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The Problem
“I see two of things.”
Common Causes
Physiological diplopia
Breakdown of phoria
Cranial nerve palsy
Third nerve palsy
Fourth nerve palsy
Sixth nerve palsy
Other Causes
Decompensated childhood strabismus
Duane syndrome
Myasthenia gravis (discussed in ptosis chapter)
KEY FINDINGS
History
Physiological diplopia
Usually noticed about ages 5 to 6 years
Most common in bright, observant children
Not bothered by symptoms
Breakdown of phoria
Often no known history of strabismus
Develop strabismus and diplopia during severe illness
Resolves after recovery of illness
Cranial nerve palsies
Third nerve palsy
Horizontal and vertical diplopia
Ptosis
Unequal pupils (anisocoria)
Fourth nerve palsy
Usually gradually worsening vertical diplopia
Head tilt
Sixth nerve palsy
Horizontal diplopia
Recent viral illness
Idiopathic intracranial hypertension
Headache
Brief episodes of vision loss (transient visual obscurations)
Recent medication change
Corticosteroids, isotretinoic acid, others
Examination
Physiological diplopia
Normal ophthalmic examination
Normal physical examination
Breakdown of phoria
Variable esotropia or exotropia
No limitation of extraocular movements
Cranial nerve palsies
Fourth nerve palsy
Usually head tilt
Eyes straight when head tilted to unaffected side
Vertical misalignment when tilted to affected side
Sixth nerve palsy
Esotropia
Inability to move affected eye outward
Idiopathic intracranial hypertension
Obesity
Papilledema
Third nerve palsy
Eye out and down
Ptosis on affected side
Anisocoria (affected pupil larger in acquired third nerve palsy)
Possible other neurological signs
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Most children with strabismus do not experience diplopia. This symptom warrants referral to an ophthalmologist. If the examination suggests a cranial nerve palsy, or if other neurological symptoms are present, the child should be seen promptly.

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What Shouldn’t Be Missed

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Acute cranial nerve palsies may be due to idiopathic intracranial hypertension or other intracranial diseases. Prompt evaluation and treatment may improve the prognosis for both vision and the underlying disorder.

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  • 1. Physiological diplopia. This is a normal phenomenon that is most commonly noted by bright and observant children around ages 5 to 6 years. The eyes normally focus on objects in a single plane, and these are seen as single images. Objects in front of or behind the object of attention appear to be double, but most people do not notice this. The diplopia can be demonstrated by holding one finger up at arm’s distance in front of your face, with another object (e.g., something on the wall) in the background in line with your finger. If you focus on your finger but pay attention to the object in the background, the background object will appear double. Conversely, if you focus on the background object but pay attention to your finger, the finger will appear double (Figure 11–1). Most of the time these double images are ignored, but children may become aware of them and report them to their parents.
  • 2. Breakdown of a phoria. Many normal individuals have a phoria. A phoria is a tendency for the eyes to become misaligned when one eye ...

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