Double Vision From Progressives?

[drk]

One thing I have learned is to ask patients about their symptoms, first. As much as a patient wants to help in providing a diagnosis, I tend to totally ignore what they think the cause of the problem is, unless I'm stumped. Well-meaning patients often will lead you astray from the main issue.

Take home message: ask them more about what their problem is, and ignore what they think the cause of their problem is.

Note of interest: I've had a patient like the poster, a 52-y.o. WF. I did an exhaustive battery of diagnostics to rule out refractive and extraocular muscle disorders, and essentially came up with bupkiss. So I sent her to the most reputable corneal subspecialist in my town, with the express request to get a wavefront analysis to rule-out higher-order abberations. Of course, the OMD decided to run corneal topography instead, and condecendingly informed me that she had undiagnosed astigmatism! It shows you what ophthalmologists, even refractive/corneal specialists, don't understand about vision.

We made her new Rx with his specifications, and it was a flop, of course. I asked her to try another one of my friendlier refractive surgeon/corneal specialist friends, and we will eventually get those results. All this to rule out lenticular changes.

Ultimately, it will still be dry eye/precorneal tear film. Interestingly, the OMD did diagnose minor fleck corneal dystrophy, which I did not detect. That is probably contributory.

[Chris Ryser]

1) ............................. unless I'm stumped. Well-meaning patients often will lead you astray from the main issue.

2) .............................................. the OMD did diagnose minor fleck corneal dystrophy, which I did not detect.

1) drk you should be here, in south West Florida, you would be lead astray by 100% of your patients, snowbird country, they drive as legally blind, they want you to help get out and into the car.........direction indicator going to the left when they want to go to the right and I could go on and on.................

2) You put me into the shame corner............................where are you going, for not detect?

[sheltie57]

I did try using the drops today at work. I was doing alot of close up paper work. Unfortunately, it made no difference at all. My vision was just as bad as before. But it was worth a try. Thanks anyway.

Shelley

[chip anderson]

Sheltie:


I have never seen dry eyes cause diploplia in 42 years. In fact I think it is one of the most over diagnosed things we have. I have not seen an eye that did not stain without contact lenses that I could not fit with rigid contact no drops required. (Those Shirmer tests with the litmus-like strips have been proven clinically useless except for the fee and impressing the patient.)

As to the cause of the diploplia, I think you need a more experienced, more conscientious pediatric ophthalmologist. One that will examine when you are in a fatigued condition.

Chip

[Chris Ryser]

drk can go back to work and take out his textbooks, and I can get out of the shame corner and have a merry Christmas.

Chip might have a good point.

[drk]

Chip, if she has monocular diplopia, what exactly is a pediatric OMD going to do?

FYI, testing a patient when fatigued is not going to elicit anything. What, she has a high vertical phoria that can't be measured unless she's tired? A high phoria with borderline compensating vergences that go south when she's tired? Not consistent with her history that she's seen OMD's and neuro's that have given her a clean bill of health, there, anyway.

Dry eye is underdiagnosed, if you ask almost anyone. Overdiagnosed? Read some optometric journals.

Sheltie, what do you mean "my vision was as bad as before?" You have the ghost image? What you should do is keep a more precise journal of what happens. For example:
9:00 am: working on computer: no ghost image
10:00 am: starting to get ghost image in left eye, put in one drop.
10:30 am: ghost image resolving
11:00: lunch, etc.

You really have to use the drops hourly, and it would be better to try high viscosity drops.

If it is intermittent, it is virtually impossible for it to be anything other than ocular surface disease. You need to be seen by an optometrist who can refract you accurately, and find out what the cause of your ghost image is.

Chris, Ok, I'm a dunce! I deserve it, eh?

[chip anderson]

Dry eye is underdiagnosed in the optometric journals because the insurance companies and other third party payers will pay $ 450.00for punctum plugs. Without this and a compenstation for diagnosis, and Rx-ing treatment, there would be very, very few people suffering from dry eyes. I have always (usually) concidered the diagnosis an excuse for poor contact lens fitting skills.



Chip (Anybody ever say I was shy)

[Robert Martellaro]

Ouch. Take away two points for the low blow.

