Japanese Journal of Ophthalmology

, Volume 62, Issue 6, pp 659–666 | Cite as

Causes, background, and characteristics of binocular diplopia in the elderly

  • Manami Kawai
  • Toshiaki GosekiEmail author
  • Hitoshi Ishikawa
  • Miki Hoshina
  • Nobuyuki Shoji
Clinical Investigation



We evaluated the background and characteristics of elderly patients with binocular diplopia including diseases caused by abnormalities in orbital pulleys.

Study design



The participants were 236 patients aged 60 years or older who visited Kitasato University Hospital complaining of binocular diplopia. We classified strabismus by types and investigated the causes for each group. We diagnosed orbital pulley disorders using magnetic resonance imaging (MRI). Patients with orbital pulley disorders exhibited esotropia and/or vertical strabismus and did not present with cranial nerve palsy, systemic illness, or ocular injury.


Classification of strabismus types was: exotropia (24.2%); esotropia (25.0%); vertical strabismus (30.1%), combined strabismus (20.8%). There were 50.9% cases of strabismus associated with vertical deviation. The causes of disease in each group were as follows: in the exotropia group, 50.9% convergence insufficiency exotropia, 21.1% basic exotropia; in the esotropia group: 35.6% orbital pulley disorder 33.9% sixth cranial nerve palsy; in the vertical strabismus group: 32.4% forth cranial nerve palsy, 31.0% orbital pulley disorder; in the combined strabismus group: 28.6% orbital pulley disorder, 28.6% forth cranial nerve palsy.


About half of the elderly patients with binocular diplopia exhibited vertical deviation. In addition, binocular diplopia was often caused by orbital pulley disorders. It is the first epidemiological study focusing on orbital pulley disorders diagnosed on the basis of MRI.


Strabismus Binocular diplopia Orbital pulley Elderly Japanese 



We would like to thank Associate Prof. Dr. R. Ukisu of the Department of Diagnostic Radiology, Kitasato University Hospital for performing MRI and comments that greatly improved the manuscript.

