WordNet

visual impairment in which an object is seen as two objects; "diplopia often disappears when one eye is covered" (同)double_vision

Wikipedia preview

出典(authority):フリー百科事典『ウィキペディア（Wikipedia）』「2014/09/11 14:09:12」(JST)

wiki en

Diplopia, commonly known as double vision, is the simultaneous perception of two images of a single object that may be displaced horizontally, vertically, diagonally (i.e., both vertically and horizontally), or rotationally in relation to each other.^[1] It is usually the result of impaired function of the extraocular muscles (EOMs), where both eyes are still functional but they cannot converge to target the desired object.^[1] Problems with EOMs may be due to mechanical problems, disorders of the neuromuscular junction, disorders of the cranial nerves (III, IV, and VI) that stimulate the muscles, and occasionally disorders involving the supranuclear oculomotor pathways or ingestion of toxins.^[2]

Diplopia is often one of the first signs of a systemic disease, particularly to a muscular or neurological process,^[3] and it may disrupt a person’s balance, movement, and/or reading abilities.^[1]^[4]

Classification

Binocular

Binocular diplopia is double vision arising as a result of strabismus (in layman's terms cross-eyed), the misalignment of the two eyes relative to each other either esotropia (inward) or exotropia (outward). In such a case while the fovea of one eye is directed at the object of regard, the fovea of the other is directed elsewhere, and the image of the object of regard falls on an extra-foveal area of the retina.

The brain calculates the 'visual direction' of an object based upon the position of its image relative to the fovea. Images falling on the fovea are seen as being directly ahead, while those falling on retina outside the fovea may be seen as above, below, right or left of straight ahead depending upon the area of retina stimulated. Thus, when the eyes are misaligned, the brain will perceive two images of one target object, as the target object simultaneously stimulates different, non-corresponding, retinal areas in either eye, thus producing double vision.

This correlation of particular areas of the retina in one eye with the same areas in the other is known as retinal correspondence. This relationship also gives rise to an associated phenomenon of binocular diplopia, although one that is rarely noted by those experiencing diplopia: Because the fovea of one eye corresponds to the fovea of the other, images falling on the two foveas are 'projected' to the same point in space. Thus, when the eyes are misaligned, the brain will 'project' two different images in the same visual direction. This phenomenon is known as 'confusion'.

The brain naturally guards against double vision. In an attempt to avoid double vision, the brain can sometimes ignore the image from one eye; a process known as suppression. The ability to suppress is to be found particularly in childhood when the brain is still developing. Thus, those with childhood strabismus almost never complain of diplopia while adults who develop strabismus almost always do. While this ability to suppress might seem an entirely positive adaptation to strabismus, in the developing child this can prevent the proper development of vision in the affected eye resulting in amblyopia. Some adults are also able to suppress their diplopia, but their suppression is rarely as deep or as effective and takes longer to establish, and thus they are not at risk of permanently compromising their vision. Hence, in some cases diplopia disappears without medical intervention, but in other cases the cause of the double vision may still be present.

Certain persons with diplopia who cannot achieve fusion and yet do not suppress may display a certain type of spasm-like irregular movement of the eyes in the vicinity of the fixation point (see: Horror fusionis).

Monocular

More rarely, diplopia can also occur when viewing with only one eye; this is called monocular diplopia, or, where the patient perceives more than two images, monocular polyopia. In this case, the differential diagnosis of multiple image perception includes the consideration of such conditions as corneal surface keratoconus, subluxation of the lens, a structural defect within the eye, a lesion in the anterior visual cortex or non-organic conditions.

Temporary

Temporary diplopia can be caused by alcohol intoxication or head injuries, such as concussion (if temporary double vision does not resolve quickly, one should see an optometrist or ophthalmologist immediately). It can also be a side effect of the anti-epileptic drugs Phenytoin and Zonisamide, and the anti-convulsant drug Lamotrigine, as well as the hypnotic drug Zolpidem and the dissociative drugs Ketamine and Dextromethorphan. Temporary diplopia can also be caused by tired and/or strained eye muscles or voluntarily. If diplopia appears with other symptoms such as fatigue and acute or chronic pain, the patient should see an optometrist immediately.

