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Medical Forum / General / Vision / March 2007Post-cat monocular diplopia
Greetings all, My mom is 3- and 2-weeks post-op for cataracts in both eyes. While the 2nd-operated eye is excellent, she has impaired BCVA in the 1rst. I've done a number of informal tests on her. 1. She has monocular diplopia O.D., seeing two images separated vertically. 2. The vertical separation distance is unstable. 3. She has a warped visual field: the right-most 1/8th of horizontal lines appears to droop sharply downward. ACUITY 4. Distance BCVA O.D. is a fuzzy 20/50, down from a solid 20/30 pre-op. 5. Up close, her right eye BCVA isn't clear enough to read. 6. Corrected acuity O.D. is, oddly, not obviously better than uncorrected. CONVERGENCE 7. Her right eye is toed slightly inward, a recurrance of a slight strabismus she had as a child, but which she overcame with convergence practice. This produces binocular diplopia, but she's working on it, and that's improving. REFRACTIONS (formatted in Courier font) ====== O.D. ====== ===== O.S. ====== sph cyl sph cyl ----- ----------- ------ --------- Pre-op: -7.25 +1.00 x 150 -6.00 +0.75 x 45 Post-op: -0.50 +2.00 x 180 -1.50 +0.75 x 90 She's been to her surgeon, today, who worked her in for a quick, non- dialated inspection via slit lamp. He said her retina looks fine, and the implant placement looks good. He feels the monocular diplopia is a possible side-effect of the convergence problem. To my crude methods, the right implant appears off-center, shifted 1-2mm temporally. I've considered macular edema, retinal detachment, mis-oriented or damaged implant, and surgical debris as possible causes, but the matter exceeds my ken. Any ideas or comments that would help make us better, more educated healthcare consumers would be most welcome. TIA, James Arthur > ====== O.D. ====== ===== O.S. ====== > sph cyl sph cyl [quoted text clipped - 6 lines] > the implant placement looks good. He feels the monocular diplopia is > a possible side-effect of the convergence problem. I really doubt monoc diplopia is due to a convergence problem, which could produce BINOCULAR diplopia. She unfortunately ended up with HYPEROPIC astigmatism, which is probably the culprit. Previous myopes hate becoming hyperopes. Surgeons should ALWAYS target a bit of myopia on the first eye to minimize this unfortunate outcome. > To my crude methods, the right implant appears off-center, shifted > 1-2mm temporally. That could cause some of the problems. > I've considered macular edema, retinal detachment, mis-oriented or > damaged implant, and surgical debris as possible causes, but the > matter exceeds my ken. You might want to get a second opinion for her. > > ====== O.D. ====== ===== O.S. ====== > > sph cyl sph cyl [quoted text clipped - 12 lines] > hate becoming hyperopes. Surgeons should ALWAYS target a bit of myopia > on the first eye to minimize this unfortunate outcome. I encouraged her to ask for an implant giving mild myopia, but the siren-song of distance vision was too much for her to resist. The 2nd eye was targeted slightly closer, and succeeded very nicely. Curious that hyperopic astigmatism might cause monocular diplopia. I hadn't considered that possibility, and still can't quite imagine the optics of it. > > To my crude methods, the right implant appears off-center, shifted > > 1-2mm temporally. > > That could cause some of the problems. Yes, that' s what I was hoping the surgeon would find, but he said the implant's good. It was a non-dilated exam, and cursory--maybe he'll find more with a closer look. He said to call Monday if the problem persists, which of course I expect it will. I gauged the implants' centers by the positions of the reflections off their first surfaces, from which one can locate the peak of curvature, and thus the optical center, etc. From this, the right lens appears de-centered, but he's the pro, and I'm not sure. I'm new at this. It came to me this morning that maybe her new Rx is grossly wrong. Corrected, she sees a laser dot projected on the wall as a flaming vertical line, which suggests a huge cylindrical error in her new spectacles. That sure would be a relief, if it were that simple. > > I've considered macular edema, retinal detachment, mis-oriented or > > damaged implant, and surgical debris as possible causes, but the > > matter exceeds my ken. > > You might want to get a second opinion for her. Yes, possibly. I think well of the surgeon, who hasn't really had much chance at diagnosis yet. We'll certainly give him that. Presumably the slit exam ruled out emergent stuff, so we have time to think. An optical explanation would sure be nicer than a neurological one. Thanks for the thoughts--much appreciated. --James Arthur > I encouraged her to ask for an implant giving mild myopia, but the > siren-song of distance vision was too much for her to resist. That's how it worked for me. I'm happy with it. I have three pairs of OTC reading glasses, one for computer work, one for reading and one for the fine print. When I'm outside, I need no glasses. I get around the house just fine. Sometimes I wear glasses to eat, sometimes I don't. > In article <1173567468.734326.54...@c51g2000cwc.googlegroups.com>, > [quoted text clipped - 5 lines] > the fine print. When I'm outside, I need no glasses. I get around the > house just fine. Sometimes I wear glasses to eat, sometimes I don't. I'm myopic, and like it--I can see and do things up close without lenses, and grab the Rx specs for distance. Mom, however, is in the unenviable spot of having a substantial astigmatism O.D., so she might just need spectacles no matter what. Depends on whether her new Rx is really +2.00 cyl, or perhaps something less. She likes her "good" eye quite a bit (it's a smidge myopic, post- op), but even there she likes the extra clarity gained of cylindrical correction. That's quite lucky that you see so well. Congrats. Best, James Arthur [snip] > It came to me this morning that maybe her new Rx is grossly wrong. > Corrected, she sees a laser dot projected on the wall as a flaming > vertical line, which suggests a huge cylindrical error in her new > spectacles. That sure would be a relief, if it were that simple. Well, thankfully enough, that was it--they'd simply given her an incorrect Rx with a wrong sphere and lots of excess cylinder. REVISED Rx HISTORY (Courier font) ====== O.D. ====== ===== O.S. ====== sph cyl sph cyl ----- ----------- ------ --------- Pre-op: -7.25 +1.00 x 150 -6.00 +0.75 x 45 Post-op: -0.50 +2.00 x 180 -1.50 +0.75 x 90 NEW Rx: -1.50 +0.50 x 175 " " " Mom went in Monday, and was in the process of getting the grand workup. But, since she already knew from our experiments that her glasses were *way* off, she politely insisted on being re-refracted instead, and the problem was found. She got revised spectacles yesterday, and could scarcely be happier. Whew ! My heart goes out to all you practitioners refracting the general public--I'd tried to refract her immediately post-op, using simple gadgets, but her responses were so conflicting and ambiguous we gave up. It wasn't until she was _highly_ motivated these several weeks later that we refined it (her technique, and our estimate) enough to prove the Rx mistaken. She's a great mom, but a cantankerous amateur optician. Thanks all (and especially Bill), James Arthur |
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