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Medical Forum / General / Vision / September 2005Diagnosis and Treatment for Monocular Diplopia
This is an appeal for help in finding an ophthalmologist who can diagnose and treat the symptom described below. I would appreciate hearing from anyone who has had successful treatment for the condition, or from any doctor who feels competent to diagnose and treat it. I live in South Florida, but am able to travel elsewhere if necessary. I have Medicare primary and UHC secondary insurance. I am a 75 year old man. In bright light (pupil contracted) my right eye has near 20/20 vision (with glasses) but in medium and low light it has severe monocular diplopia (double vision in one eye). For example, when viewing CNN on television (with left eye covered), I see an easily readable second image of the "crawl" at the bottom of the screen. The second image is directly below and not as bright as the main image. In low light situations the interference by second image is so severe it makes night driving impossible. The second image can be completely eliminated by blocking light to the top part of the right pupil. History: Always myopic, glasses at age 12, IOL (for cataract, both eyes) in 1992, left eye dominant until 3 retinal detachments in left eye in 2002, right eye has become dominant as left eye vision deteriorated. I have had two procedures for treatment of impending detachments in right eye - in both cases I had noticed no impairment in vision - impending detachments detected during examinations for left eye problems. First procedure was laser repair in Jan. 2002: I first noticed the diplopia after this procedure. Second procedure was pneumatic retinopexy in Dec. 2003. At present the right eye seems to be stable. I have appt. in June for checkup by retinologist that performed PR. I have just received new glasses but they do not improve the diplopia. I have discussed the diplopia with three ophthalmologists (retinologists/vitrologists). All have stated that the IOL is correctly centered. None seemed to know what was causing the diplopia. The last ophthalmologist prescribed Pilocarpine HCL 0.5% drops to contract the pupil during low light situations. (I do not have glaucoma.) This corrects most the diplopia and enables me to drive at night. Some publications on the side effects of pilocarpine state it may cause retinal detachments - this make me reluctant to use it. I would like to know the cause of the diplopia and, if possible, have some permanent correction for it. Thanks to all for any help you can give, Bob Peyton > This is an appeal for help in finding an ophthalmologist who can diagnose > and treat the symptom described below. I would appreciate hearing from [quoted text clipped - 12 lines] > The second image can be completely eliminated by blocking light to the top > part of the right pupil. I am two years younger than you. My background is in optics but not optometry. I have posted on this subject here before without getting much in the way of helpful suggestions. Recently, I had cataract surgery on an eye that pretty much the way you describe. Without glasses, a point source appeared to become a starburst of multiple points. That persisted after surgery. This told me that the distorting crystalline les was not the source of these extra images. I could see more than six images of a traffic light of various intensities. I mentioned it to my opthalmologist. He said to ignore the problem until I was fitted with new glasses. Then If there still was a problem, he would look into it. The problem went away with my new glasses. He was very pragmatic and did not want to speculate on what the cause might be on a non-problem. This left the cause unresolved in my mind. I came to the conclusion that the cornea of that eye had a series of lenslets, each producing its own image. Although I have not figured out the detailed explanation, stopping part of the eye with a finger would eliminate some of those images. It as if the cornea was polygonal rather than spherical in the first approximation. Again, without understanding the details, I analogize it somewhat to the focussing screens used in some reflex cameras. The screen acts as a ground glass for observing the image formed upon it by the lens. Thus, no matter how it scatters, the light leaving it gets focussed by the crystalline lens onto the retina. If the image is not formed at the screen, then the various prisms and other perturbations on the screen enhance the blurriness. This makes it possible to get better focus accuracy. Bill Bill, Thanks for your quick reply. As a former SLR enthusiast - now gone digital - I particularly liked the camera analogy. Although not as experienced as you are in optics, I agree that I probably have two image forming systems operating in the one eye. With my limited knowledge I assume that the extra "lenslet" (good term) could be on any surface of the optical system where a change in density (air-cornea, cornea-aqueous, aqueous-IOL, IOL-vitreous) occurs. It seems to me that the most likely place is either the anterior or posterior surface of the cornea, but it could be some sort of bubble on the IOL or elsewhere. I can't think of any way to determine the location. I also like the term "stopping" you used instead of my "blocking". I see very well when I stop down to f22 or so :>) I have not been able to arouse any real interest in or serious comment about my diplopia from the ophthalmologists I have seen. The last guy thought of and prescribed the pilocarpine after I asked if it was possible to get a contact