Conflicts of interest

M. Kawai, None; T. Goseki, None; H. Ishikawa, None; M. Hoshina, None; N. Shoji, Equipment (RE Medical, Tomey).


  1. 1.
    Martinez-Thompson JM, Diehl NN, Holmes JM, Mohney BG. Incidence, types, and lifetime risk of adult- onset strabismus. Ophthalmology. 2014;121:877–82.CrossRefGoogle Scholar
  2. 2.
    Tamhankar MA, Biousse V, Ying GS, Prasad S, Subramanian PS, Lee MS, et al. Isolated third, fourth, and sixth cranial nerve palsies from presumed microvascular versus other causes. Ophthalmology. 2013;120:2264–9.CrossRefGoogle Scholar
  3. 3.
    Casetta I, Groppo E, De Gennaro R, Cesnik E, Piccolo L, Volpato S, et al. Myasthenia gravis: a changing pattern of incidence. J Neurol. 2010;257:2015–9.CrossRefGoogle Scholar
  4. 4.
    Vincent A, Clover L, Buckley C, Grimley Evans J, Rothwell PM, UK Myasthenia Gravis Survey. Evidence of underdiagnosis of myasthenia gravis in older people. J Neurol Neurosurg Psychiatry. 2003;74:1105–8.CrossRefGoogle Scholar
  5. 5.
    Demer JL, Oh SY, Poukens V. Evidence for active control of rectus extraocular muscle pulleys. Invest Ophthalmol Vis Sci. 2000;41:1280–90.PubMedGoogle Scholar
  6. 6.
    Rutar T, Demer JL. “Heavy Eye” syndrome in the absence of high myopia: a connective tissue degeneration in elderly strabismic patients. J AAPOS. 2009;13:36–44.CrossRefGoogle Scholar
  7. 7.
    Chaudhuri Z, Demer JL. Sagging eye syndrome: connective tissue involution as a cause of horizontal and vertical strabismus in older patients. JAMAOphthalmol. 2013;131:619–25.Google Scholar
  8. 8.
    Yokoyama T, Tabuchi H, Ataka S, Shiraki K, Miki T, Mochizuki K. The mechanism of development in progressive esotropia with high myopia. In: de Faber JT, editor. In: Transactions of the 26th meeting of European Strabismological Association. Barcelona, Spain, September 2000. Lisse (Netherland): Swets & Zeitlinger Publishers. 2000. pp. 218 –21.Google Scholar
  9. 9.
    Tan RJD, Demer JL. Heavy eye syndrome versus sagging eye syndrome in high myopia. JAAPOS. 2015;19:500–6.Google Scholar
  10. 10.
    Demer JL. Knobby eye syndrome. Strabismus. 2018;26:33–41.CrossRefGoogle Scholar
  11. 11.
    Kohmoto H, Inoue K, Wakakura M. Divergence insufficiency associated with high myopia. Clin Ophthalmol. 2011;5:11–6.Google Scholar
  12. 12.
    Nakao Y, Kimura T. Prevalence and anatomic mechanism of highly myopic strabismus among Japanese with severe myopia. Jpn J Ophthalmol. 2014;58:218–24.CrossRefGoogle Scholar
  13. 13.
    Kobashi R, Ohtsuki H, Hasebe S. Clinical studies of ocular motility disturbances. Part 1. Ocular motility disturbances: causes and incidence. Jpn J Ophthalmol. 1996;40:502–10.PubMedGoogle Scholar
  14. 14.
    Mimura O, Utsumi T, Kimura A, Tanaka H, Kurimoto T. Prognosis of ocular motor nerve palsies. Jpn Rev Clin Ophthalmol. 2007;101:178–81 (in Japanese).Google Scholar
  15. 15.
    Akagi T, Miyamoto K, Kashii S, Yoshimura N. Cause and prognosis of neurologically isolated third, fourth, or sixth cranial nerve dysfunction in cases of oculomotor palsy. Jpn J Ophthalmol. 2008;52:32–5.CrossRefGoogle Scholar
  16. 16.
    Park UC, Kim SJ, Hwang JM, Yu YS. Clinical features and natural history of acquired third, fourth, and sixth cranial nerve palsy. Eye. 2008;22:691–6.CrossRefGoogle Scholar
  17. 17.
    Ohta I, Kataoka N. Causes and characteristics of patients who visit ophthalmologists for diplopia. Jpn J Clin Ophthalmol. 2011;6:1505–10 (in Japanese).Google Scholar
  18. 18.
    EL-Sahn MF, Granet DB, Marvasti A, Roa A, Kinori M. Strabismus in adults older than 60 years. J Pediatr Ophthalmol Strabismus. 2016;53:365–8.CrossRefGoogle Scholar
  19. 19.
    Leat SJ, Chan LL-L, Maharaj PD, Hrynchak PK, Mittelstaedt A, Machan CM, Irving EL. Binocular vision and eye movement disorders in older adults. Invest Ophthalmol Vis Sci. 2013;54:3798–805.CrossRefGoogle Scholar
  20. 20.
    Kono R, Okanobu H, Ohtsuki H, Demer JL. Absence of relationship between oblique muscle size and Bielschowsky head tilt phenomenon in clinically diagnosed superior oblique palsy. Invest Ophthalmol Vis Sci. 2009;50:175–9.CrossRefGoogle Scholar
  21. 21.
    Hoshina M, Ishikawa H, Goseki T, Handa T, Sato T, Shimizu K. Nine-direction deviation examination of superior oblique paralysis using the 3D visual function trainer-ORTe. J Eye. 2016;33:915–9 (in Japanese).Google Scholar
  22. 22.
    Goseki T, Ishikawa H. The prevalence and types of strabismus, and average of stereopsis in Japanese adults. Jpn J Ophthalmol. 2017;61:280–5.CrossRefGoogle Scholar
  23. 23.
    Palomo Álvarez C, Puell MC, Sánchez-Ramos C, Villena C. Normal values of distance heterophoria and fusional vergence ranges and effects of age. Graefe’s Arch Clin Exp Ophthalmol. 2006;244:821–4.CrossRefGoogle Scholar
  24. 24.
    Wiggins RE, Baumgartner S. Diagnosis and management of divergence weakness in adults. Ophthalmology. 1999;106:1353–6.CrossRefGoogle Scholar
  25. 25.
    Thomas AH. Divergence insufficiency. J AAPOS. 2000;4:359–61.CrossRefGoogle Scholar
  26. 26.
    Daniel MJ. Divergence insufficiency revisited natural history of idiopathic cases and neurologic associations. Arch Ophthalmol. 2000;118:1237–41.CrossRefGoogle Scholar
  27. 27.
    Mittelman D. Age-related distance esotropia. J AAPOS. 2006;10:212–3.CrossRefGoogle Scholar
  28. 28.
    Stacy LP. Divergence insufficiency esotropia: surgical treatment. Am Orthopt J. 2015;65:35–9.CrossRefGoogle Scholar
  29. 29.
    Gómez de Liaño Sánchez P P, Olavarri González G, Merino Sanz P, Xescribano Villafruela JC. Age-related distance esotropia: Clinical features and therapeutic outcomes. Arch Soc Esp Oftalmol. 2016;91:561–6.CrossRefGoogle Scholar
  30. 30.
    Gómez de Liaño Sánchez PP, Olavarri González G, Merino Sanz P, Xescribano Villafruela JC. Orbital magnetic resonance imaging is useful in age-related distance esotropia. J Optom. 2018;11:86–92.CrossRefGoogle Scholar
  31. 31.
    Manchandia AM, Demer JL. Sensitivity of the three-step test in diagnosis of superior oblique palsy. J AAPOS. 2014;18:567–71.CrossRefGoogle Scholar
  32. 32.
    Muthusamy B, Irsch K, Peggy Chang HY, Guyton DL. The sensitivity of the bielschowsky head-tilt test in diagnosing acquired bilateral superior oblique paresis. Am J Ohpthalmol. 2014;157:901–7.CrossRefGoogle Scholar

Copyright information

© Japanese Ophthalmological Society 2018

Authors and Affiliations

  • Manami Kawai
    • 1
  • Toshiaki Goseki
    • 1
    • 2
    Email author
  • Hitoshi Ishikawa
    • 1
    • 3
  • Miki Hoshina
    • 4
  • Nobuyuki Shoji
    • 1
    • 2
  1. 1.Graduate School of Medical SciencesKitasato UniversitySagamiharaJapan
  2. 2.Department of OphthalmologyKitasato UniversitySagamiharaJapan
  3. 3.School of Allied Health SciencesKitasato UniversitySagamiharaJapan
  4. 4.Sanno HospitalMinato-kuJapan

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