Causes and treatment of dizziness and double vision

Double vision is often confused with blurred vision. However, fog in the eyes is a visual impairment in which a person sees one blurry, unclear image, and with double vision, one object is perceived as two images of it.

Diplopia manifests itself in different ways. Some patients report this condition from time to time, others live with it constantly. In some cases, people claim to experience double vision only when they look in a certain direction (vertical or horizontal plane).

Dry eyes and diplopia: is there a connection?

The causes of double vision can be various diseases and pathologies. The following factors contribute to the development of monocular diplopia:

• Astigmatism. A vision defect that occurs due to changes in the shape of the cornea, lens, and eyeball. Against the background of this pathology, the clarity of vision decreases.
• Keratoconus. An ophthalmological disease that is characterized by thinning and curvature of the cornea (becomes cone-shaped).
• Pterygium. The formation of a pterygoid hymen on the conjunctiva, which grows into the cornea.
• Cataract. Decreased transparency (clouding) of the lens, leading to partial or complete blindness.
• Dry eye syndrome. A pathological condition caused by disruption of the stability of the tear film. Most often it occurs due to a decrease in the amount of tear fluid produced.

Binocular diplopia indicates that the eyes have lost the ability to work in pairs. Therefore, the reasons for its development must be sought in other organs, namely in the brain and nervous system. Most often, the pathological condition occurs against the background of such diseases:

• diabetes mellitus (causes damage to nerve structures);
• myasthenia gravis (pathological weakness of the eyelids);
• strabismus;
• diffuse toxic goiter (thyroid disease);
• cranial nerve palsy;
• inflammatory damage to the optic nerves.

Diplopia that occurs against the background of dry eye syndrome or other pathologies can lead to the development of complications. Many patients experience dizziness, nausea, photosensitivity, and visual strain due to double vision.

Dizziness - symptoms and treatment

Diagnosis of dizziness is based primarily on the collection of complaints, anamnesis (history) of the disease and clinical examination.

Collection of complaints and anamnesis

Basic questions that can be asked to a patient with acute dizziness:

1. How and when did the dizziness start?
2. How long does it last?
3. What character, in the patient’s opinion, is dizziness (systemic, non-systemic, presyncope).
4. Are there certain factors that provoke dizziness (turning the head or body, standing from a horizontal to a vertical position, being in crowded or noisy places, etc.).
5. Is dizziness accompanied by pain (headache, chest pain, ear pain), hearing loss, noise in the ears or in the head.
6. Are there any accompanying symptoms (double vision, difficulty swallowing, speech disorders, weakness in the limbs, nausea and vomiting) [1].

Physical examination

When examining a patient, the presence and characteristics of nystagmus, the presence of gait disturbances, the performance of coordination tests and stability in the Romberg position (standing with feet together, eyes closed and arms extended in front of you) are first assessed.

Evaluation of nystagmus. In order to correctly distinguish peripheral from central vertigo during the diagnostic process, it is important to determine the nature of the nystagmus. For this purpose, special Frenzel glasses are used: in them, it is difficult for the patient to fix his gaze on any object, which allows him to determine without distortion exactly how nystagmus manifests itself.

Differential diagnosis of peripheral and central dizziness:

• With a peripheral origin, nystagmus is usually horizontal or horizontal with rotational movements of the eyeballs, unidirectional and directed towards a more active labyrinth. When the gaze is fixed, the nystagmus decreases.
• In the case of central origin, nystagmus can be horizontal bidirectional (left-sided when looking to the left and right-sided when looking to the right), vertical or rotational. When fixing your gaze, it may decrease slightly, but, as a rule, does not change.

Positional tests are carried out at the appointment and help determine the cause of systemic vertigo and differentiate positional nystagmus from central nystagmus. The most commonly performed test is the Dix-Halpike test. The patient, who is sitting on the couch, is turned 45° to one side and quickly placed on the couch so that the head is thrown back over the edge of the couch. The doctor monitors the appearance of nystagmus, and the patient reports on his well-being. In the same way, the test is repeated with the head turned in the other direction.

If the answer is positive, it is possible to identify the most common cause of true dizziness, BPPV, and determine in which of the semicircular canals the otoliths causing dizziness are located [18]. With the appearance of nystagmus and dizziness, the most common localization of otoliths is revealed - the posterior semicircular canal.

Assessment of the vestibulo-ocular reflex (VOR). In the work of the vestibular system, the VOR is of utmost importance: thanks to it, a person can keep the object of observation in the field of view during various movements of the head. This is possible due to the fact that when the head is turned to the side, the eyes make a movement of the same amplitude and speed in the opposite direction.

VOR is assessed using the head rotation test (Halmagi-Kertoiz test): the patient is asked to fix his gaze on an object (for example, the doctor’s nose), then the doctor clasps his hands around the patient’s head in the temporal regions and sharply turns the patient’s head to the right and left by 10-20 °.

Normally, when turning the head, the gaze remains fixed on the object. The same thing is observed with damage to the central part of the vestibular analyzer. When the peripheral part is affected, when the head is turned, the eyes first move in the direction of the turn, after which the gaze is again fixed on the object.



Marching test (Fukuda test). To carry out the test, the patient closes his eyes, stretches his arms forward and begins to walk in place, raising his knees high. After 50 steps, the doctor assesses how much the patient has deviated from the initial position; normally, the angle of deviation should not exceed 30-45°. If there is a unilateral peripheral lesion, the patient turns towards the affected labyrinth. In case of damage to the central department, there is a lack of coordination, deviation in different directions, sometimes the patient falls or turns towards the pathological process when the cerebellum is damaged [28].

