign, whereas others can be vision-threatening or life-threatening. This article advocates for a systematic approach that includes a targeted history, specific examination techniques, an understanding of basic neuroanatomy, ancillary testing when appropriate, and familiarity with the most important and common causes of double vision and their management.

The past prevailing view was that patients older than 50 years with vascular risk factors with a suspected microvascular cranial nerve palsy did not require further evaluation. The frequency of other, sometimes serious, causes of cranial nerve palsies in this patient group justifies the use of neuroimaging, preferably with MRI, for those with an acute palsy of cranial nerve III, IV, or VI, including vascular imaging to exclude aneurysm in patients with a third nerve palsy.

A systematic, localization-based approach to evaluating patients with diplopia identifies serious causes, avoids wasting health care resources with unnecessary testing, and facilitates timely and appropriate treatment.