Approach to Double Vision (Diplopia)

Key Points 

  • Must ask if double vision goes away when covering one eye. If it does, then higher concern for ocular misalignment issue (= true binocular diplopia) 
  • Acute and constant diplopia requires more urgent evaluation than if intermittent 
  • Examine pupils and extraocular movements 
  • Classic complete CN3 palsy: dilated pupil, abducted and infraducted (“down and out” ) eye, ptosis. Requires immediate neuroimaging (e.g. CTA head) to rule out a compressive pathology like aneurysm 
  • “Pupil-sparing” CN3 lesion: the above with a normal pupillary reaction to light. Concerning for ischemic lesion rather than compression
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