Voluntary

Some people are able to consciously uncouple their eyes, either by over focusing closely (i.e. going cross eyed) or unfocusing. Also, while looking at one object behind another object, the foremost object's image is doubled (for example, placing one's finger in between one's face while reading text on a computer monitor). In this sense double vision is neither dangerous nor harmful, and may even be enjoyable. It makes viewing stereograms possible.^[5]

Causes

Diplopia has a diverse range of ophthalmologic, infectious, autoimmune, neurological, and neoplastic causes.

Damage to the third, fourth, or sixth cranial nerves, which control eye movements.
Cancer
Trauma
Diabetes
Migraine
Multiple sclerosis
Fluoroquinolone antibiotics^[6]
Botulism
Guillain-Barré syndrome
Brain tumor
Sinusitis
Abscess
Wernicke's syndrome
Graves disease
Drunkenness
Opioids
Orbital myositis
Myasthenia gravis^[7]
Anisometropia
Salicylism
Strabismus
Lyme Disease

Treatment

The appropriate treatment for binocular diplopia will depend upon the cause of the condition producing the symptoms. Efforts must first be made to identify and treat the underlying cause of the problem. Treatment options include eye exercises,^[1] wearing an eye patch on alternative eyes,^[1] prism correction,^[8] and in more extreme situations, surgery^[4] or botulinum toxin.^[9]

If diplopia turns out to be intractable, it can be managed as last resort by obscuring part of the patient's field of view. This approach is outlined in the article on diplopia occurring in association with a condition called horror fusionis.

References

^ ^a ^b ^c ^d O'Sullivan, S.B & Schmitz, T.J. (2007). Physical Rehabilitation. Philadelphia, PA: Davis. ISBN 978-0-8036-1247-1.
^ Blumenfeld, Hal (2010). Neuroanatomy through Clinical Cases. Sunderland MA: Sinauer. ISBN 978-0-87893-058-6.
^ Rucker, JC. (2007). "Oculomotor disorders". Semin Neurol. 27 (3): 244–56. doi:10.1055/s-2007-979682. PMID 17577866.
^ ^a ^b Kernich, C.A. (2006). "Diplopia". The Neurologist 12 (4): 229–230. doi:10.1097/01.nrl.0000231927.93645.34. PMID 16832242.
^ http://www.focusillusion.com/Instructions/ Instructions on how to view stereograms such as magic eye
^ Fraunfelder FW, Fraunfelder FT (September 2009). "Diplopia and fluoroquinolones". Ophthalmology 116 (9): 1814–7. doi:10.1016/j.ophtha.2009.06.027. PMID 19643481.
^ http://www.merck.com/mmpe/sec09/ch098/ch098e.html
^ Phillips PH. (2007). "Treatment of diplopia". Semin Neurol. 27 (3): 288–98. doi:10.1055/s-2007-979680. PMID 17577869.
^ Taub, M.B. (2008). "Botulinum toxin represents a new approach to managing diplopia cases that do not resolve". Journal of the American Optometric Association 79 (4): 174–175. doi:10.1016/j.optm.2008.01.003.

^ Cassin, B. & Solomon, S. (1990) Dictionary of Eye Terminology. Gainesville, Florida: Triad Publishing Company

External links

Common Cause of Double Vision
All About Double Vision
International Orthoptic Association
All About Lazy Eye
FAQ -- Eye Muscle Surgery Information
Brain Injuries and Double Vision
Some more info about diplopia
Addtl info about diplopia
What is Stereovision?
What is Vision Therapy?
VisionSimulations.com | What the world looks like to people with various diseases and conditions of the eye
GPnotebook

Look up diplopia in Wiktionary, the free dictionary.

UpToDate Contents

全文を閲覧するには購読必要です。 To read the full text you will need to subscribe.

1. 複視の概要 overview of diplopia
2. 視覚変化が認められた小児患者に対するアプローチ approach to the pediatric patient with vision change
3. 眼筋型重症筋無力症 ocular myasthenia gravis
4. 成人における第三脳神経（動眼神経）麻痺 third cranial nerve oculomotor nerve palsy in adults
5. 小児における第6脳神経（外転神経）麻痺 sixth cranial nerve abducens nerve palsy in children

English Journal

Presentation, management and outcomes in acute pituitary apoplexy: a large single-centre experience from the United Kingdom.

