Monocular Diplopia

  • Double vision that persists when one eye is closed
  • Related to intrinsic eye problem[1]

Binocular Diplopia

  • Double vision that resolves when the other eye is closed
  • Related to a problem with visual axis alignment[2]

3 Main Causes Binocular Diplopia

  • Eye musculature dysfunction
  • Cranial nerve dysfunction
  • Brainstem or intracranial process

Clinical Features


  • Determine monocular vs binocular
  • Evaluate for visual field defects
  • Evaluate visual acuity
  • Assess cranial nerves
    • Multiple cranial nerve involvement suggests an intracranial process or cavernous sinus involvement
  • Check extraocular muscle function
    • Entrapment will show extraocular muscle restriction with extremes of gaze
  • Sudden painful or non painful onset suggest a vascular cause such as thrombosis, dissection, ischemia, or vasculitis
  • Other neuro deficits should raise suspicion for a CVA or MS
  • Systemic illness is more likely with meningitis involving the brainstem
  • Bilateral symptoms are more likely with neuromuscular problems such as Miller Fischer syndrome, botulism, or myasthenia gravis

Differential Diagnosis

Monocular Diplopia

Binocular Diplopia



  • Slit Lamp Exam
    • Assess for Cataract
    • Lens symmetry
    • Posterior orbital mass
    • Macular dysruption
  • Consider ophthalmology consult
  • Consider ocular ultrasound


  • Third nerve palsy: eye is down and out
    • Always needs CTH/CTA to rule out [[Posterior Communicating Artery (PCOM) Aneurysm|aneurysm given that nerve runs under PCA
  • Fourth nerve palsy: head tilt down and away from side of lesion
    • These are tough to catch and can be referred to ophtho outpatient for prisms
    • No imaging needed unless other deficits present
  • Sixth nerve palsy: eye can't track laterally
    • Children need imaging to r/o tumor
    • In > 50, m/l ischemic and can get MRI outpt or just watch, assuming no papilledema as it can cause isolated CN VI palsy
    • If other nerves/deficits noted, consider MRI and further wu
  • Other potential studies also include:
    • CTH with and without contrast ± CTA neck to rule out dissection and intracranial mass
    • MRV or CTV to eval for cavernous sinus thrombosis
    • CT orbits w/ contrast to eval for orbital apex syndrome (like CST above, but with CN II involvement)
    • MRI + DWI to if concern for CVA
    • MRI ± MRA if unable to classify intracranial process on initial contrast CT with contrast
    • MRI if concerned for MS
    • LP if concern for meningitis
    • Metabolic workup to rule out diabetes or cause of mononeuropathy


  • Treat underlying cause
  • Neurology or neurosurgical consult is warranted if evidence of an ICH, aneurysm or CVA


  • Depends greatly on the cause of the diplopia
  • Admit if:
  • Isolated Cranial Nerve III and VI palsy can be discharge if close neurology follow-up and cause due to diabetes, microvascular ischemia and intracranial process ruled out[5]

See Also

  • Third Nerve Palsy


  1. Coffeen P, Guyton DL: Monocular diplopia accompanying ordinary refractive errors. Am J Ophthalmol 1988; 105:451
  2. Rucker JC, Tomsak RL: Binocular diplopia. A practical approach. Neurologist 2005; 11:98-110
  3. Kusner LL, Puwanant A, Kaminski HJ: Ocular myasthenia: Diagnosis, treatment, and pathogenesis. Neurologist 2006; 12:231-239
  4. Bushra JS: Miller Fisher syndrome: An uncommon acute neuropathy. J Emerg Med 2000; 18:427-430
  5. Sanders SK, Kawasaki A, Purvin VA: Long-term prognosis in patients with vasculopathic sixth nerve palsy. Am J Ophthalmol 2002; 134:81-84
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