JKOS Journal of the Korean Ophthalmological Society J Korean Ophthalmol Soc 0378-6471 2092-9374 Korean Ophthalmological Society 10.3341/jkos.2013.54.11.1772 jkos-54-1772 Original Article Clinical Features for Patients Presenting with Diplopia KimMin Seok MD ChoiJin MD KimJung Hoon MD KimJae Suk MD, PhD LeeJoo Hwa MD, PhD Department of Ophthalmology, Inje University Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea Address reprint requests to Jin Choi, MD, Department of Ophthalmology, Inje University Sanggye Paik Hospital, #1342 Dongil-ro, Nowon-gu, Seoul 139-707, Korea, Tel: 82-2-950-1096, Fax: 82-2-935-6904, E-mail: jinchoi@paik.ac.kr 09 2013 02 09 2013 54 11 1772 1777 26 01 2013 10 06 2013 09 09 2013 Copyright © 2013 Korean Ophthalmological Society 2013 This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Abstract Purpose

To evaluate the clinical features, causes and outcomes of patients with diplopia.

 Methods

All patients presenting with diplopia from October 2010 to March 2012 and followed up for more than 3 months were retrospectively investigated.

 Results

During the study period, 59 patients with diplopia were identified. There were 42 males and 17 females with an average age of 50 years. Binocular diplopia accounted for 54 cases (92%) and 5 cases (8%) had monocular diplopia. Cranial nerve palsies were the most common cause of binocular diplopia (28 cases, 52%). Within the cranial nerve palsies group, 14 cases (50%) were accompanied by hypertension or diabetes mellitus. Binocular diplopia spontaneously resolved in 35 cases (65%) by 3 months rising to 41 cases (76%) by 7 months. Thirteen (93%) out of 14 cases of cranial nerve palsies with hypertension or diabetes resolved spontaneously by 3 months.

 Conclusions

Binocular diplopia was caused most commonly by cranial nerve palsy and resolved after 3 months in 65% of patients. A spontaneous recovery from diplopia was observed after 3 months in 93% of patients with cranial nerve palsies and microvascular disease such as hypertension or diabetes. Therefore, the initial observation without additional treatment would be sufficient in these patients.

 Cranial nerve palsy Diplopia Microvascular disease Prognosis References MorrisRJDouble vision as a presenting symptom in an oph- thalmic casualty departmentEye (Lond)199151249 RuckerJCTomsakRLBinocular diplopia. A practical approachNeurologist20051198110 NolanJDiplopiaBr J Ophthalmol19685216671 KangHJHaMSA clinical feature of the patients of orbital wall fracture with diplopiaJ Korean Ophthalmol Soc20095096975 RushJACauses and prognosis in 4,278 cases of paralysis of the oculomotor, trochlear, and abducens cranial nervesAm J Ophthalmol19921147778 HolmesJMMutyalaSMausTLPediatric third, fourth, and sixth nerve palsies: a population-based studyAm J Ophthalmol199912738892 TrimbleRDiplopia as a presenting sign of neoplasiaTrans Ophthalmol Soc U K1980100498500 ComerRMDawsonEPlantGCauses and outcomes for pa- tients presenting with diplopia to an eye casualty departmentEye (Lond)2007214138 LeporeFEYarianDLMonocular diplopia of retinal originJ Clin Neuroophthalmol198661813 RushJAYoungeBRParalysis of cranial nerves III, IV, and VI. Cause and prognosis in 1,000 casesArch Ophthalmol198199769 JacobsonDMMcCannaTDLaydePMRisk factors for ischemic ocular motor nerve palsiesArch Ophthalmol19941129616 PatelSVHolmesJMHodgeDOBurkeJPDiabetes and hyper- tension in isolated sixth nerve palsy: a population-based studyOphthalmology20051127603 PrasadSVolpeNJParalytic strabismus: third, fourth, and sixth nerve palsyNeurol Clin20102880333 StraussbergRCohenAHAmirJVarsanoIBenign abducens pal- sy associated with EBV infectionJ Pediatr Ophthalmol Strabismus19933060 ShinHParkSEA clinical study of acquired paralytic strabismus in a secondary hospitalJ Korean Ophthalmol Soc2007483114 ParkUCKimSJHwangJMYuYSClinical features and natural history of acquired third, fourth, and sixth cranial nerve palsyEye (Lond)2008226916 KimHSLeeJBHanSHNontraumatic aquired paralytic strabismusJ Korean Ophthalmol Soc199435112731 KimSSJinKHKimSMNeuro-ophthalmologic evaluation of the third, fourth and sixth cranial nerve paralysisJ Korean Ophthalmol Soc1991322838 LeeWYKimJHShinHA clinical study of paralytic strabismusJ Korean Ophthalmol Soc19933454954 CackettPWeirCHoustonCATransient monocular diplopia re- sulting from the treatment of amblyopiaJ Pediatr Ophthalmol Strabismus2003402456 Figures and Tables

The Kaplan-Meier survival curve for recovery of diplopia. The difference between two groups was statistically insignificant (p = 0.291, log rank test). Cumulative recovery rate in the microvascular group was 93% at 12 weeks; that in the non-microvascular group was 64% at 12 weeks and 79% at 20 weeks from the development of diplopia.

Characteristics of the patients

Number of patients (%)
Age (years)
 10-30 14 (24)
 30-50 15 (25)
 50-70 19 (32)
 70-90 11 (19)
Sex
 Male 42 (71)
 Female 17 (29)
Diplopia
 Monocular 5 (8)
 Binocular 54 (92)
Total 59 (100)

Causes of monocular diplopia

Cause Number of patients
Astigmatism 3
Trauma 1
Migraine 1
Total 5

Causes of binocular diplopia

Cause Number of patients
Cranial nerve palsies
 III nerve palsy 2
 IV nerve palsy 12
 VI nerve palsy 14
Convergence/Accommodation problems
 Convergence insufficiency 2
 Accommodative spasm 1
Trauma
 Soft tissue 3
 Orbital floor fracture 1
 Previous blow out fracture surgery 1
Muscle/neuromuscular junction
 Thyroid 6
 Ocular myasthenia gravis 1
 Previous strabismus surgery 1
Decompensating phoria
 Exophoria 2
 Hyperphoria 2
Others
 Previous cataract surgery 2
 Idiopathic intracranial hypertension 1
 Amblyopia 1
Unknown 2
Total 54

Causes of cranial nerve palsies

Cause Number of patients
III IV VI
Microvascular cause
 Hypertension — 5 7
 Diabetes — 3 4
Trauma — 4 —
Infection — — 2
Brain infarction 1 — 1
Internuclear ophthalmoplegia 1 — —
Brainstem tumor — — 1
Unknown — 2 2

Five patients had coexistent hypertension and diabetes.

Age-stratified causes of binocular diplopia

Cause Age
10-30 30-50 50-70 70-90
Microvascular disease — 1 6 7
Trauma 4 — 5 —
Thyroid disease 1 — 3 2
Upper respiratory infection — 2 — —
Myasthenia gravis — 1 — —
Other neurological 2 2 1 —
Decompensation phoria 1 2 1 —
Previous strabismus surgery — 1 — —
Amblyopia — 1 — —
Convergence insufficiency 1 1 — —
Accommotive spasm 1 — — —
Previous cataract surgery — — — 2
Unknown 2 1 3 —