lens with an opaque annular ring that blocked out the outer part of the pupil. Actually, I think I need one with the transparent inner part in the shape of a capital "D" rotated 90 degrees right, although I doubt if this is practical. I don't see many msgs. on this group from people who seem to be professionals. I have tried Emailing a couple of highly advertised Eye Clinics (at addresses on their Web Pages) and have not received an answer. Do you know of any ophthalmology BB, mailing list, etc. that is open to posting by non-professionals and read by professionals? Thanks again, Bob > > This is an appeal for help in finding an ophthalmologist who can diagnose > > and treat the symptom described below. I would appreciate hearing from [quoted text clipped - 42 lines] > > Bill > Thanks for your quick reply. As a former SLR enthusiast - now gone > digital - I particularly liked the camera analogy. Although not as [quoted text clipped - 6 lines] > could be some sort of bubble on the IOL or elsewhere. I can't think of any > way to determine the location. There are all kinds of possibilities, but without detailed lab measurement and test, it would be hard to pin them down. They would have to have serious clinical consequence in terms of numbers of patients and decreased vision before there would be enough money to make it a funded project. Another conclusion I reached in regard to myopic eyes is that the real image formed in front of the retina can produce a moire interaction with floatgers. Bill > I have discussed the diplopia with three ophthalmologists > (retinologists/vitrologists). All have stated that the IOL is correctly > centered. None seemed to know what was causing the diplopia. The cause of any problem of the eyes and vision is mental strain. You should discard the glasses and understand the proper treatment with rest methods. For example, try to train your mind to remember a small letter you can see at 20 feet, with eyes closed in good light. You should learn to retain the letter even with eyes closed, and then with eyes open and looking on a blank wall. You will see that in a few minutes the diplopia will disappear, even if for few instants. Once you demonstrate this, all that you have to do is to continue the practice until you are cured. Don't follow any ophthalmologists, they know knothing about the eyes and vision. If you are interested, please visit http://TheCentralFixation.com If your IOL is correctly positioned, the only surface left to generate diplopia is your cornea. Ideally your cornea would have the same curvature everywhere. Your cornea has likely developed some irregularity of shape that gives you separate focal points for two major areas. You can prove this by looking through a pinhole. When your pupils are large and you see the double image, hold up a pinhole and move it around in front of your pupil. You will only see one image, but if you move it around just so, you may see some "jump" or dislocation in the image. I can think of three or four ways to fix this. Wavefront-guided LASIK would map out the irregularities and try to smooth them. It will cost $1500-$2500. Pilocarpine drops, you've already tried. A soft contact lens could be made with an opaque ring, essentially giving you a new pupil that does not get large. A clear soft lens _might_ reduce the diplopia simply by providing a (somewhat) more regular front surface. A rigid contact lens would very likely replace the irregular corneal surface with a smooth, machine-made spherical shape. This may be the most practical solution. -MT, OD > This is an appeal for help in finding an ophthalmologist who can diagnose > and treat the symptom described below. I would appreciate hearing from [quoted text clipped - 40 lines] > > Bob Peyton > If your IOL is correctly positioned, the only surface left to generate > diplopia is your cornea. Oops, I meant "the only surface _likely_ to generate diplopia." There are three or four other conceivable causes but they're rare, and corneal irregularities are common. If your symptoms are disabling, LASIK might be covered by your insurance, especially if you have some demonstrable cause like pterygium or a tightening cataract wound. In any case, medical insurance should cover a simple topography to diagnose the cause of your diplopia and to rule out keratoconus. Out-of-pocket shouldn't be more than $200 if it wasn't covered. -MT, OD Mike, Thank you very much. Both of your posts are right on. I tested by creating a black screen on my PC, then placing some very small white type in the center. Experience has shown me that a high contrast image like that gives me the best look at the "ghost" image. Viewed in a darkened room, with or without glasses, I see the main image with the ghost below and slightly to the right. Viewed thru a pinhole, only one image is ever visible, and the image jumps from up to down and back as I move the pinhole over or below the top of my pupil. At first, I was confused by the fact that the up and down images were of the same brightness (which is not true without the pinhole), then I realized that the pinhole was limiting the "aperture" and I was getting the same reduced amount of light in either image. Will you bear with me for a couple of questions? Is it true, as it seems to me when I think about it, that the inner surface of the cornea is likely to be smooth and without localized distortions since pressure form the aqueous would tend to make it so, and therefore the distortion is most likely to be on the outer surface? Could the outer surface of the cornea have been distorted by trauma? If