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Supplementary Testing. Besides the basic comprehensive eye examination, additional testing should include versions and ductions (forced ductions if possible). Parks three-step test (for vertical diplopia) and Hess Lancaster or red lens test (for horizontal diplopia) to help identify the paretic muscle.
Patients complain of horizontal diplopia worse in the distance, and examination reveals an esotropia that increases with ipsilateral horizontal gaze. In some cases, cover testing may also reveal a small, less than 5 Δ of hypertropia (likely a hyperphoria that manifests itself when fusion is interrupted).
Because any eye muscle or motility pattern can occur in myasthenia gravis (MG), it should remain on the differential diagnosis of any patient with binocular diplopia. The pupillary examination should be normal and there should be no sensory symptoms (ie, pain or numbness).
Exophthalmos is one possible finding in patients who present with thyroid disease, one of several possible diagnoses in patients who present with diplopia. A thorough history, while important for any comprehensive eye examination, can really help determine the diagnosis in patients with diplopia.