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Intermittent diplopia: a practical guide
Wilco Perini1,2, Veron Verhorst2, Anne van den Berg2
1Neurology, Amsterdam UMC, Amsterdam, The Netherlands w.perini@amsterdamumc.nl.
Practical Neurology
|April 30, 2026
Summary
Intermittent binocular diplopia requires a structured approach for accurate diagnosis. This method helps differentiate causes, from simple decompensation to serious conditions, ensuring timely and appropriate patient care.
Area of Science:
- Ophthalmology
- Neurology
Background:
- Intermittent binocular diplopia presents diagnostic challenges due to symptom variability.
- Potential causes range from benign to severe pathologies.
Purpose of the Study:
- To present a practical, four-step method for evaluating intermittent binocular diplopia.
- To guide clinicians in differentiating causes and avoiding unnecessary investigations.
Main Methods:
- Confirming binocular diplopia.
- Assessing monocular ductions for deficits.
- Determining strabismus comitance.
- Evaluating fatigability for ocular myasthenia.
Main Results:
- The outlined method facilitates efficient assessment of intermittent diplopia.
- Identifies specific clinical scenarios requiring targeted investigations (e.g., giant cell arteritis, malignancy).
- Distinguishes between fusional, neurological, and orbital causes.
Conclusions:
- This systematic approach aids in avoiding missed diagnoses of serious pathology.
- Provides guidance on appropriate referral pathways (orthoptic, ophthalmic, or neurological).
- Recognizes specific neurological entities like ocular neuromyotonia and superior oblique myokymia.
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