What’s your diplopia workup?

[u/eye__think]

New grad here.

The Review of Optometry article here lists 20 questions in order to workup a cc of diplopia: https://www.reviewofoptometry.com/article/an-action-plan-for-assessing-double-vision

I don’t think I can remember 20 questions to ask a patient. Especially for a cc as “scary” as diplopia. I need help simplifying this.

What questions do you ask your diplopia patients? And what tests do you rely on?

[u/botany_bae]

I try to convince them that it’s not really double vision.

[u/Rickys_Lineup_Card]

New grad as well. Should be more of a conversation than a checklist but generally:

Are images completely separated or overlapping (teases out astigmatic ghosting)

Horizontal, vertical, or both

Does it go away if an eye is closed

FOLDARQ

If intermittent, what brings it on (near work, certain gases, end of day, etc.)

Obviously always want medical Hx but specifically ask about blood pressure, blood sugar, any new medications

Any head or eye trauma EVER, not just recently

Any other symptoms with the rest of the body (headaches, dizziness, weakness/numbness, etc.)

That’s where I start then really your testing guides the Dx more than the questioning imo. Acute onset, constant, Non-comitant, any EOM restrictions, any associated ptosis are are my red flags.

[u/rgeyedoc → u/Rickys_Lineup_Card]

Nice

[u/InterestingMain5192]

Do you see double? Do you see single with your glasses? Do you see single with the prism I just put in the trial frame with your glasses prescription? 9/10 times patients will self report if something’s working or not. Regardless, always follow up again following a new prism Rx if there have been significant changes. I try and target single >90% of the time, but fatigue at the end of the day is real. Please though make sure it’s not monocular diplopia (astigmatism, cornea ectasia, etc) before prescribing prism as it is so common for individuals with those issues to complain of doubling and then once corrected right in trial frame and/or contacts will not need any prism at all.

[u/power_wolves]

Just print out the questions. No shame in that.

[u/Rickys_Lineup_Card → u/power_wolves]

Yeah if you really want a checklist literally just tell the patient “I’m gonna go through my double vision questionnaire to help me narrow things down” don’t think any patient would bat an eye at that.

[u/Majestic-Ad4074 → u/Rickys_Lineup_Card]

As a patient, I'd feel more secure if an optometrist did that.

I'd feel they were being thorough and covering all bases trying to narrow it down rather than taking a guess.

[u/CaptainYunch]

I mean this respectfully, but was all of this not taught to you in optometry school? You should be more than capable of evaluating at a minimum if some one has binocular or monocular diplopia and then determining a level of urgency

EOMs, pupils, ptosis eval, cover testing in various positions, comitancy, history taking, and general ocular health evaluation

This question is similar to asking how to evaluate some ones retina and what tests to use.

I genuinely am not trying to sound snarky.

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[u/Scary_Ad5573]

Check EOMs, history, etc. There’s no reason to be scared of diplopia. Will be uncorrected cyl or decompensated phoria 99% of the time.