Double Vision. An example of learning to learn when health gets personal - Updated
It is very rewarding to have the means and skills to investigate with open curiosity something that is very personal, consequential and potentially life changing or even lifesaving.
Double Vision (Diplopia)
It is very rewarding to have the means and skills to investigate with open curiosity something that is very personal, consequential and potentially life changing or even lifesaving.
Health challenges or surprising debilitating symptoms can have significantly better outcomes when simple investigation skills are acquired and resultant communication and collaboration with health professionals (if needed) is acted upon.
I will use a personal example of a surprising crippling episode of double vision, also known as Diplopia, that I experienced unexpectedly yesterday.
As I am the patient here, yet also a health professional and educator who is passionate about getting best possible health outcomes, we will break this article down into these sections -
What to do when something unusual is happing to you - either recently or happening for some time.
How to best recall and jot down what lead up to the issue
Composing brief letter to Doctor or Health professional with
a/ description of symptoms , b/ associated activities at the time or leading up to the event or longer term health condition, c/ possible causes according to YOUR knowledge, intuition and/or research and d/ a simple and concise Differential Diagnosis provided by Medical Ai.
We often don’t have time or can feel intimidated to express these 4 points clearly on the spot in a meeting or consult. A Differential Diagnosis is a thorough well established process, used in various forms in science, medicine and criminology and is used to hypothesise potential causes, do some initial simple tests to eliminate to usual suspects and go deeper with investigations if needed.All the while developing simple investigation techniques and skills to quickly find out the seriousness or urgency of this issue or other issues as they arise. How we acquire these skills and knowledge. How to use Medical Ai so as to assist your knowledge and give the Doctor or Health Professional a head start, thus saving you both time and stress and you, money. It’s not rocket science.
Work on interventions and/or lifestyle changes to alleviate symptoms (short term) and causes of the issue (long term).
Ongoing Double Vision case study (Myself). So we’ll start with the symptoms. The episode started at 8am in the morning with sudden onset and following symptoms. The most severe symptom is seeing double. If block either eye, then it's okay, the vision is normal. But when both eyes are open, everything is in double vision, not blurred, but just double vision. Difficult to move as the double vision affects being able to see when moving. There's not an issue with balance per se, but just the double vision makes it difficult. This has happened about three times in the last year.
Associated activities. The day before the issue there was a lot of time spent on the computer and moving the mouse. That's one. Second, at 7am in morning, just before this happened, got up out of bed, went for a walk, had a coffee and a biscuit at a restaurant, then went to the loo, and when got up from the loo, this is when symptoms came on suddenly, very suddenly. And then had shower, and after five or ten minutes, the symptom of the double vision gradually resolved or receded.
What to do when something unusual, health wise, is happing to you - either recently or happening for some time.
Pay attention. Observe and feel as many details as possible. Note them mentally so that recall and writing them down later is easier. Obviously, if concerned, call an ambulance immediately or ask for help. If possible make some changes to posture or other things - like closing one eye in our example - to see if things improve or worsen. In our example I was able to look in the mirror and observe the pupils of both eyes. This can gather important information that will inform which tests are needed and the building of the Differential Diagnosis and resultant treatments.
When able, write it all down. Sooner the better. Memory fades if recall is not practiced soon after the event. Document all symptoms, signs, feelings and mental processes, no matter how trivial. We are manifesting our open curiosity, our desire to learn more. Simply by documenting in as much detail as possible what we observed. Document all associated activities during and before the episode/health condition.
Now the next 2 suggestions require developing some simple skills and experience. Only requires a little time. Look, doing this process just once will change you, for the better, forever. The second time you do it, everything will be much easier and more enjoyable. If you need to do it a third time, you actually start looking forward to the process - which is really about learning. When you are deeply invested in a personal outcome, like your health, motivation is not a problem or obstacle to learning something new. Seize the moment.
So we can gather information our selves about what is happing to us using several options. Manually, using Google and other known trusted sources. This may require some training, coaching or at least experience. Depending on your experience or previous knowledge, time is required to get up to a level where you know the terrain and key words that can be built upon and most importantly, so you can begin to ask the right questions. In this life, it’s not just about what you know, but also becoming aware of what you still need to know.
Another option also requires a bit of time to get up to speed. Humanity is about to have tools available to everyone that have never existed before. Amidst the hype and controversy, these tools are quietly rolling out as we speak, and they will empower, inform and provide insight to individuals about their health and many other useful things. My father gave me the gift of 10 one hour driving lessons when I turned 18, many years ago. The time spent built a skill (driving) that set me up for many journeys and explorations during my life. In just 10 hours I learnt how to use this life changing technology tool (the car). And I got my licence.
