29th December 2023

Management

General advice

All patients should be advised to stop driving and report their visual symptoms to the DVLA, who may perform their own assessment or advise on criteria to be met prior to driving again. Suspected underlying pathologies should be appropriately investigated and managed, which is often driven by ophthalmology after routine or urgent referrals.

Monocular diplopia

Close examination and use of a pinhole will confirm monocular diplopia, the causes of which are often uncorrected refractive errors and cataracts. Routine referrals to optometry or ophthalmology are suggested for treatments such as glasses, contact lenses, cataract surgery and even simple measures like artificial tears.

Binocular diplopia

Acute management is aimed at relieving any debilitating symptoms due to the diplopia. The aim is to regain single binocular vision by unilateral occlusion of the poorer eye. In younger patients, there is a risk of developing amblyopia, and so the occlusion is alternated between each eye. Other options include using prisms to realign the visual axis in vertical or horizontal diplopia. When the binocular diplopia is long-standing or an underlying cause cannot be identified or managed, then surgery can be considered. Some cases are managed with botulinum injections into the antagonistic muscle to the paretic one, i.e. MR to LR in a 6ᵗʰ nerve palsy.