Bujawansa S, Thondam SK, Steele C, Cuthbertson DJ, Gilkes CE, Noonan C, Bleaney CW, Macfarlane IA, Javadpour M, Daousi C.Author information Department of Endocrinology & Diabetes, University Hospital Aintree, Liverpool, UK.AbstractOBJECTIVE: To study the presentation, management and outcomes and to apply retrospectively the Pituitary Apoplexy Score (PAS) (United Kingdom (UK) guidelines for management of apoplexy) to a large, single-centre series of patients with acute pituitary apoplexy.
Clinical endocrinology.Clin Endocrinol (Oxf).2014 Mar;80(3):419-24. doi: 10.1111/cen.12307. Epub 2013 Aug 26.
OBJECTIVE: To study the presentation, management and outcomes and to apply retrospectively the Pituitary Apoplexy Score (PAS) (United Kingdom (UK) guidelines for management of apoplexy) to a large, single-centre series of patients with acute pituitary apoplexy.DESIGN: Retrospective analysis of casen
PMID 23909507

Complications of tube implants and their management.

Bailey AK, Sarkisian SR Jr.Author information Department of Ophthalmology, University of Oklahoma Health Science Center, Dean McGee Eye Institute, Oklahoma City, Oklahoma, USA.AbstractPURPOSE OF REVIEW: The use of glaucoma drainage devices (GDD) in the treatment of glaucoma has become widely accepted for cases of refractory glaucoma. Expansion in the indications for implantation of GDD beyond refractory glaucoma is increasingly common. As such, tube implant complications are reviewed to aid in prevention and improve their management.
Current opinion in ophthalmology.Curr Opin Ophthalmol.2014 Mar;25(2):148-53. doi: 10.1097/ICU.0000000000000034.
PURPOSE OF REVIEW: The use of glaucoma drainage devices (GDD) in the treatment of glaucoma has become widely accepted for cases of refractory glaucoma. Expansion in the indications for implantation of GDD beyond refractory glaucoma is increasingly common. As such, tube implant complications are revi
PMID 24463417

Mobilization of the transcavernous oculomotor nerve during basilar aneurysm surgery: biomechanical bases for better outcome.

Basma J, Ryttlefors M, Latini F, Pravdenkova S, Krisht A.Author information *Arkansas Neuroscience Institute, St. Vincent's Infirmary, Little Rock, Arkansas; ‡Department of Neurosurgery, Uppsala University Hospital, Uppsala, Sweden; §Division of Neurosurgery, Department of Neuroscience and Rehabilitation, Santa Anna University Hospital, Ferrara, Italy.AbstractBACKGROUND: The transcavernous approach adds a significant exposure advantage in basilar aneurysm surgery. However, one of its frequently reported side effects is postoperative oculomotor nerve palsy.
Neurosurgery.Neurosurgery.2014 Mar;10 Suppl 1:106-15. doi: 10.1227/NEU.0000000000000027.
BACKGROUND: The transcavernous approach adds a significant exposure advantage in basilar aneurysm surgery. However, one of its frequently reported side effects is postoperative oculomotor nerve palsy.OBJECTIVE: To present the technique of mobilizing the oculomotor nerve throughout its intracranial c
PMID 24056316

Japanese Journal

メトロニダゾールによる薬剤性末梢神経障害に対して薬物療法を行った1症例

大路牧人,境徹也,田中絵理子,澄川耕二
日本ペインクリニック学会誌 21(1), 27-30, 2014
メトロニダゾール（MNZ）は，嫌気性菌や原虫による感染症に有効な抗菌薬である．薬剤性神経障害の原因薬剤は多岐にわたるが，MNZでも起こりうる．今回われわれは，MNZにより生じた薬剤性末梢神経障害に対し薬物療法を行ったので報告する．症例は77歳の男性である．5カ月前に腰痛が出現し，非結核性抗酸菌性脊椎炎と診断された．MNZ 1,500 mg／日が開始されたが，投与より1カ月で四肢の痛みとしびれ，複視 …
NAID 130003386640

Postural Stability Changes during Large Vertical Diplopia Induced by Prism Wear in Normal Subjects

