Double Vision (Diplopia) in Children: Diagnostic Evaluation Tool
Clinical History Assessment
Systematic approach to history taking for a child presenting with double vision (diplopia)
Physical Examination Guide
Systematic approach to examining a child with double vision (diplopia)
Diagnostic Approach
Initial Assessment
For a child presenting with double vision (diplopia), the initial assessment should include:
- Detailed history focusing on onset, duration, and pattern of diplopia
- Complete ocular and neurological examination
- Assessment of visual acuity and refractive error
- Evaluation for associated symptoms and red flags
Key Characteristics of Diplopia
Different characteristics help classify diplopia:
| Classification | Definition | Clinical Significance |
|---|---|---|
| Monocular vs. Binocular | Persists with one eye covered (monocular) or resolves with one eye covered (binocular) | Monocular suggests ocular pathology; binocular suggests neurologic or muscular etiology |
| Horizontal vs. Vertical | Images separated side-by-side or one above the other | Horizontal more common in lateral rectus or medial rectus dysfunction; vertical in superior/inferior rectus or oblique muscle dysfunction |
| Constant vs. Intermittent | Present all the time or only in certain conditions/positions | Intermittent may suggest decompensating phoria or myasthenic pattern |
| Comitant vs. Incomitant | Same separation in all gazes (comitant) or varying with direction (incomitant) | Comitant suggests longstanding strabismus; incomitant suggests recent neurologic, restrictive, or myopathic process |
Differential Diagnosis
| Category | Conditions | Key Features |
|---|---|---|
| Neuromuscular |
- Myasthenia gravis - Cranial nerve palsies (III, IV, VI) - Orbital myositis - Internuclear ophthalmoplegia |
- Worsening with fatigue (myasthenia) - Specific muscle restriction pattern - Associated ptosis or pupillary abnormalities (CN III) - Vertical diplopia in downgaze (IV) - Horizontal diplopia with abduction weakness (VI) |
| Central Nervous System |
- Brain tumor - Intracranial hemorrhage - Multiple sclerosis - Brainstem lesions - Increased intracranial pressure |
- Associated headache, vomiting - Papilledema - Other neurological deficits - Additional cranial nerve palsies - History of demyelinating disease |
| Ocular/Orbital |
- Strabismus - Orbital fracture - Orbital cellulitis/abscess - Orbital tumor - Orbital inflammatory disease |
- History of trauma - Orbital pain, swelling, erythema - Proptosis - Restrictive eye movements - May have lid or pupillary abnormalities |
| Refractive/Media |
- Uncorrected refractive error - Lens dislocation - Cataract - Corneal irregularities - Retinal disorders |
- Monocular diplopia - Persists with one eye covered - May have visual acuity changes - History of trauma or genetic disorders (lens dislocation) - Often relieved with pinhole |
| Systemic |
- Diabetes (rare in children) - Thyroid eye disease - Juvenile idiopathic arthritis - Inflammatory bowel disease - Autoimmune disorders |
- Systemic symptoms - Family history - Other organ involvement - Growth or developmental issues - Associated laboratory abnormalities |
Laboratory and Imaging Studies
Consider these studies based on clinical presentation:
| Investigation | Clinical Utility | When to Consider |
|---|---|---|
| MRI Brain/Orbits | Evaluate for intracranial lesions, demyelination, or orbital pathology | Acute onset, associated neurological symptoms, cranial nerve palsies, papilledema |
| CT Orbits/Sinuses | Evaluate for orbital fractures, sinusitis, or bony abnormalities | History of trauma, orbital symptoms, suspected sinusitis |
| Acetylcholine Receptor Antibodies | Diagnose myasthenia gravis | Fluctuating symptoms, fatigable weakness, ptosis |
| Thyroid Function Tests | Evaluate for thyroid eye disease | Proptosis, lid retraction, restrictive ophthalmopathy |
| Lumbar Puncture | Evaluate for infection, inflammatory conditions, or increased ICP | Suspected meningitis, encephalitis, demyelinating disease, or IIH |
Advanced Studies
Reserve for specific clinical scenarios:
| Investigation | Clinical Utility | When to Consider |
|---|---|---|
| Single-fiber EMG | Increased sensitivity for neuromuscular junction disorders | Suspected myasthenia with negative antibody testing |
| Tensilon Test | Diagnostic for myasthenia gravis | Suspected myasthenia, though less commonly used in children |
| MR Angiography/Venography | Evaluate vascular causes | Suspected vascular malformation, thrombosis, or aneurysm |
| Optical Coherence Tomography | Evaluate retinal and optic nerve disorders | Suspected optic neuropathy or retinal pathology |
| Autoimmune Panel | Evaluate for systemic autoimmune conditions | Multiple system involvement, family history of autoimmunity |
Diagnostic Algorithm
A stepwise approach to diagnosing double vision:
- Determine if monocular or binocular by covering each eye alternately
- Assess visual acuity in each eye separately
- Perform complete ocular examination including pupils, anterior segment, and fundus
- Evaluate ocular motility in all nine positions of gaze
- Test for comitancy by assessing degree of separation in different gazes
- Perform neurological examination with attention to cranial nerves
- Consider red flags for urgent neuroimaging (headache, papilledema, other neurological signs)
- Order targeted laboratory testing based on suspected etiology
Management Strategies
General Approach to Management
Key principles in managing pediatric diplopia:
- Urgent assessment: New-onset diplopia requires timely evaluation
- Identify and treat the underlying cause: Address primary etiology when possible
- Protect binocular vision: Prevent amblyopia development
- Alleviate symptoms: Provide short-term symptom relief when appropriate
- Monitor for progression: Regular follow-up to assess response and development
Immediate Management Options
| Intervention | Description | Appropriate Use |
|---|---|---|
| Patching |
- Occlusion of one eye - Eliminates diplopia immediately - Various methods (adhesive patch, frosted lens) |
- Short-term symptomatic relief - During driving or critical activities - Not for long-term use in children due to amblyopia risk |
| Prism Correction |
- Fresnel prisms (temporary) - Ground-in prisms (permanent) - Realigns images without surgery |
- Stable, small-moderate angle deviations - When underlying cause isn't immediately treatable - As bridge to surgery or definitive treatment |
| Refractive Correction |
- Corrective lenses - Addresses any underlying refractive error - May include prism component |
- Accommodative esotropia - Monocular diplopia from refractive errors - Decompensated phorias |
| Emergent Intervention |
- Neurosurgical consultation - High-dose steroids - Antimicrobial therapy |
- Space-occupying lesions with mass effect - Demyelinating conditions - Infectious causes (meningitis, orbital cellulitis) |
Management Based on Etiology
| Etiology | Management Approach | Follow-up & Prognosis |
|---|---|---|
| Strabismus |
- Optical correction - Prism therapy - Vision therapy/orthoptics - Strabismus surgery |
- Frequent follow-up during amblyopia risk period - Monitor fusional status - Assess for amblyopia development - Good prognosis with early intervention |
| Cranial Nerve Palsies |
- Treat underlying cause - Patching for symptomatic relief - Prism therapy for stable palsies - Surgery for persistent palsies (>6 months) |
- Monitor for spontaneous recovery (3-6 months) - Serial measurements of deviation - Variable prognosis based on cause - CN IV has highest rate of successful surgical correction |
| Myasthenia Gravis |
- Acetylcholinesterase inhibitors (pyridostigmine) - Immunosuppression (corticosteroids, azathioprine) - IVIG for crisis - Thymectomy in selected cases |
- Regular neurological follow-up - Monitor for respiratory compromise - Ocular symptoms may be refractory to treatment - Variable course, possible remission |
| Orbital Fracture |
- Observation for small fractures - Surgical repair for entrapped muscles or large defects - Antibiotics if indicated - Steroids to reduce swelling |
- Early follow-up (1 week) - Forced duction testing - Good prognosis with appropriate management - May have residual diplopia requiring prism or surgery |