You don’t need a licence to drive a well established Ai Tool like OpenAi’s Chat GPT or Anthropic’s Claude but you do need to put in some time to learn how to use the tool well so that you get what you need from it. Turns out you need about 10 hours of your time to get proficient. See Ethan Mollick’s article entitled “Getting started with AI: Good enough prompting” for more substance around the use of Ai for medical or health related inquiry including the importance of putting in the initial 10 hours to learn how to drive this tool for optimal and long term benefit as we keep using it. We keep learning, mostly through feedback. The driving analogy holds true here also.
While reading a new paper on doctors using GPT-4 to diagnose disease, I saw a familiar problem with AI. The paper confirmed what many other similar studies have found: frontier Large Language Models are surprisingly good at diagnosis, even though they are not specifically built for medicine. You'd expect this AI capability to help doctors be more accurate. Yet doctors using AI performed no better than those working without it—and both groups did worse than ChatGPT alone. Why didn't the doctors benefit from the AI's help?
One reason is algorithmic aversion. We don’t like taking instructions from machines when they conflict with our judgement, which caused doctors to overrule the AI, even when it was accurate. But a second reason for this problem is very specific to working with Large Language Models. To people who aren’t used to using them, AI systems are surprisingly hard to get a handle on, resulting in a failure to benefit from their advice.
from Ethan Mollick’s article
Lastly schedule appointment with your doctor or health professional and present your findings. This may sound like a lot of work or even overly professional. Why not just show up? That’s fine. Yet, as we have said - being informed with clear communication, leads to better long term health outcomes.
Next we will show an example of using the latest version of Chat GPT to explore Double Vision, in addition to several well established web sites and clear articles.
We will even ask Ai to compose a letter that outlines all the above including a Differential Diagnosis and suggested interventions and other recommendations and followup test, at least in the short term for our upcoming doctors appointment.
Double Vision (Diplopia) background
“Diplopia is the perception of 2 images of a single object. Diplopia may be monocular or binocular. Monocular diplopia is present when only one eye is open. Binocular diplopia disappears when either eye is closed.”
Simply using Google to look up double vision revealed this site/article -
Diplopia (Double Vision), By Christopher J. Brady, MD, Wilmer Eye Institute, Retina Division, Johns Hopkins University School of Medicine, Reviewed/Revised Dec 2023.
The website is an online medical manual and Christopher is Assistant Professor of Ophthalmology at the Wilmer Eye Institute, Retina Division, Johns Hopkins University School of Medicine. Credible source.
Even though it took me about 1 minute to find this, some experience, coaching and skill is needed to quickly assess the quality and reliability of the source and information. Simple but like the Ai tool, requires a little time to get good at. Worth it.
Also, as can be seen next, when new information is found, often words are used that we don’t know. Have an online dictionary open while reading. Because what you are investigating is important and relevant to you, these new words will be more easily remembered next time you see them.
From the above article/website the following was revealed regarding possible cause of Double Vision.
From - Diplopia (Double Vision) By Christopher J. Brady, MD, Wilmer Eye Institute, Retina Division, Johns Hopkins University School of Medicine, Reviewed/Revised Dec 2023
One thing to watch out for is Medical Student Syndrome when investigating health related information. One assumes easily that they have anything and everything that is discovered as a possible cause. Rememberer, we are only gathering information and learning new words and concepts and we are collaborating with a health professional by gathering this information, presenting it and letting them follow through with relevant tests after further questioning and physical examination.
Important Point
Getting information from an article or website is mostly static. Meaning, you can’t interact with it, ask it to explain more or ask it something unique to you. However, useful relevant info that is found online can be added to what you find next.
What we explore next is not static and as you will see opens up to very personal, unique and highly relevant information for you.
Questioning Chat GPT
First give some background. For this example I used the paid version of Open AI’s latest 4.o version of Chat GPT. (It’s 5th December 2024). I explained my symptoms and associated factors as described above to Polly. You can now talk in normal everyday language to Chat GPT and tell it your name and even give the voice a name ( I chose Polly as it was a female voice and short for Polymath) and precede to have a natural conversation that is simultaneously printed out.
Here is Polly’s response after I gave my symptoms and associated events and asked for possible causes, a Differential Diagnosis and strategies in the short term.
