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Medical Forum / General / Vision / July 2005Strabismus acquired though monovision contacts
I am a woman in my 50's who began wearing monovision contacts about 9 years ago. I began experiencing occasional episodes of horizontal diplopia during my 4th year of monovision under specific circumstances (mostly night driving and watching movies in a theater). The ophthalmologist I consulted dismissed my concerns, telling me that he experienced double vision himself when he wasn't feeling well. So I continued using monovision, although the episodes of diplopia increased in frequency during each of the next five years. I decided to stop using monovision this spring (against the advise of my optometrist), and that's when my real vision problems began! The episodes of diplopia occurred throughout the day (distance vision only), impairing my ability to function. After a couple of useless consultations with eye care professionals, I found an optometrist who diagnosed strabismus and prescribed prism glasses (OS 3BO OD 3BO). The prisms (which are quite heavy) eliminate almost all of the diplopia, but my depth perception is still impaired. The optometrist also suggested vision therapy, but he did not appear to be too optimistic about the probability of successful results. So I am now considering strabismus surgery. Despite my research, I cannot find a single study about treating someone with my history. In case it is relevant, I did not have strabismus as a child and have no family history of the disorder. My glasses prescription is OD-5.50-1.50x175 OS-6.00-1.00x175 ADD +2.00. Any information/suggestions for treatment would be greatly appreciated! I assume the base out prism glasses were combined with the high minus spectacle correction. If that is true, then it sounds like they just didn't give you enough prism. Go to an O.D. who deals with binocular vision (or back to the prism prescriber) and have him/her measure exactly how much prism it will take to get you comfy, and get glasses with your minus AND that amount of prism in them. You'll do fine. BTW the glasses should NOT be that heavy. Base out prism in -6 lenses is almost a no brainer and should not make the glasses all that heavy. w.stacy, o.d. > I am a woman in my 50's who began wearing monovision contacts about 9 > years ago. I began experiencing occasional episodes of horizontal [quoted text clipped - 19 lines] > OD-5.50-1.50x175 OS-6.00-1.00x175 ADD +2.00. Any > information/suggestions for treatment would be greatly appreciated! Actually, the base out prism glasses are combined with the +2.00 ADD to be worn over my (non-monovision) contact lenses. Despite several adjustments, the weight of the prisms constantly drag them down my nose, making it hard to find the reading correction at the bottom of the lens. Any suggestions for restoring my binocular vision, or am I stuck with the current status? I seriously doubt that your strabismus was entirely the cause of the monovision. I have prescribed monovision in thousands of cases without inducing strabismus. This will only happen if the patient has latent strabismus that is held in check by both binocular fusion and accommodation. Adult strabismus typically breaks down during presbyopia. Most people, however, will experience more problems at night because of the lack of peripheral visual cues. Interesting that the strabismus is apparently esotropia. In a myope, I would have expected exotropia, convergence insufficiency, or divergence excess. Some vision therapy may be indicated at this point along with some adjustment of the prism, and/or the prescription. DrG > I seriously doubt that your strabismus was entirely the cause of the > monovision. I hope you meant "doubt your monovision was entirely the cause of the strabismus". w.stacy, o.d. Of course I did. Thanks for sweeping up after me. Now, strabismus can be the cause of monovision if it causes amblyopia :-) DrG > Of course I did. Thanks for sweeping up after me. > > Now, strabismus can be the cause of monovision if it causes amblyopia > :-) Can amblyopia be trigered at this age? Roland Izaac > DrG Conventional wisdom says that refractive amlyopia cannot be induced at this age...however, I seem to remember some obscure article arguing that it can. All I know is I haven't seen it. DrG Of course I did. Thanks for sweeping up after me. Now, strabismus can be the cause of monovision if it causes amblyopia :-) DrG Of course I did. Thanks for sweeping up after me. Now, strabismus can be the cause of monovision if it causes amblyopia :-) DrG >Of course I did. Thanks for sweeping up after me. > >Now, strabismus can be the cause of monovision if it causes amblyopia >:-) > >DrG Google was hanging again, huh? ;-) If I had been aware of this site a couple of months ago, I would have been spared a lot of frustration and wasted money. I really appreciate the information I have received. I realize it's absurd to wear prism glasses over contact lenses. A previous consulation resulted in a prescription for 1BO in each eye; I was able to have the glasses remade at no charge. It would have been several hundred dollars to remake the bifocals. I don't have all the information that Dr. Robins requested. I do know that eye turns were measured at between 11 and 20 on different dates (worse at the end of the day). The optometrist seemed to feel that I was a candidate for surgery but suggested I do vision therapy first. This did not make much sense to me. Obviously, the monovision alone is not the reason for the breakdown of my alignment. I came across an interesting article by Burton Kushner in which changes in refractive management precipitated diplopia in adults with long-standing strabismus. Such changes commonly occur to treat presbyopia (e.g., monovision), which may account for the increased incidence of symptoms at this age. However, the article suggests that the diplopia can be eliminated by stopping the use of monovision when the symptoms begin. I feel angry that all of the practioners I saw over the past five years dismissed my complaints of diplopia (but documented them in my record) and kept pushing monovision. And it's frustrating that there doesn't seem to be much that I can do now to reverse the damage. It is entirely possible that these changes in your binocularity might have occurred without monovision. 