Matsuo Toshihiko,Yamasaki Hanako,Yasuhara Hirotaka,Hasebe Kayoko
Acta Medica Okayama 67(3), 177-183, 2013-06
… In conclusion, postural stability did not change with the eyes open in the condition of large vertical diplopia, induced by prism-wearing for 60min, while the stability became better when measured with the eyes closed. … A postural control mechanism other than that derived from visual input might be reinforced under abnormal visual input such as non-fusionable diplopia. …
NAID 120005295916

複視が初発症状の神経サルコイドーシスに対しγグロブリン療法が著効した1例 (特集第66回日本臨床眼科学会講演集(3))

小林志乃ぶ,井上麻衣子,山根真 [他]
臨床眼科 67(5), 759-763, 2013-05
NAID 40019685148

Related Pictures

★リンクテーブル★

リンク元	「100Cases 14」「複視」「dipl」「polyopsia」「vertical diplopia」
拡張検索	「monocular diplopia」「horizontal diplopia」

「100Cases 14」

Diplopia
	Classification and external resources
	Photo showing how a patient experiences diplopia
ICD-10	H53.2
ICD-9	368.2
DiseasesDB	31225
eMedicine	oph/191
MeSH	D004172

　　[★]

☆case14　複視

■glossary

diplopia n. 複視

筋力低下、筋無力、筋脱力 muscle weakness, muscular weakness

sunken

vt. sinkのpp.

adj.

沈没した、沈んだ、水中の

沈下した、一段低いところにある

落ち込んだ、くぼんだ

3,4-ジアミノピリジン 3,4-diaminopyridine 3,4-DAP K+チャネル阻害薬;ランバート・イートン筋無力症治療

■症例

43-year-old woman

cheif complaint: diplopia

present history: diplopia and holding her head up ; more marked in the evenings, for the last 3 months. difficulty of chewing. voice has become quieter. weight loss (3kg / 6months). non-smoker. drinks about 15 units/week. no regular medication.

past history: no significant previous medical illnesses.

family history: lives with her husband and three children.

・診察 examination

looks well.

organ systems: normal; cardiovascular, respiratory, and abdominal systems.

muscle power; grossly normal. decrease after testing a movement repetitively.

motor function: normal; tone, coordination, reflexes and sensation.

bilateral ptosis. exacerbated by prolonged upward gaze

eye: normal; pupillary reflexes, eye movements, and funduscopy

■答え

diagnosis: myathenia gravis

differential diagnoses:

CASES

上位and/or下位運動ニューロン motor neurone disease　運動ニューロン疾患：線維束性攣縮。進行例では筋力低下

筋 muscular dystrophy　筋ジストロフィー：ある種の筋肉が選択的に筋力低下する。家族歴がある。

筋 dystrophia myotonica　強直性筋ジストロフィー：咬筋、側頭筋、胸鎖乳突筋の筋萎縮、四肢遠位端の筋萎縮。顔貌が特徴的(前頭部脱毛、無表情、窪んだ頬)。家族歴ある。筋電図が診断に有用(急降下爆撃音)。

筋 polymyositis　多発筋炎：普通は皮疹と関節痛が出現。CKが上昇。筋生検が診断に有用

筋 myopathy　ミオパチー：甲状腺中毒性ミオパチー、甲状腺機能低下症によるミオパチー、クッシング症候群によるミオパチー、アルコール性のミオパチー

神経筋接合部？ non-metastatic associations of malignancy (paraneoplastic syndrome(傍腫瘍性症候群 = 腫瘍随伴症候群)のこと)：胸腺腫の症例の10%に重症筋無力症がみられる。ランバート・イートン筋無力症症候群は小細胞癌と関連がある。

HIM.2674

神経筋接合部 congenital myasthenia syndrome　先天性筋無力症症候群
神経筋接合部 drug-induced myasthenia　薬剤性筋無力症

Treatment with penicillamine (used for scleroderma or rheumatoid arthritis) may result in true autoimmune MG, but the weakness is usually mild, and recovery occurs within weeks or months after discontinuing its use.

　重症筋無力症の誘発：ペニシラミン(強皮症や関節リウマチの治療に用いられる)。

　　mildだし、薬剤の中断で改善する。

Aminoglycoside antibiotics or procainamide can cause exacerbation of weakness in myasthenic patients; very large doses can cause neuromuscular weakness in normal individuals.