| Intracranial Tumors |
- Neurosurgical consultation - Tumor resection/decompression - Radiation/chemotherapy if indicated - Symptomatic management of diplopia |
- Multidisciplinary follow-up - Serial neuroimaging - Monitor for recurrence - Prognosis varies by tumor type and location |
| Multiple Sclerosis/Demyelination |
- High-dose corticosteroids for acute attacks - Disease-modifying therapy - Symptomatic management of diplopia - Visual rehabilitation |
- Neurological and ophthalmological follow-up - Monitor for recurrent episodes - Visual recovery often good but may be incomplete - Risk of recurrence |
| Increased Intracranial Pressure |
- Treat underlying cause - CSF diversion procedures - Acetazolamide for IIH - Weight management if appropriate |
- Regular fundus examination - Visual field monitoring - Potential for resolution with ICP normalization - May need long-term management |
| Monocular Diplopia |
- Correct refractive error - Treat corneal irregularities - Cataract extraction if indicated - Pinhole correction for demonstration |
- Follow-up based on underlying cause - Excellent prognosis with appropriate correction - May require specialty contact lenses for irregular astigmatism |
Orthoptic and Surgical Interventions
| Intervention | Description | Indications & Considerations |
|---|---|---|
| Orthoptic Exercises |
- Fusional vergence exercises - Convergence training - Accommodative therapy - Eye tracking exercises |
- Convergence insufficiency - Decompensated phorias - Post-surgical diplopia - Requires good compliance and follow-through |
| Botulinum Toxin Injection |
- Temporary weakening of extraocular muscles - Effect lasts 3-4 months - May be diagnostic and therapeutic |
- Acute cranial nerve palsies - Diagnostic for restrictive strabismus - Alternative to surgery in some cases - Risk of ptosis and overcorrection |
| Strabismus Surgery |
- Recession/resection procedures - Transposition techniques - Adjustable sutures (older children) - Posterior fixation sutures |
- Stable deviations (>6 months) - Failed conservative management - Significant functional impairment - Timing important for binocular potential |
| Special Surgical Techniques |
- Superior oblique tuck (IV palsy) - Knapp procedure (VI palsy) - Harada-Ito procedure (torsional diplopia) - Jensen procedure (complete III palsy) |
- Specific patterns of muscle dysfunction - Complex or long-standing cases - May require oculoplastic surgical expertise - Often requires subspecialty evaluation |
Special Considerations in Children
- Developmental concerns: Critical period for binocular vision development
- Amblyopia risk: Prolonged patching or untreated strabismus can lead to amblyopia
- Diagnostic challenges: Young children may not report diplopia accurately
- Psychological impact: Body image concerns with visible strabismus
- Functional impairment: Impact on reading, sports, and academic performance
- Long-term monitoring: Need for extended follow-up through visual development
When to Refer
- Emergency referral: Acute onset with neurological symptoms, papilledema, or severe headache
- Ophthalmology referral: All cases of pediatric diplopia for complete assessment
- Pediatric neuro-ophthalmology: Complex cases, suspected neurological etiology
- Neurosurgery: Evidence of space-occupying lesion or increased intracranial pressure
- Pediatric neurology: Suspected myasthenia gravis, multiple sclerosis, or other neurological disorders
- Oculoplastics/orbital surgery: Orbital fractures, restrictive ophthalmopathy
Patient Education and Support
- Explanation of condition: Age-appropriate discussion of diplopia and its causes
- School accommodations: Proper seating, enlarged materials, additional time if needed
- Safety concerns: Guidance for activities with impaired depth perception
- Treatment compliance: Importance of following patching, glasses, or exercise regimens
- Psychological support: Addressing social concerns, especially with visible strabismus
- Support groups: Connection with other families managing similar conditions