20 diopters of esotropia is a surgical amount of strabismus, but 11 diopters might be within the range of feedback control. DrG >It is entirely possible that these changes in your binocularity might >have occurred without monovision. 20 diopters of esotropia is a >surgical amount of strabismus, but 11 diopters might be within the >range of feedback control. > >DrG NB: I'm not an eye doctor, but am a strabismus patient of many years. I'm thinking Prism Adaptive Trials. Sounds like the OP /was/ a latent esotrope, but had the fusional amplitudes to maintain binocularity despite. It seems possible-to-likely that monovision /could/ have played a role in the accelerating the degredation of fusional amplitudes (which is why I--a three-time strabismus surgery patient have refused monovision). Prism Adaptive Trials involve pushing steadily higher power prisms on you on the theory that you may actually have a higher deviation than you manifest. If you're manifesting between 11 and 20 diopters in primary gaze, you may well have 20-24d of total esotropia--some of which is compensated for by your residual fusional amplitudes. As Dr. G said -- 20d is definitely in the cut range. If you've /had/ fusion in the past, and the surgical result is successful, it's very likely you'd regain ample fusion/steropsis again, but--as Dr. Robins said, it matters whether your deviation is stable in every direction or not. Also, I wore plano prism glasses over contact lenses for years. Nothing at all 'absurd' about it. If it works, you wear it, IMO. Good luck! There is no way monovision would have "caused" 20 prism diopters of esotropia. However, it could have accelerated the decompensation, which would probably have occurred anyway due to the presbyopia. DrG Please review "Recently Acquired Diplopia in Adults with Long-standing Strabismus" by BJ Kushner, MD in Archives of Ophthalmology, Vol.119, No. 12, December 2001. I'm a psychologist, not an opthalmogist/optometrist, so I'd be very interesting in hearing your interpretation. (It's accessible online.) My reading suggests that monovision can indeed cause the breakdown of a stable alignment, and it is the monovision (not presbyopia) that triggers the symptoms. The article includes numerous case examples. I read the abstract, and the author is essentially saying the same thing, that a change in refractive status, refractive needs, or refractive management can bring about sudden onset diplopia in a patient with long-standing strabismus. It is likely that you had long-standing strabismus. Your refractive management brought about by your refractive needs probably triggered the diplopia. That is a slightly different spin than saying that the monovision caused the strabismus. You should know that I have also seen diplopia in such patients occur spontaneously, without any significant change in refractive management, simply because the accommodative-convergence relationship changed with the onset of presbyopia. I strongly believe that a thorough binocular vison workup is essential for any patient undergoing monovision or refractive surgery. DrG On 7/21/05 9:21 PM, in article 1122006092.395747.229990@g47g2000cwa.googlegroups.com, "Dr. Leukoma" <drg@leukoma.com> wrote: > I read the abstract, and the author is essentially saying the same > thing, that a change in refractive status, refractive needs, or [quoted text clipped - 13 lines] > I strongly believe that a thorough binocular vison workup is essential > for any patient undergoing monovision or refractive surgery. ^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^ Couldn't agree more. Problem is, most LASIK surgeons pretty much ignore this advice. > Couldn't agree more. Problem is, most LASIK surgeons pretty much > ignore this advice. My guess is that this will lead to successful lawsuits, despite the iron clad consent forms. To ignore these issues given the literature should be considered to fall way short of best practice.  SignatureScott Reverse name to reply In the full article by Kushner, one example of a change in refractive management (which brings about sudden onset diplopia) is the "intentional creation of monovision to treat presbyopia...In 7 patients, monovision resulted in a breakdown of the stability of a previously well-controlled strabismus." These patients are categorized as "intentional monovision causing loss of fusion." Kushner goes on to describe a 50-year-old woman who began experiencing diplopia and intermittent exotropia of 20 PD after being fitted for monovision contact lenses. She obtained bifocals per the author's advice, resulting in the elimination of her symptoms, and "(s)he has been asymptomatic for 4 years." I really hope that patients undergoing refractory surgery get a thorough binocular vision workup. However, my research suggests that successful use of monovision contacts is sometimes used as a criterion for monovision laser vision correction. This gives me the chills, since my first three years of monovision were problem-free. (And look where I am now!) The take home message (for me, anyway) from this thread is that binocular vision disorders are all too often ignored and too often go undetected and undiagnosed. In the more than 20 years that I have been prescribing monovision, I am not aware of any incidents similar to this. Of course, I wouldn't be putting intermittent strabismus patients, or patients with high phorias into monovision, either. Contact lens monovision would be considered by most to be an elective, reversible procedure. The fact that your symptoms increased with age confirms what I said about the presbyopia being a factor in all of this. I am not a strabismus