　重症筋無力症の悪化：アミドグリコシド系抗菌薬、プロカインアミド

　　MGの患者の筋脱力が悪化する。

神経筋接合部 Lambert-Eaton myasthenic syndrome　ランバート・イートン筋無力症症候群：全身の筋肉が冒されるが、特に下肢の近位筋が冒される。MGと同じように～70%の患者で脳神経所見(眼瞼下垂、複視など)が認められる。MGと違うのは(1)反射が消失・減弱すること、(2)自律神経系の変化(口渇、勃起不全)を生じる、(3)神経刺激検査で漸増(waxing)が見られることである。病因は神経筋接合部のP/Q type calcium channelsに対する抗体の出現であり、85%の患者で見いだされる。治療はMGのように血漿交換や免疫抑制薬が使われる。3,4-DAPやpyridostigmineは症状に対する治療のために用いる。前者は運動神経の終末部でカルシウムチャネルをブロックし活動電位を延長させる。後者はアセチルコリンエステラーゼを阻害してシナプスにおける神経伝達物質の濃度を上げる。
精神疾患 neurasthenia　神経衰弱症：歴史的な用語。器質的な障害を伴わない筋無力症のような脱力を伴う症候群。患者は筋脱力や疲労を訴えてやってくる。筋肉の検査では器質的変化は認めないが"jerky release"あるいは"give-away weakness"が認められる。患者の主訴は反復動作による筋力低下よりむしろ疲労や感情鈍麻である。
内分泌疾患 hyperthyroidism　甲状腺機能亢進症：MGが疑われる患者にはthyroid function testをルーチンにやる。甲状腺機能異常は筋無力症の筋力低下を大きくすることがある。
神経筋接合部 botulism　ボツリヌス症：ボツリヌス毒素はシナプス前膜からの神経伝達物質の開口分泌を妨げる。症状はbulbar weakness (複視、構音障害、嚥下困難)。感覚障害はない。深部腱反射は初期には保たれている。進行すれば反射は見られなくなる。筋脱力は全身性。呼吸困難に陥ることがある。精神状態は正常。自律神経症状(麻痺性イレウス、便秘、urinary retention、瞳孔の散大、瞳孔の反応性低下、口渇)。確定診断は血清中の毒素の検出だけど、見つかることはまれ。神経伝導検査(nerve conduction studies)：compound muscle action potentials (CMAPs)の低下。高頻度の刺激で振幅が増加。治療：intubation for airway protection、呼吸補助、aggressive inpatient supportive care(e.g., nutrition, DVT prophylaxis)。馬の抗毒素を検査結果が帰ってくる前に投与する(？)。
上位運動ニューロン intracranial mass lesions　頭蓋内占拠病変：複視はintracranial mass lesionが外眼筋の神経を圧迫することにより生じる。
筋 progressive external ophthalmoplegia　進行性外眼筋麻痺：外眼筋の筋脱力を伴う。四肢の近位筋の筋力低下やそのほかの全身症状を伴うことがある。ミトコンドリアの異常を有する。

■参考文献

HIM = Harrison's Principles of Internal Medicine 17th Edition

CASES = 100 Cases in Clinical Medicine Second edition

IMD = 内科診断学第2版

「複視」

　　[★]

dipl opia
英: diplopia, double vision
関: 両眼視

概念

ある視標を見たときにものが二重に見える状態を複視という。(SOP.269)

分類

仮像の出現する方向

同側複視 homonymous diplopia：患眼(内斜視)と同じ方向に仮像がある複視
交叉性複視 crossed diplopia：患眼(外斜視)と反対方向に仮像がある複視

両眼・単眼の別

両眼複視：両眼で物が二重に見える場合。動眼神経麻痺、滑車新家麻痺、重症筋無力症、眼窩吹き抜け骨折など
単眼複視：単眼で物が二重に見える場合。正乱視、不正乱視、あるいは白内障が原因となる。

