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MILES E. DRAKE, Jr., M.D.
Migraine as an organic
cause of monocular diplopia
Diplopia generally represents a failure of binocular The general physical examination was unremarkable.
fusion of vision, with the double image caused by a Ophthalmologic examination indicated normal visual acuity
different location of the retinal image in either eye. and fields, no demonstrable diplopia, and no evident ana
Such diplopia is binocular, and clears when monocular tomic cause for diplopia. Neurologic examination was nor
vision is used and only one retinal image is seen. mal except for mild left hyperreflexia. The CBC, platelet
count, coagulation studies, blood chemistry, urinalysis,
Diplopia during use of only one eye is less frequently
ECG, and chest roentgenogram were normal. Thyroid
encountered, and may rarely represent organic in
function tests had proved normal a few weeks earlier during
volvement of the visual system but more often is an evaluation by the family physician.
functional in origin. This report concerns a patient with An EEG showed infrequent and transient bitemporal ac
monocular diplopia that was not of functional origin tivity, but was within normal limits. Routine and enhanced
but represented migrainous involvement of the occipi computed tomographic (CT) brains scans were normal. The
tal lobes. patient had been placed on aspirin and dipyridamole, and
was given propranolol for headaches and hypertension.
Case report She has since reported no further episodes of monocular
A 40-year-old woman noted the abrupt development of diplopia.
episodes of diplopia. These occurred infrequently, lasted up
to 30 minutes, were usually Vertical but occasionally hori Discussion
zontal in nature, and were unrelieved by her covering either This patient had a well-defined personal and family
eye. The double vision was occasionally associated with history of migraine. She later developed monocular
initial or subsequent blurring of vision bilaterally, but with no diplopia involving either eye in association with mi
other neurologic Symptoms. The diplopia improved gradu graine attacks. No ocular disease was demonstrated,
ally after approximately 30 minutes, and was succeeded by and there was no indication of a potential neurologic
severe generalized throbbing headache, sometimes asso cause for diplopia other than migraine. It is likely that
ciated with nausea and vomiting. Her medical history was
this case represents an infrequently encountered or
remarkable for generalized throbbing headaches with nau
sea and vomiting, which had previously been considered to ganic cause of monocular diplopia, namely bilateral
represent migraine, and for hypertension, treated with a occipital dysfunction owing to migraine.
diuretic. There was a family history of atherosclerotic car Monocular diplopia and polyopia is most frequently
diovascular disease, stroke, and migraine. of functional origin) Unilateral diplopia involving one
eye only may occur on the basis ofocular disease in the
Dr. Drake is assistaniprofessor in the department of neurology involved eye, chiefly cataracts, corneal opacities, astig
at the Ohio State University College of Medicine. Reprint matism of severe degree, and dislocation of the lens.2
requests to him there, 46 7 Means Hall, 410 West 10th A ye., Bielschowsky3 described a patient with long-standing
Columbus, OH 43210. convergent strabismus and amblyopia of the left eye,
who developed monocular diplopia in that eye after vious accounts have not distinguished between monoc
loss of the right eye. This was ascribed to divergence ular and binocular diplopia, but it is likely that most
between the true macula ofthe left eye and the previous diplopia was of the more common binocular variety.
false macula in that amblyopic eye. Lance and Anthony'Â° found visual involvement, in
Monocular diplopia in only a specific eye is occa cluding obscuration ofthe type reported by our patient,
sionally encountered inamblyopic patients, on account in association with diplopic episodes, in 32.8% of all
of presentation of dissimilar targets on refraction, or migraine patients. Symptoms referable to brain stem
soon after the initial establishment of a dominant dysfunction, including diplopia that was not further
macula.2 Cass4 encountered monocular diplopia in 33 classified, were reported in 24.4%.
of 70 patients with strabismus. This was ascribed to a Three of the twelve patients studied by Swanson and
disparity in retinal images caused by incongruity of the I experienced diplopia. One of these manifested
false macula in the squinted eye with the true macula in definite binocular diplopia in association with abdu
the normal eye; such monocular diplopia was likewise cent-nerve palsy. The monocular or binocular character
confined to the squinted eye. Unilateral monocular of the diplopia in the other two patients was not
diplopia has also been reported5 in patients with a specified. Such patients have often been reportedt2 to
refractive difference between upper and lower portions have various nonspecific EEG changes, and it is likely
of the retina, resulting in vertical displacement of the that our patient with intermittent bitemporal activity
images with the fainter one above. could be included in this group of migraine sufferers.
