Diplopia refers to the perception of two images of a single object. Diplopia may be monocular or binocular. The monocular diplopia manifests itself when only one eye is open. The binocular diplopia disappears when one eye is closed. Etiology A monocular diplopia can occur if some light transmission distorted by the eye on the retina. There may be> 2 images. One of the images is of normal quality (such as brightness, contrast, sharpness.); the rest of the pictures are of inferior quality. The most common causes of monocular diplopia are cataract Korneaverformungen as keratoconus or surface irregularity not corrected refractive error, usually astigmatism Other causes include corneal scars and lens dislocation. The complaints can also be a simulation. Binocular diplopia speaks for dyskonjugierte eye movements. There are only two images, and these are of equal quality. There are many possible causes of binocular diplopia (s. Some causes of binocular diplopia). The most common are paralysis of a cranial nerve (III., IV. And VI.) Myasthenia gravis Orbital infiltration (z. B. Graves’ disease, orbital pseudotumor) Most eyes are misaligned because of a disease that affects those cranial nerves that innervate the extraocular eye muscles (III., IV., or VI. cranial nerve). This paralysis can be isolated and idiopathic or the result of various disorders involving the cranial nerve nuclei or one or more infranukleärer nerves. If pain is present, depends on the disease. Other causes include mechanical impairment in ocular movements (which often cause pain) or a generalized disorder of neuromuscular transmission. Some causes of binocular diplopia cause suspicious findings diagnostic approach diseases that affect the cranial nerves to extraocular muscles (The presence of pain varies depending on the cause cerebrovascular disease that affects the pons or the midbrain Elderly, risk factors (eg. As hypertension, arteriosclerosis, diabetes) Sometimes internuclear ophthalmoplegia or other deficiencies No pain MRI Compressing Lesion (eg. B. aneurysm, tumor) (suddenly Often pain when by aneurysm) and other neurological deficits Immediate imaging (CT, MRI) Idiopathic (usually caused microvascular) If isolated on (no other manifestations) Ophthalmic referral for review of other shortcomings In isolated diplopia observation whether spontaneous regression occurs imaging (MRI, CT), if no regression after several weeks Inflammatory or infectious lesions (z. B. sinusitis, abscess, cavernous sinus thrombosis) Persistent pain sometimes fever or systemic Beschwe lems, sensory changes in the face, exophthalmos CT or MRI pseudo encephalitis Wernicke a history of alcohol abuse, ataxia, confusion Clinical diagnosis Mechanical disorders in ocular movements (often associated with pain) Graves’ disease (infiltrative ophthalmopathy, usually with hyperthyroidism associated) Local symptoms: eye pain, proptosis, watery eyes, dry eyes, irritation, photophobia, diplopia due to ocular muscle weakness, vision loss by optic nerve Systemic Sym toms: palpitations, anxiety, increased appetite, weight loss, insomnia, goiter, pretibial myxedema sometimes go ocular abnormalities of a malfunction of the thyroid gland requires tests of thyroid function orbital myositis constant eye pain, worsened by eye movement, exophthalmos, sometimes injections MRI trauma (eg. B. fracture, hematoma) signs of an external trauma; be determined by medical history computed tomography or MRI tumors (near the base of the skull, in or near the sinuses or orbit) Often, pain (regardless of eye movement), unilateral exophthalmos, sometimes other neurological manifestations is computed tomography or MRI disorders of neuromuscular transmission (typically no pain before) botulism sometimes gastrointestinal symptoms go ahead Descending weakness, dysfunction of other cranial nerves, dilated pupils, normal sensations serum and stool studies on toxin Guillain-Barre syndrome, Miller Fisher variant ataxia, loss of reflexes lumbar puncture multiple sclerosis Intermittent, wandering neurological symptoms, including paresthesias or weakening of the extremities, blurred vision, voiding dysfunction Sometimes internuclear ophthalmoplegia MRI of the brain and spinal cord myasthenia gravis intermittent diplopia , often with ptosis, Bulbärsymptomen, weakness that worsens with repeated use of the muscle Edrophoniumtest assessment history The history should shed light on whether the diplopia relates to an eye or both eyes whether the diplopia is intermittent or constant, and whether the images exceed vertically or horizontally or side by side, or both. Any pain associated should be noted and whether it occurs with or without eye movements. The review of organ systems should look for symptoms of other cranial nerve dysfunction such. As visual disturbances (II cranial nerve.); Numbness of the forehead and cheeks (fifth cranial nerve); Facial weakness (VII. Cranial nerve), dizziness, hearing loss or transitional difficulties (VIII. Cranial nerve), and swallowing or speech difficulties (IX. And XII. Cranial nerve). Other neurological symptoms such as weakness and sensory abnormalities should be considered, and it must be stated whether they are intermittent or constant. Non euro Logical symptoms of potential causes are determined. These include nausea, vomiting and diarrhea (botulism); Palpitations, heat