鑑別疾患

単眼視したときに物体が二重に認識される状態 monocular diplopia

水晶体脱臼(外傷、マルファン症候群)
早期白内障
角膜白濁(corneal opacities)
二重虹彩(手術や外傷)
ヒステリー

両眼視したときに物体が二重に認識される状態 biocular diplopia

DIF

外眼筋麻痺：MINT

malformation 筋強直性ジストロフィー、眼筋麻痺
inflammatory 皮膚筋炎、眼窩蜂窩織炎
neoplasm 眼窩/外眼性の甲状腺腫　orbit and exophthalmic goiter
trauma 眼窩骨折、外眼筋の裂傷/打撲

神経筋接合部

重症筋無力症

脳神経末梢：VINCE

venous 静脈洞の静脈血栓症
inflammatory 梅毒性髄膜炎、結核性髄膜炎、ジフテリア後神経炎、蝶形骨洞副鼻腔炎、錐体炎、脳圧亢進
neoplasm 下垂体腫瘍、鞍上部腫瘍、鼻咽頭腫瘍、脊索腫、蝶形骨縁髄膜腫
congenital 動静脈奇形
endocrine 糖尿病性ニューロパチー

脳神経核：VINDICATE

vascular 脳底動脈血栓症/出血/塞栓症/動静脈奇形。片頭痛？
inflammatory 梅毒性脳炎、結核性脳炎、ウイルス性脳炎
neoplasms 脳幹神経膠腫、転移性脳腫瘍、ホジキンリンパ腫
deficiency ウェルニッケ脳症
intoxication ボツリヌス症、臭素・ヨウ素中毒
congenital 水頭症、アーノルド・キアリ奇形
autoimmune 多発性硬化症、感染後脳症、ループス脳症
traumatic 硬膜下血腫、頭蓋底骨折、橋血腫
endocrine 糖尿病による脳底動脈血栓症

核上性

松果体腫瘍、脳血栓/脳出血のconjugate plasy、局在性皮質てんかんのconjugate gaze、テント切痕への早期ヘルニアにおける瞳孔の拡張

検査

バゴリーニ試験 Bagolini test

「dipl」

　　[★]

comb form.

2(two)。二重(double)。多重。複。2倍の染色体を持つ

ex.

「polyopsia」

　　[★]

多視

関: diplopia、double vision、horizontal diplopia、monocular diplopia、vertical diplopia

「vertical diplopia」

　　[★]

垂直複視

関: diplopia、double vision、horizontal diplopia、monocular diplopia、polyopsia

「monocular diplopia」

　　[★]

単眼複視

関: diplopia、double vision、horizontal diplopia、polyopsia、vertical diplopia

「horizontal diplopia」

　　[★]

水平複視

関: diplopia、double vision、monocular diplopia、polyopsia、vertical diplopia

[osullivan-1] O'Sullivan, S.B & Schmitz, T.J. (2007). Physical Rehabilitation. Philadelphia, PA: Davis. ISBN 978-0-8036-1247-1.

[2] Blumenfeld, Hal (2010). Neuroanatomy through Clinical Cases. Sunderland MA: Sinauer. ISBN 978-0-87893-058-6.

[3] Rucker, JC. (2007). "Oculomotor disorders". Semin Neurol. 27 (3): 244–56. doi:10.1055/s-2007-979682. PMID 17577866.

[kernich-4] Kernich, C.A. (2006). "Diplopia". The Neurologist 12 (4): 229–230. doi:10.1097/01.nrl.0000231927.93645.34. PMID 16832242.

[5] ttp://www.focusillusion.com/Instructions/ Instructions on how to view stereograms such as magic eye

[pmid19643481-6] Fraunfelder FW, Fraunfelder FT (September 2009). "Diplopia and fluoroquinolones". Ophthalmology 116 (9): 1814–7. doi:10.1016/j.ophtha.2009.06.027. PMID 19643481.

[7] ttp://www.merck.com/mmpe/sec09/ch098/ch098e.html

[8] Phillips PH. (2007). "Treatment of diplopia". Semin Neurol. 27 (3): 288–98. doi:10.1055/s-2007-979680. PMID 17577869.

[9] Taub, M.B. (2008). "Botulinum toxin represents a new approach to managing diplopia cases that do not resolve". Journal of the American Optometric Association 79 (4): 174–175. doi:10.1016/j.optm.2008.01.003.

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案内

diplopia