Double vision (diplopia)

Questionnaire/history: Does the double vision go away when closing either eye? - Monocular (persists after the other eye is covered)? - Binocular (goes away after one eye is covered)? How are the two images separated? - Vertically? - Horizontally? - Obliquely? - Torsionally? Is the double vision worse at distance or at near? Worsening of horizontal double vision - at distance (eg when driving) (lateral rectus or abducens nerve dysfunction)? - at near (eg when reading) (medial rectus dysfunction)? In which direction is the double vision worse? Associated symptoms? - Pain? - Headache? - Neurological symptoms? - Other? PMH? - Congenital strabismus? - Abnormal head position? - Thyroid disorder? DH: Drug allergies? Examination: Inspection? Ptosis? Anisocoria? Pupillary reflexes? Direct pupillary reflex? Consensual pupillary reflex? Swinging light test? Relative Afferent Pupillary Defect (RAPD)? Accommodation reflex? Monocular diplopia: Visual acuity? RE: /6 LE: /6 Confrontational visual field test? RE: LE: Schirmer test? Binocular diplopia: Saccades: None? Hypermetric? Hypometric? Dysmetric? Ductions (with covering one eye): RE: - Abudction? - Adduction? - Supraduction/elevation? - Infraduction/depression? LE: - Abudction? - Adduction? - Supraduction? - Infraduction? Versions: - Right gaze? - Left gaze? - Up gaze? - Down gaze? - Gaze up and right? - Gaze down and right? - Gaze up and left? - Gaze down and left? Vergences: - Convergence? - Divergence? Cover test: - Esotropia? - Exotropia? - Hypertropia? - Hypotropia? Cover-uncover test: - Esophoria? - Exophoria? - Hyperphoria? - Hypophoria? Fundoscopy: Papilledema? - Other abnormality? Neurological exam? - Hemiparesis? - Areflexia? - Delirium or amnesia? Management: According to cause Reference(s): Amercian Academy of Ophthalmology: Evaluation and Management Dinkin M: Diagnostic Approach to Diplopia. Continuum (Minneap Minn) 2014;20(4):942-965 EyeWiki: Basic Approach to Diplopia Geeky Medics: Examination of the Eyes and Vision – OSCE Guide Information for patients/carers: NHS Health A to Z: Double vision