Postural reflexes , which make it possible to maintain a stable body position, are examined by gently pushing the patient into the upper torso. At the same time, the doctor is behind his back so that the patient does not see when and in what direction he will be pushed. With vestibular disorders, instability is possible, but in general the person maintains the posture.

Gait assessment (with eyes open and then closed). When observing a patient's gait, a balance disorder is often diagnosed. Many diseases of the peripheral and central nervous system are accompanied by typical gait changes, but in most patients with vestibular disorders it is not impaired, except in the acute stage of the disease.

An orthostatic test involves measuring blood pressure while lying down, immediately after moving to an upright position, and then over the next three minutes. The test is considered positive if systolic blood pressure decreases by 20 mmHg. Art. or more or diastolic pressure decreases by 10 mm Hg. Art. and more. The method allows you to identify pre-fainting conditions associated with orthostatic hypertension.

Instrumental examination

In most cases, data from a detailed survey, analysis of complaints and examination of the patient are sufficient to make a diagnosis. Instrumental methods are necessary if a central lesion of the vestibular analyzer is suspected and in the presence of concomitant diseases (for example, previous acute cerebrovascular accidents, the presence of space-occupying lesions or vascular anomalies in the past or present).

The need for computed or magnetic resonance imaging (CT/MRI) may arise if objective data are detected that require further examination. For example, vertical nystagmus, multidirectional, beating down or up may indicate damage to the stem structures of the brain or cerebellum [1].

Most often, CT and MRI can diagnose cerebral infarction, cerebral hemorrhage, multiple sclerosis, tumors of the brain stem and cerebellopontine angle, anomalies and other diseases accompanied by dizziness.

Ultrasound examination of extracranial and intracranial arteries is indicated if cerebrovascular disease is suspected with an appropriate history and the presence of risk factors (arterial hypertension, diabetes mellitus, obesity, hypercholesterolemia, heredity for cardiovascular diseases, previous acute cardiovascular diseases).

For dizziness that is accompanied by noise in the ear or hearing loss, pure tone threshold audiometry to determine auditory sensitivity to sounds of different frequencies. During this examination, the auditory threshold of bone and air conduction is compared, and if deviations from the norm are detected, the probable cause is determined (cerumen plug, otosclerosis, labyrinthitis, Meniere's disease, etc.).

A cardiac examination (ECG, ECHO-CG, Holter monitoring) is indicated if a cardiogenic cause of dizziness is suspected [5][8].

Stabilography is the study of balance using a moving platform. Using this method, it is possible to quantify involuntary postural reflexes, thanks to which a person does not fall, and also determine what role information from various senses plays in maintaining balance.

How to get rid of diplopia?

Only a specialist knows how to treat diplopia. But in order to understand why there is double vision, you need to undergo a comprehensive diagnosis. It includes an eye examination, blood sugar level determination, and an MRI or CT scan of the vision organ. This allows you to determine the cause of the visual defect and select rational treatment.

As part of therapy, a specialist may recommend special exercises, wearing a bandage, corrective lenses, and glasses. In difficult cases, diplopia of the eye is treated surgically.

The development of pathology can be prevented by minimizing the impact of negative factors on the organ of vision. First of all, it is necessary to prevent the development of dry eye syndrome, which can cause monocular diplopia.

Will tear substitutes help eliminate dry eyes and diplopia?

The key treatment for dry eye syndrome is eye drops that mimic tears. They have a composition close to native tears and help compensate for the lack of hydration. But drops are not a panacea for dry eyes and diplopia, but only a temporary solution to the problem.

None of the existing tear substitutes can eliminate the true causes of dry eyes. The drops do not in any way affect the functioning of the lacrimal apparatus, so they can only temporarily eliminate the unpleasant symptoms of dry eye syndrome, but not the causes of the disease.

In addition, the use of such drugs can lead to its progression. The fact is that frequent instillation of drops helps to wash out important components of tears from the conjunctival cavity. Therefore, their composition changes, the tear film becomes unstable and dries quickly. Because of this, dry eye disease begins to progress, which threatens corneal perforation.

Some drugs can even be dangerous to eye tissue. We are talking about drops with preservatives, which extend the shelf life of the drops, but cause the destruction of goblet cells (they produce an important component of tears - mucin). Therefore, when using tear substitutes with preservatives, there is a risk of rapid progression of dry eye syndrome and the development of diplopia.

Causes in pathologies

The study of such causes has shown that they can cause irreversible consequences. The most dangerous pathological processes can be identified:

• motor nerve infection;
• paralysis of the eye muscles;
• the oculomotor nerve is subject to increased pressure.

Accordingly, we can note diseases that cause bifurcation:

• meningitis;
• neurological diseases;
• infectious pathologies;
• orbital tumors;
• vasculitis;
• intoxication of the body.

In the presence of even one disease, the cause of diplopia can be assumed. The symptom will not go away on its own. The underlying disease must be treated, otherwise attacks of this condition will often recur.

Delfanto® – an innovative product for restoring tear fluid production

Delfanto® capsules are a modern product based on a standardized extract of Aristotelia chilean (MaquiBright®). It contains at least 35% polyphenolic anthocyanins, which help eliminate the effects of oxidative stress and make the tear glands work stably.

Unlike tear substitutes, Delfanto® eliminates not only the signs of dry eye syndrome, but also the causes. The product stimulates the production of your own tears, which provides protection, nutrition, and hydration of eye tissue. Already 14 days after the start of the course of therapy, the first positive changes are noticeable, and after a month, the manifestation of dry eye symptoms is reduced by 45-89% (according to the results of clinical studies).