One-and-a-half Syndrome
Clinical Presentation 73 years old male with sudden onset of horizontal diplopia for 1 day PMH - hypertension, hyperlipidemia no history of headache, facial/eye pain, seizure, weakness, or sensory abnormality.
What to consider first when a patient comes with horizontal diplopia? Neuro or Eye problem?
Ask the patient to cover each eye and see whether diplopia goes away or not!
If diplopia goes away ( diplopia occurs only when both eyes are open ) ( binocular diplopia ) - it’s due to misalignment of the eyes - likely Neurological problems Brainstem CN 3,4,6 palsies Extraocular muscles Neuromuscular junction Central coordination
If diplopia does not go away and persists when the other eye is closed ( monocular diplopia ) - it’s due to ocular problem in that opened eye Refractive error Lens abnormalities Corneal issues Retinal problems
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