sensitivity, and weight loss (Graves disease), difficulties with bladder control (multiple sclerosis). The history should clarify whether hypertension, diabetes or both is known; whether atherosclerosis, specifically including cerebrovascular disease, and alcohol abuse vorliegt.Körperliche investigation The investigation begins with an assessment of vital signs with regard to fever and general appearance of the signs of toxicity (eg. as fatigue, confusion). The eye examination starts with the determination of the initial eye position, followed by measurement of visual acuity (with correction) in each eye, and the two together, which also aids in determining whether the diplopia is monocular or binocular. In the eye examination should be taken, if one eye bulges / both eyes bulge whether an eyelid hangs whether pupils anomalies exist and whether dyskonjugierte eye movements and nystagmus during ocular Motilitätsprüfung occur. A ophthalmoscopy should be performed, wherein in particular any anomalies of the lens (z. B. cataract, displacement) and the retina (z. B. peel) should be recorded. In studying the eye movements of the patient should keep the head still and follow with the eyes the finger of the examiner, which is moved to the extreme viewing positions to the right, left, up, down and diagonally on both sides and finally to the inside on the nose of the patient (Kovergenz). Nevertheless, a slight paralysis of ocular motility sufficient to generate a diplopia, be overlooked in this investigation. If a diplopia on in a particular line of sight, it can be established that the eye produces the double image when the investigation is repeated with a red glass in front of a patient’s eye. The image produced more peripheral lying in the hemiplegic eye; d. H. if the picture more peripheral lying is red, there is the red glass in front of the paretic eye. If a red glass is not available, the hemiplegic eye can sometimes be detected by the patient closes each eye individually. The paretic eye is the eye, which eliminates the more peripheral image when closed. The other cranial nerves are tested and the rest of the neurological examination, including the examination of the starch, of sensation, reflexes, the cerebellum and the observation function of the passage is completed. Relevant nichtneurophthalmologische components of the study include the scanning of the neck for a goitre and a check on the shins with respect to a pretibial myxedema (Graves’ disease) ein.Warnzeichen The following findings are of particular importance: More than a cranial nerve deficit pupil inclusion of any degree Any neurological symptoms or complaints next diplopia pain proptosis interpretation of results the findings sometimes close which cranial nerve is involved. III .: Drooping eyelid, lateral and downward gaze deviation, sometimes dilated pupils IV .: Vertical diplopia worse when the patient looks down (the patient tilts the head in order to improve vision) VI .: medial gaze deviation, diplopia worsens when the patient looks laterally (patient turns his head to improve vision) Other findings help to find a cause (s. Some causes of binocular diplopia). An intermittent diplopia indicates a fluctuating neurological disorder such as Myasthenia gravis or multiple sclerosis or unmasks a latent Phorie (gaze deviation). Patients with latent phoria have no other neurological manifestations. Internuclear ophthalmoplegia (INO) is caused by a brainstem lesion in the medial longitudinal fasciculus (MLF). INO manifests itself in horizontal viewing investigation diplopia, weak adduction on the affected side (usually not over the center line adduct the eye) and nystagmus of the contralateral eye. However, the affected eye adducted normal for a convergence test (which does not require intact MLF). Pain indicates a compressive lesion or inflammatory disease hin.Tests patients with monocular diplopia be referred to an ophthalmologist for evaluation of ocular pathology; advance no further testing is required. In binocular diplopia patients can be observed mostly without trial for a few weeks with a unilateral, simple cranial nerve palsy, a normal pupillary light response and no other symptoms or complaints. Many cases recover spontaneously. An ophthalmologic assessment can be made to monitor the patient and further delineate the deficit. Most other patients require imaging with MRI to determine orbital or cranial anomalies or abnormalities of the central nervous system. A computed tomography is indicated if there is concern about a metallic intraocular foreign body or if an MRI otherwise contraindicated or unavailable. An imaging should be performed immediately when the findings (h <3) suggest an infection, an aneurysm or an acute stroke. Patients with manifestations of Graves' disease thyroid tests should pass through (serum thyroxine [T4] and Level thyroid-stimulating hormone [TSH]). Tests for myasthenia gravis and multiple sclerosis should be considered especially for patients with intermittent diplopia into consideration. Treatment Treatment consists of treating the underlying disorder. Summary An isolated, not the pupils concerned palsy in patients with no other symptoms may regress spontaneously. Imaging is required in patients with serious findings. Focal weakness (in each muscle) may indicate a disorder of neuromuscular transmission.