Overview of diplopia
- Don C Bienfang, MD
Don C Bienfang, MD
- Associate Professor of Neurology and Ophthalmology
- Harvard Medical School
Dysfunction of the extraocular muscles may be the result of an abnormality of the muscle itself or an abnormality of the motor nerve to the muscle. The major symptom associated with this dysfunction is diplopia. The evaluation of neuromuscular diplopia is reviewed here.
Three pairs of extraocular muscles move each eye in three directions: vertically (superior and inferior), horizontally (medial and lateral), and torsionally (intorsion when the eye rotates toward the patient's nose and extorsion when the eye rotates toward the patient's shoulder). The following muscles are responsible for these movements (table 1 and figure 1 and figure 2):
- The superior rectus and inferior oblique muscles are responsible for upward vertical movements. The superior rectus acts in all fields of gaze and the inferior oblique on medial gaze.
- The inferior rectus and superior oblique muscles are responsible for downward vertical movement. The inferior rectus acts in all fields of gaze, and the superior oblique on medial gaze.
- The lateral rectus is responsible for abduction.
- The medial rectus is responsible for adduction.
- The superior oblique is responsible for intorsion.
- The inferior oblique is responsible for extorsion.
The superior oblique muscle is innervated by cranial nerve IV, the lateral rectus muscle by cranial nerve VI, and all others by cranial nerve III (table 1).
Details of the neurologic examination with regard to eye movements are discussed separately. (See "The detailed neurologic examination in adults".)
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- Tempo of the problem
- Other cranial nerves
- Ocular motility
- - Restrictive ophthalmoplegia
- - Quantitation
- Vertical diplopia
- Horizontal diplopia
- Fourth cranial nerve palsy
- - Congenital
- - Traumatic
- - Idiopathic
- - Other
- Third cranial nerve palsy
- Sixth nerve palsy
- Internuclear ophthalmoplegia
- Myasthenia gravis
- Thyroid ophthalmopathy
- Ophthalmoplegic migraine
- Wernicke's syndrome
- Orbital myositis
- Tolosa-Hunt syndrome
- DIAGNOSTIC APPROACH
- SUMMARY AND RECOMMENDATIONS