After this response I asked a deeper question about something I did just before and how it could lead to the double vision.
Finally I asked for help to construct a letter to give my doctor on our next appointment.
Polly’s Response - unedited
Thanks for the detailed account. Let me break this down and explore possible causes and differential diagnoses first, then move to strategies.
Potential Causes and Differential Diagnosis:
Ocular Issues (Eye Muscle or Nerve Problem):
Strabismus or intermittent exotropia: Misalignment of the eyes could cause sudden double vision.
Cranial nerve palsy: Involvement of cranial nerves III (oculomotor), IV (trochlear), or VI (abducens), which control eye movement.
Neurological Causes:
Transient ischemic attack (TIA): A mini-stroke could cause sudden double vision, resolving quickly.
Increased intracranial pressure: Could explain episodic occurrences.
Multiple sclerosis (MS): If the person has other neurological symptoms, MS could cause intermittent vision disturbances.
Vascular Causes:
Orthostatic hypotension: Sudden position change after defecation could cause temporary lack of blood flow to the brain.
Vertebrobasilar insufficiency: Insufficient blood flow in the vertebrobasilar artery system can cause double vision and other symptoms.
Metabolic or Systemic Issues:
Hypoglycemia: Low blood sugar could contribute, especially after a period of fasting or a light breakfast.
Electrolyte imbalances: These might explain transient symptoms.
Cervical Spine or Musculoskeletal Issues:
Cervical spondylosis or nerve impingement: Could affect the nerves controlling the eyes or blood flow to the brain.
Muscle tension: From prolonged computer use and posture strain.
Psychogenic Causes:
Rare but possible: stress or anxiety could trigger transient neurological symptoms.
Strategies to Avoid or Treat:
Immediate Measures:
Monitor blood pressure and blood sugar after these episodes.
Avoid sudden position changes, particularly after sitting or straining.
Medical Interventions:
A thorough evaluation by an ophthalmologist or neurologist.
Tests: MRI/CT scan of the brain, cervical spine imaging, or blood work to rule out systemic causes.
Consider referral for cardiovascular evaluation if vascular causes are suspected.
Lifestyle Adjustments:
Take breaks during computer use and adjust posture to avoid musculoskeletal strain.
Stay hydrated and have balanced meals to maintain blood sugar levels.
Avoid excessive straining during defecation; increasing fiber intake could help.
Preventative Health Maintenance:
Regular eye check-ups.
Screening for diabetes, hypertension, and other vascular risk factors.
Next I asked about the possible influence of the thing I was doing just before the Double vision came on
Okay can you elaborate on as the immediate action just before it came on - sitting on the loo and then getting up - can you expand a little bit on what might have happened in that process?
Polly said…
The act of defecating combined with the action of standing up suddenly, could have triggered one or more physiological responses:
Valsalva Maneuver:
Straining during defecation involves holding your breath and bearing down, which can temporarily increase intra-abdominal pressure. This can reduce venous return to the heart, momentarily lowering blood flow to the brain and causing symptoms like lightheadedness or visual disturbances, including double vision.
Orthostatic Hypotension:
After standing up from the toilet, there may be a temporary drop in blood pressure, especially if the person stood up too quickly. This can reduce blood flow to critical areas of the brain, potentially causing transient double vision. It's more likely if dehydration or poor vascular tone is present.
Cervical Compression or Nerve Impingement:
Sitting on the toilet, particularly with poor posture, can compress the cervical spine or stretch neck muscles. If nerves or blood vessels in the neck are momentarily affected, it could result in symptoms like double vision.
Vasovagal Response:
Defecation can sometimes trigger a vasovagal reaction, where the vagus nerve becomes overactive, causing a brief drop in heart rate and blood pressure. This could lead to reduced blood flow to the brain and visual disturbances.
Cerebrovascular Insufficiency:
Straining or positional changes could momentarily affect the vertebrobasilar circulation (the blood supply to the brainstem and eyes). This might explain transient vision issues.
Given that the symptoms resolved after a short period, it’s less likely to be a structural or permanent issue, but recurrent episodes may warrant further investigation into vascular or neurological causes.
The letter to my doctor simply summarised the above and I will print this for my next appointment so we can decide together what to do next.
Hope you got something useful from this discussion and please feel free to leave comments and ask questions.
Finally, in my clinic and online phone coaching, I help people improve their skills in all aspects of what was spoken about above. Reach out if you wish to know more or book a session.