so, I think I might make a good guess at when it occurred, although I could never be sure. At any rate, I guess the next step is to have a corneal topography measurement. A quick Google shows there is a very highly rated (at least by themselves) Eye Center that does the procedure located within a few miles of where I live. Probably they can suggest the best corrective method after the measurement. Also, I will start to check what my primary and secondary health insurers will pay for. In any case $2000 would not be too much to pay for the ability to drive at night without fear. I am enjoying your discussion with Bill. Thanks so much for your help. Bob > > If your IOL is correctly positioned, the only surface left to generate > > diplopia is your cornea. [quoted text clipped - 12 lines] > > -MT, OD > Will you bear with me for a couple of questions? Is it true, as it seems to > me when I think about it, that the inner surface of the cornea is likely to [quoted text clipped - 3 lines] > distorted by trauma? If so, I think I might make a good guess at when it > occurred, although I could never be sure. Trauma, cataract surgery, or the onset of pterygium, keratoconus, keratoglobus, Terrien's marginal degeneration, and a whole bunch of corneal dystrophies. Don't get alarmed, tho. Most of the causes aren't that serious. > At any rate, I guess the next step is to have a corneal topography > measurement. Bingo. > A quick Google shows there is a very highly rated (at least by > themselves) Eye Center that does the procedure located within a few miles of > where I live. Probably they can suggest the best corrective method after > the measurement. Also, I will start to check what my primary and secondary > health insurers will pay for. In any case $2000 would not be too much to > pay for the ability to drive at night without fear. Ask about "custom ablation" with the Alcon laser. -MT Mike, Thanks for your advice. I am pursuing it. I'd like to impose on you for one more question. Following your suggestion I have been testing my vision with a homemade pinhole. I notice that it makes floaters less blurry, more contrasty and more objectionable. I hypothesize this is because the floaters intercept a greater percentage of the focused light when the aperture is smaller. I know that vision professionals generally adopt the position that floaters are just something you have to live with, but if my guess is correct, would this not make solutions that correct the basic problem with the cornea more desirable than those, such as pilocarpine or a soft lens with opaque ring, that restrict the pupil size? Thanks, Bob > > Will you bear with me for a couple of questions? Is it true, as it seems > to [quoted text clipped - 31 lines] > > -MT > Following your suggestion I have been testing my vision with a homemade > pinhole. I notice that it makes floaters less blurry, more contrasty and > more objectionable. I hypothesize this is because the floaters intercept a > greater percentage of the focused light when the aperture is smaller. In a fashion. A small light source casts a more distinct shadow than a large source, like there are big differences in the shadows formed by a single bulb versus a 2x4 fluorescent fixture. > this not make solutions that correct the basic problem with the cornea more > desirable than those, such as pilocarpine or a soft lens with opaque ring, > that restrict the pupil size? Yes. The two treatments I'd recommend first are rigid contacts and custom LASIK. These treatments wouldn't exaggerate floaters. -MT > If your IOL is correctly positioned, the only surface left to generate > diplopia is your cornea. [quoted text clipped - 6 lines] > image, but if you move it around just so, you may see some "jump" or > dislocation in the image. I have used the pinhole and saw the jumps just as you describe. The question that has not been answered is: Why does a properly fitted lens merge all this images into one? Bill > I have used the pinhole and saw the jumps just as you describe. The question > that has not been answered is: Why does a properly fitted lens merge all > this images into one? Which kind of lens? I presume you mean CL and not IOL? A rigid contact immediately eliminates corneal diplopia because the the lens and tears and cornea are all nearly the same index of refraction, compared to air. When you combine all those surfaces, only the frontmost surface matters, and if it's machined perfectly regular then there's only one point of focus. A soft lens can reduce corneal diplopia, for the same reason, but not usually so effective because it tends to conform to large irregularities. It's hard to imagine how an IOL could produce diplopia, except where a) the pupil is bigger than the IOL or b) there's a peripheral iridectomy or a hole in the iris that acts as a second pupil or c) the IOL is multifocal, or out of place, or has irregular defects. -MT >> I have used the pinhole and saw the jumps just as you describe. The > question [quoted text clipped - 18 lines] > > -MT I am talking about a conventional spectacle lens in a regular frame. The condition first get my intention when I was sleeping. As usual, I was sleeping without glasses. I just happened to see Mars through the window. Instead of seeing it as a single blurred image, it appeared to be a star-burst as from a firework frozen in time. When I put on my glasses, the spread of the star-burst was greatly diminished. After cataract surgery, the star-burst was still there at first. After getting new fitted glasses, all these images coalesced into one. I do not the optics that reconciles