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Medical Forum / General / Vision / May 2008cataracts and diplopia
I have monocular double vision in both eyes. It comes and goes fairly quickly. It lasts between a few hours and a couple days. It occurs in both eyes at the same time, but not to the same degree. Sometimes I see two images quite clearly focused, other times it can be multiple images. The double vision goes away completely if I look through a pin hole. I went to an MD ophthalmologist who recommended new glasses. I tried them and it makes little difference. I went to an OD who thinks it is probably cataracts and referred me to a cataract surgeon. I have an appointment at the end of the month. From my reading double vision can be a symptom of cataracts. I don't think I have other symptoms. With cataracts does the double vision come and go quickly? Any ideas of what else it might be that I should have checked? Monocular dioplopia would come-and-go very readily with changes in the size of your pupil and the qualities of the scene. High-contrast, bright targets against dark backgrounds are classically best for eliciting monocular diplopia. Large pupils make it much more noticeable. Holding a pinhole close to your cornea would eliminate double images immediately. The only other reasonable cause for monocular diplopia would be corneal irregularities. These would vanish with pinholes too, but they are MUCH less likely to develop suddenly, if you're over 50 with no history of corneal trauma, surgery or degeneration. Have the surgery on one eye first, the eye with more noticeable diplopia. Surgical implants have their own phenomena, like flare and reflections. To some degree you're trading one for the other. -MT, OD >I have monocular double vision in both eyes. It comes and goes fairly > quickly. It lasts between a few hours and a couple days. It occurs [quoted text clipped - 10 lines] > come and go quickly? Any ideas of what else it might be that I > should have checked? Thank you, both Mike and Jan for the good explanation. I recently moved north by 30 degrees (from Hawaii to Washington state). The dimmer light in Washington would tend to dialate my eyes and make the double vision more evident. I will look to see if pupil size and diplopia track. The condition is most evident on red traffic lights and point sources such as small LEDs. With the LEDs I can sometimes see 6 clearly focused images. It can be very obvious on high contrast items such as black on yellow traffic signs, computer monitors, and text in books. When at it's worst everything is double. The condition seems to get worse after reading. My eyes focus at a comfortable distance for reading, so I read without glasses. Maybe I should get brighter lights for reading? I can live with the condition at present, so I am not in a big hurry to get surgery. Medicare will pay when the corrected vision is 20/40. I assume this is a progressive condition. If so how fast does it normally progress? >Monocular dioplopia would come-and-go very readily with changes in the size >of your pupil and the qualities of the scene. [quoted text clipped - 33 lines] >> come and go quickly? Any ideas of what else it might be that I >> should have checked? "ray" <spammers@do.not.reply.com> wrote in message > The condition seems to get worse after reading. My eyes focus at a > comfortable distance for reading, so I read without glasses. Maybe I > should get brighter lights for reading? By all means, if it helps. > I assume this is a progressive condition. If so how fast does it > normally progress? It's too variable. Sometimes it remains stable for years then changes suddenly. The Medicare justification may vary with state carrier, and with how cooperative a surgeon you find. Seems to me that diplopia and large or frequent changes in refraction are also justifications. -MT I went to the eye surgeon. He said my cataracts were very small and not the cause of my problem. He said that I had Fuch's Endothelial Corneal dystrophy. This was based on see divots in the cornea and measuring the cornea thickness with some device that contacted my eye. On looking the condition up I don't see diplopia as being one of the symptoms. I don't seem to have the symptoms attributed to the condition. Any insight would be appreciated. Below is a description of the condition. Fuch's endothelial dystrophy is a disorder of corneal degeneration in which edema (swelling) and gradual vision decrease are characteristic. This condition usually presents between 50 and 70 years of age, more commonly in women. Most cases are of dominant inheritance, which implies that both eyes are affected and the disorder may affect blood relatives. The underlying defect is an abnormal deep layer of the cornea, known as the endothelium. This layer of cells, situated on the "back" side of the cornea, must be of sufficient number in order to maintain a relatively dehydrated and clear cornea (with consequent good vision). In Fuch's' endothelial dystrophy, this layer of cells is more rapidly lost by attrition than normal, and the consequence is swelling of the cornea and gradual vision loss. As the disorder progresses, swelling of the cornea causes "blisters" on the front of the cornea known as epithelial bullae. This latter condition is known as bullous keratopathy. >Monocular dioplopia would come-and-go very readily with changes in the size >of your pupil and the qualities of the scene. [quoted text clipped - 11 lines] >likely to develop suddenly, if you're over 50 with no history of corneal >trauma, surgery or degeneration. >Have the surgery on one eye first, the eye with more noticeable diplopia. > [quoted text clipped - 17 lines] >> come