Bilateral monocular diplopia has been described in Evidence of diminished cerebral blood flow during
association with visual-field defects and abnormalities the migrainous aura clearly suggests a vascular basis for
of fixation that conduce to the formation of a false these symptoms,'3 and raises the possibility of fixed
macula, and in association with tumors of the occipital neurologic deficits after an attack. Cerebral infarctions
lobe.6 Gordon and Bender7 encountered monocular and edema have been demonstrated in migraine pa
diplopia and polyopia along with oscillating visual tients with neurologic deficits associated with their
disturbances in multiple sclerosis patients having in attacks,'4 and this underscores the importance of recog
volvement of the medial longitudinal fasciculus. nition and treatment of complicated migraine syn
Benders also studied four patients with monocular dromes. Although monocular diplopia independent of
diplopia or polyopia with use of either eye. He found a the eye's being used is most often a functional symp
consistent pattern of scotoma in one eye; visual dis tom, our case indicates that such complicated migraine
turbance in the field affected by the scotoma that syndromes may present in this fashion. 0
involved obscuration, fluctuation, or extinction; and
the presence of optical illusions or spatial disorienta
tion. Two ofthe patients had suffered occipital injuries, 1. Bender MB: Neuro-ophthalmotogy, in Baker AB, Baker LM (eds): Clinical
one had diffuse cerebral dysfunction including occipital Neurology. Hagerstown, Md. Harper and Row. 1976, vol 1. pp 38, 115.
2. Pincus MH: Monocular diplopia. Am J Ophthalmol 24:503-506. 1941.
involvement after encephalitis, and one had a defect in 3. Bielschowsky A: Ueber monokular Diplopie ohne physikalische Grund
visual fixation oft@ncertain etiology but presumed occi age nebst Bemerkungen ueber das sehen Schelenden. Arch Ophthalmol
pital origin. Bender' has proposed that bilateral mon 4. Cass EE: Monocular diplopia occurring in cases of squint. Br J Ophthal
ocular diplopia represents a disturbance in visual inte mol25:565-577, 1941.
5. Fincham EF: Monocular diplopia. Br J Ophthalmol 47:705-712. 1956.
gration on the basis of occipital disease, and that such 6. Walsh FB, Hoyt WF: Clinical Neuro-ophthalmology. ed 2. Baltimore,
diplopia of organic origin can be recognized by in Williamsand Wilkins, 1969, vol 1. p 140.
7. Gordon RM, Bender MB: visual phenomena in lesions of the medial
volvement of homonymous portions of the visual field longitudinal fasciculus. Arch Neurol 15:238-240, 1966.
in both eyes, proximity of the involved area to an area 8. Bender MB: Polyopia and monocular dsplopia of cerebral origin. AMA
Arch Neurol Psychiatry 54:323-338, 1945.
of visual-field defect in each eye, and increase in 9. Bickerstaff ER: Basilar artery migraine. Lancet l:15-17, 1961.
diplopia when observing moving objects. Although our 10. Lance JW, Anthony M: Some clinical aspects of migraine. Arch Neurol
patient had no evidence by EEG or CT brain scan of an 11. Swanson JW, Vick N: Basilar artery migraine. Neurology 28:782-786,
occipital lesion, it is most likely that her bilateral 1978.
monocular diplopia was of the cerebral type, and rep 12. Smyth VO. Winter Electroencephalogr
AL: The EEG inmigraine. Gun
Neurophysiol 16:194-202, 1964.
resented occipital involvement by migraine. 13. Lance JW: Mechanism and Management of Headache. ed 4. London.
Butterworth, 1982, pp 155-156.
Diplopia has been described in migraine, particular 14. Gala LA. MastÃ gliaFL: Computerised axial tomographic findings in
ly in vertebrobasilar- or basilar-artery migraine.9 Pre patients with migrainous headaches. Br Med J 2:149-150. 1976.
NOVEMBER 1983 VOL 24@NO 11 1027