the multiple images without glasses with the single image with glasses even though I can explain each individually by itself. It is certainly true that stopping along the periphery of the entrance pupil can get rid of some images. Bill > itself. It is certainly true that stopping along the periphery of the > entrance pupil can get rid of some images. To me, this indicates corneal irregularities. Defocus exaggerates the multiple images, and the correcting lens makes them converge. No mystery. -MT > To me, this indicates corneal irregularities. Defocus exaggerates the > multiple images, and the correcting lens makes them converge. No mystery. I came to the same conclusion. Neverthelss, my understanding is vague and amorphous. It is not as satisfactory as understanding what happens in a Hartmann where a multiple aperture plate is used to sample different parts of a telescope objective. Bill >I am talking about a conventional spectacle lens in a regular frame. > [quoted text clipped - 12 lines] > >Bill If you had double images after cataract surgery that went away with conventional glasses, one of the most logical explanations is that the surgery induced a little astigmatism (not an uncommon thing). Because astigmatism by definition means that there are more than one focal point in different parts of the eye, it can cause a blur effect that appears to be a doubling. Since conventional astigmatism is corrected by glasses, that would explain why the problem went away when you put your glasses on. > If you had double images after cataract surgery that went away with > conventional glasses, one of the most logical explanations is that the surgery [quoted text clipped - 4 lines] > conventional astigmatism is corrected by glasses, that would explain why the > problem went away when you put your glasses on. I am pretty sure that the astigmatism was present before as well as after the surgery. I had come to the conclusion that I was getting multiple focal points. The appearance of point sources were more like what I would expect from an array of separate lenses--a fly's ey but with a single retina. Simple cylindrical error will not do that. Bill > I had come to the conclusion that I was getting multiple focal points. The > appearance of point sources were more like what I would expect from an array > of separate lenses--a fly's ey but with a single retina. Simple cylindrical > error will not do that. I like your "fly's eye" analogy. Local hills and valleys in the cornea do act like "lenslets". I've been learning the terminology that's been floating around in wavefront studies. The best fit I can find in the Zernicke polynomials are "trefoil" and "tetrafoil". Simple astigmatism (2-axis) creates a characteristic wave front that looks saddle-shaped just like a potato chip. The true cornea has some of the qualities of a raisin. -MT > I like your "fly's eye" analogy. Local hills and valleys in the cornea do > act like "lenslets". > > I've been learning the terminology that's been floating around in wavefront > studies. The best fit I can find in the Zernicke polynomials are "trefoil" > and "tetrafoil". Zernicke polynomials are the way to go. They are what are called a complete set of orthogonal functions. That is, they can represent any smooth variation of phase over a circular area. Rather than giving names like "trefoil" and the like, I would just give the mode numbers. It is only when certain polynomials get a lot of use that a specific name is really useful. For example, the spherical aberration polynomial is worth a name. > Simple astigmatism (2-axis) creates a characteristic wave front that looks > saddle-shaped just like a potato chip. The true cornea has some of the > qualities of a raisin. One of the problems with current prescription notation is that a cylinder representation is not unique. It takes two cylinders at 45° to each other to be unique. If they were at 90°, you would just get a sphere again. It is easier, however, to manufacture cylindrical lenses rather than the saddles x*y and x^2-y^2 that represent astigmatism. Besides, the astimatism of optometry is not the astigmatism of camera lenses. At least the Zernicke description can always give a prescription that is unique. Bill >Zernicke polynomials are the way to go. They are what are called a complete >set of orthogonal functions. That is, they can represent any smooth >variation of phase over a circular area. Rather than giving names like >"trefoil" and the like, I would just give the mode numbers. It is only when >certain polynomials get a lot of use that a specific name is really useful. >For example, the spherical aberration polynomial is worth a name. There is a company in San Diego, Opthonix, which makes lenses based on wavefront measurement of the eye, described in Zernicke polynomial coefficients up to 5th order. they have a multiply patented process whereby they can make lenses (for eyeglasses) utilizing this correction. the cost for these lenses is about $160 each. this may help with your diplopia. Optometrists, who can prescribe these lenses, have a wavefront measuring, device sold by Opthonix, which can take the necessary measurements, which are then sent electronically. I was/am a high myope, and had Lasik in 1998. this resulted in corrected vision, but with a lot of optical artifacts including some diplopia, starburst, coma and flare. I am waiting for a pair of glasses right now. The company is very new and has not yet really automated the process. it takes them about a month to make the lenses. Mat |
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