and go quickly? Any ideas of what else it might be that I >> should have checked? > I went to the eye surgeon. He said my cataracts were very small and > not the cause of my problem. It's the "small" or "early" cataracts that cause monocular diplopia. > He said that I had Fuch's Endothelial > Corneal dystrophy. This was based on see divots in the cornea and I'm very familiar with Fuch's and it's very common. The optical effects are negligible in early Fuch's. You haven't described essential Fuch's symptoms - morning erosions, diurnal haze - so presumably you're "pre-symptomatic". You might never have optical problems resulting from Fuch's. Many don't. The important thing is, if you do, it'll be fog, not diplopia. Not saying your surgeon was wrong, just I have trouble explaining static polyopia on the basis of asymptomatic fuch's. He prolly would too, if he slowed down to think about it. Don't change your treatment on my advice. But he didn't recommend any treatment, right? So just re the physics of monocular diplopia, I still think yours is lenticular. > symptoms. I don't seem to have the symptoms attributed to the > condition. Any insight would be appreciated. Fuch's is usually detectable in the microscope long before there are symptoms. Sometimes it never causes symptoms. It's a 10-20 year disease, but even at 20 years they aren't all "bullous", and keratoplasty is a safe and effective treatment if it ever went that far. You still _could_ have corneal irregularities that produce diplopia, but FWIW, it's still likely your diplopia is just loss of uniformity in the crystalline lens. -MT Thank you for your informative response. As you might guess I am confused and frustrated. My symptoms are not really those of Fuch's and mostly not cataracts. Question, if it were the cataracts would the polyopia come and go in both eyes at the same time? If just an optical problem how does one eyeball know what the other is doing? The doctor said to use a 5% salt solution eye drops 4 times a day and a ointment at night. He says this will slow down the progression of the process. He said come back in 2 months. Other than the outrageous price of an ounce of salt water ($20) it seems to be a reasonable course of action if I really do have Fuch's? The doctor diagnosed based on microscopic inspection of the cornea and a device that measures corneal thickness. Is this a definitive diagnose, or is it very much subject to interpretation? Ray >> I went to the eye surgeon. He said my cataracts were very small and >> not the cause of my problem. [quoted text clipped - 35 lines] > >-MT > Thank you for your informative response. As you might guess I am > confused and frustrated. > > My symptoms are not really those of Fuch's and mostly not cataracts. > Question, if it were the cataracts would the polyopia come and go in > both eyes at the same time? Depends. Lenticular diplopia, if present in both eyes, could easily vary with external conditions (background illumination, target brightness/contrast) but it would be the same each time you reproduce the conditions. If there is diurnal variation, like it's worst in the morning, then lenticular problems don't do that. A cycle of corneal edema could make diplopia appear to wax and wane but there'd also be haze. > If just an optical problem how does one > eyeball know what the other is doing? Pupils normally change the same in each eye, and accommodation likewise is lockstep left/right. Both eyes inhabit the same environment, optically but both eyes also swell at night. > The doctor said to use a 5% salt solution eye drops 4 times a day and > a ointment at night. He says this will slow down the progression of > the process. I didn't know it was standard to treat asymptomatic Fuch's so aggressively. You've had no erosions and no morning haze, right? I'll have to check on that. > He said come back in 2 months. Other than the > outrageous price of an ounce of salt water ($20) it seems to be a > reasonable course of action if I really do have Fuch's? The doctor > diagnosed based on microscopic inspection of the cornea and a device > that measures corneal thickness. Is this a definitive diagnose, or is > it very much subject to interpretation? It's hard to miss Fuch's in the microscope, so you can be sure you have some endothelial changes. But that doesn't guarantee you'll have symptoms. I'm no expert but it seems you'd have to measure corneal thickness at least twice to demonstrate edema in Fuch's. I've always held off using salt solutions and ointments until there was observable swelling or morning erosions, but I could be a few years behind. -MT >> Thank you for your informative response. As you might guess I am >> confused and frustrated. [quoted text clipped - 11 lines] >lenticular problems don't do that. A cycle of corneal edema could make >diplopia appear to wax and wane but there'd also be haze. >> If just an optical problem how does one >> eyeball know what the other is doing? [quoted text clipped - 10 lines] >You've had no erosions and no morning haze, right? I'll have to check on >that. I tend to only notice changes. I didn't realize how bad my shoulder felt until I had my torn rotator cuff repaired. I didn't feel all the problems associated with hypothyroidism until I started thyroid treatment. So it is difficult for me to judge what is "normal" vision unless I can compare normal to what I have at present. So I have a hard time judging morning haze or other subtle symptoms, but no problem recognizing two images. The condition comes and goes and will or will not be present under conditions that I judge to be the same. I have been looking for this. I have read that Fuch's can cause blisters on the