surgeon, but I have seen enough cases of adult onset strabismus to know that monovision isn't always a pre-requisite. Best, DrG Of course, monovision isn't a prerequesite! The Kushner article classifies the causes for acquired diplopia in 132 patients with long-standing strabismus as being attributable to changes in: (1) ocular alignment, (2) refractive needs or (3) refractive management. Monovision (which is classified as a change in refractive management) is just one of a number of causative factors. In this regard, age/presbyopia are relevant only to the extent that they necessitate the change in refractive management. I believe that Kushner's thesis can be extended from adults with long-standing strabismus to those with "latent strabismus" (whatever that involves, and how do you know if you're a "latent" ?). And from what I've read lately, the (latent) strabismus group is not uncommon in the post-laser-vision correction population. I hope that you will take the time to read the entire Kushner article. My eye care practioners here in Chicago seemed to be bright and caring people like yourself, but they were not knowledgeable about this issue. If they had been more responsive to my complaints about diplopia, I might not be posting at this site today since the breakdown described is apparently reversible in its early stages. Here are a couple of articles you should read regarding the onset of convergent strabismus with presbyopia. I think they apply in your case. ===================================== Presbyopia complicating pre-existing strabismus. Oystreck DT, Lyons CJ. Department of Ophthalmology, University of British Columbia, British Columbia's Children's Hospital, Vancouver, BC. Stangler-Zuschrott E. [Convergent strabismus in the age of presbyopia (author's transl)] Klin Monatsbl Augenheilkd. 1976 Jun;168(6):775-83. German. PMID: 994382 [PubMed - indexed for MEDLINE] ===================================== DrG On 7/21/05 7:41 PM, in article 1122000093.637916.302810@g44g2000cwa.googlegroups.com, "filmbuffchgo" <ssulkes@sbcglobal.net> wrote: > Please review "Recently Acquired Diplopia in Adults with Long-standing > Strabismus" by BJ Kushner, MD in Archives of Ophthalmology, Vol.119, [quoted text clipped - 4 lines] > is the monovision (not presbyopia) that triggers the symptoms. The > article includes numerous case examples. I must say I have had a few patients in this same monovision situation, some by contacts, and some by LASIK. Burton Kushner is a very well respected (by me, anyway ...) strabismologist. On 7/21/05 2:35 PM, in article 1121981717.344588.113960@g43g2000cwa.googlegroups.com, "Dr. Leukoma" <drg@leukoma.com> wrote: > There is no way monovision would have "caused" 20 prism diopters of > esotropia. However, it could have accelerated the decompensation, > which would probably have occurred anyway due to the presbyopia. > > DrG No, just aided and abetted it .... One treatment not mentioned is BOTOX - a non-surgical injection way of helping regain the alignment IF there is some fusion potential to hold the alignment once it is straight. Is done in the office by some strabismus specialists, takes very little time, and less risk than surgery. However, for it to work, it has to cause a large exotropia (eye angled out) with diplopia that may require a patch for more than several weeks. And as mentioned, PAT (prism adaptation testing) to find if there is a latent esotropia that is hidden, which might change the proposed treatment, as surgery would want to be done for the total (non-hidden) angle, as Neil Brooks mentioned. David Robins, MD Board certified Ophthalmologist Pediatric and adult strabismus subspecialty Member of AAPOS (American Association of Pediatric Ophthalmology and Strabismus) > Actually, the base out prism glasses are combined with the +2.00 ADD to > be worn over my (non-monovision) contact lenses. Despite several [quoted text clipped - 4 lines] > Any suggestions for restoring my binocular vision, or am I stuck with > the current status? You could try some orthoptics/vision training, but eso is hard to help. Regarding your prism glasses, if they are made for over your mono contacts, then this is not a very good arrangement. I mean why bother with mono if you're wearing glasses over the contacts? Why not go full distance Rx and make the prism glasses bifocals? And they should NOT be heavy as you stated in the original post. In a reasonable sized frame, 3^ lenses should be quite light, and could be made VERY light in Trivex. w.stacy, o.d. While you have prisms of 6^ total,there is no information as to the actual deviation readings at distance in primary position, and looking left, right, up and down. In addition, the angle at near is needed. This information would help tell something about the kind of acquired strabismus that you have. Monovision may have played a role, in causing a mild pre-existing deviation to "break down". In addition, it is not uncomman at this age to have minor deviations become symptomatic. Question is, is the angle stable? If the 6 prism is just enough for comfort, but the angle itself is actually much larger, would be nice to know. In general, the threshold for most strab surgery is about 15 prism. Is it possible to do single-muscle surgery for slightly smaller angles, but in general, if the total angle is only 6, most people would not operate. David Robins, MD Board certified Ophthalmologist Pediatric and adult strabismus subspecialty Member of AAPOS (American Association of Pediatric Ophthalmology and Strabismus) On 7/20/05 8:55 PM, in article 1121918145.900283.195010@g44g2000cwa.googlegroups.com, "filmbuffchgo" <ssulkes@sbcglobal.net> wrote: > I am a woman in my 50's who began wearing monovision contacts about 9 > years ago. I began experiencing occasional episodes of horizontal [quoted text clipped - 19 lines] > OD-5.50-1.50x175 OS-6.00-1.00x175 ADD +2.00. Any > information/suggestions for treatment would be greatly appreciated! |
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