cornea. This would seem to be consistent with what I am seeing, but I am not sure that completely explains it happening in both eyes at the same time. When I have undergone pupil dilation the condition did not appear. I was not prepared for the diagnoses so I did not have a list of questions to ask. The doctor's description was the cells on the endothelial layer were dying and therefore the layer is thinner than normal and can't pump out excess water from the cornea. He also said there were "divots", might that be the same as erosion? The doctor said he sees about one case a month like mine, but it is usually after cataract surgery. The treatment is supposed to slow the progress of the condition. It will not cure, reverse or stop it. >> He said come back in 2 months. Other than the >> outrageous price of an ounce of salt water ($20) it seems to be a [quoted text clipped - 11 lines] >I've always held off using salt solutions and ointments until there was >observable swelling or morning erosions, but I could be a few years behind. I go back in 2 months so I will be better prepared to ask questions. The corneal thickness will be measured again and compared. What are the downsides to using the salt solutions? Thanks again for your knowledgeable answers. >-MT > unless I can compare normal to what I have at present. So I have a > hard time judging morning haze or other subtle symptoms, but no > problem recognizing two images. I think you would have no trouble noticing AM haze. It's like looking through dirty cellophane, hard to miss. > I have read that Fuch's can cause blisters on the cornea. This would > seem to be consistent with what I am seeing, but I am not sure that > completely explains it happening in both eyes at the same time. Except not many Fuch's patients get to the blister stage, and you couldn't miss it because it's _painful_ and it's usually preceded by a decade of other problems. I don't think you have erosions either. They hurt. They hurt enough to drive people to the doctor. You haven't described corneal erosions or bullous keratopathy. > I was not prepared for the diagnoses so I did not have a list of > questions to ask. The doctor's description was the cells on the > endothelial layer were dying and therefore the layer is thinner than > normal and can't pump out excess water from the cornea. That's what creates morning haze. Closing the eyes overnight reduces the oxygen and the endothelial pump slows down. > He also said > there were "divots", might that be the same as erosion? Erosions might look like "divots" but they HURT. You aren't hurting. So your divots probably aren't erosions. Normal endo looks like a carpet of hexagonal tiles. "Missing tiles" are the only finding you've described and I think that's what he meant by divots. > The doctor > said he sees about one case a month like mine, but it is usually after > cataract surgery. The treatment is supposed to slow the progress of > the condition. It will not cure, reverse or stop it. I didn't know it would slow the progress. I'll find someone soon to ask. > I go back in 2 months so I will be better prepared to ask questions. > The corneal thickness will be measured again and compared. What are > the downsides to using the salt solutions? None. Just cost. Don't try to make your own. -MT Mike, Maybe you could give me your interpretation of the test results. Guttata grade 3 plus. Corneal pressure 17 right 15 left. Corneal thickness .630 right .645 left. Corneal cell count not done. Can be done in Seattle. The vision tends to come and go. When I visited this doctor my visual acuity was 20/20. A month ago when I was having moderate doubling it was 20/30. When bad it is somewhat worse than that. Doctor still maintains that the saline solution will keep more cells from dying. I wasn't thinking of making my own, just commenting that $2,500 a gallon seems like a lot for salt water. So it looks like guttata grade is not so good, cornea are a little thick, pressure is OK. So what does that really mean? Thanks Ray >> unless I can compare normal to what I have at present. So I have a >> hard time judging morning haze or other subtle symptoms, but no [quoted text clipped - 46 lines] > >-MT > So it looks like guttata grade is not so good, cornea are a little > thick, pressure is OK. So what does that really mean? It looks like you have early Fuch's, nothing more. It doesn't explain your monocular diplopia, IMO. -MT ray schreef: > I have monocular double vision in both eyes. It comes and goes fairly > quickly. It lasts between a few hours and a couple days. It occurs [quoted text clipped - 10 lines] > come and go quickly? Any ideas of what else it might be that I > should have checked? Did one of the two eyecare specialists explained that the size of the pupil and the changing of it could make the difference? You mentioned the use of a pinhole and by using it you didn't have double vision in one eye at the time. Think about that in bright light conditions, your pupil act like a pinhole at that moment being small in diameter. On the other hand, dark(er) light conditions are resulting in a larger pupil diameter, the image passes a greater area (in diameter) of your inner lens (the lens behind your pupil) If you are suffering of cataract it is possible that in that large area the power of the lens differs on several places in that area due to imperfections such as changes in refraction indices or obstructions. Such differences are causing different images which are seen simultaneously. With a small pupil, there are less such differences and there fore less "different" images. Hope this helps. Jan (normally Dutch spoken) |
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