Whether the cornea, lens, or some other less common abnormality of the eye system is at fault, I would still recommend that the poster try readers and/or a reduced VI multifocal for computer use. At least there would be an immediate improvement in the posters visual comfort.

Merry Christmas

Robert

[Homer]

While DRK may be on to something it does not take away form the over 1.75 D of vertical imbalance produced when viewing through the reading section of this or most any PAL.

Dry eye seems to be more and more prevelant these days, especially in dry climates and in Winter when the modern heaters wring even more of the moisture from the air. This could be one very observant, well educated guess.

Not being that well educated in such things as an optician, I want to address the vertical imbalance with either; 1) a very short corridor progressive, 2) an occupational PAL like RD or Office, 3) a lined bifocal with the OCs place only 2 or 3 mm above the segment line (simmilar to the suggestion of reading glasses), or a very high set 8x35 mm trifocal with the OCs place below the upper segment line.

In addition, some people are sensative to the image size difference created in this situation.

Happy New Year to all!

[sheltie57]

Whether the cornea, lens, or some other less common abnormality of the eye system is at fault, I would still recommend that the poster try readers and/or a reduced VI multifocal for computer use. At least there would be an immediate improvement in the posters visual comfort.


Robert

So which brand of lenses should I be trying out? I'm getting a little confused about what my course of action should be. I'm willing to try just about anything to get better vision!

[Spexvet]

It lasts depending on how long I perserve to read, do computer work, etc. It can last up to an hour at times. If I close my left eye (the bad one) I can see without the ghosting. If I close my right eye, the ghosting is there or if both eyes are open.

...

What do you mean by near only lenses? Does that mean I can only use them for computer or close work? Do I then need two pairs of glasses? I guess I'm concerned about the cost. What if I do get these near only glasses only to find out that it does not make any difference? I'm thinking that you can't take them back like you could an oversized sweater.

Shelley

Optical folks, single eye diplopia means that you can rule out any type of imbalance - not possible with one eye.

Shelley, If your double vision is from glasses, and not your eye, you may in fact need multiple pairs to meet all your needs. You are performing tasks that are very visually demanding, and one pair of glasses may not meet all of your needs. The issue may very well be dry eyes or Rx.

LensCrafters, I think, has a 30 day, no question refund policy. Get your glasses there (hope they're having a sale) and if they don't work, return them for a refund.

[Chris Ryser]

LensCrafters, I think, has a 30 day, no question refund policy. Get your glasses there (hope they're having a sale) and if they don't work, return them for a refund.

Always forgive your enemies - Nothing annoys them so much.

[Spexvet]

Always forgive your enemies - Nothing annoys them so much.

I am honored...I think.:p

[Robert Martellaro]

So which brand of lenses should I be trying out? I'm getting a little confused about what my course of action should be. I'm willing to try just about anything to get better vision!

To some degree you will benefit from a separate pair of glasses for the monitor and/or close tasks. The brand is not an issue. Pick up or borrow a pair of over the counter reading glasses. Power should be a +1.00 if the screen is more than 25" away and +1.25 if less than 25". With a straight ahead gaze look at the small print or numbers at the top of screen. Without tipping your head back place the readers right on top your glasses. Note the increase in contrast and clarity. If have a 23" monitor set at 32", and your downgaze to the desktop is not frequent and/or for extended periods, you might not see much benefit from computer glasses. If you are an avid reader at home, properly made single vision reading glasses will make long periods of reading much more pleasant. If this describes your situation try the readers first; the cost could be as little as $100, less if you have an old frame that's suitable and serviceable.

Hope this helps

[socal]

I'm not a doctor, I'm a patient. I currently wear progressive lenses. I too have monocular diplopia. I have diplopia in each eye separately and in both eyes together, ergo it is monocular vs. binocular. I see extra images that extend outward, vertically and diagonally, overlapping the main image and neighboring images. It is more prevalent and stronger at night though it does now occur in the daytime too. It is aggravated by dim light, when fatigued, or after visually demanding tasks such as reading or using the computer. I also notice it more with bright objects on dark backgrounds. It doesn't matter which direction I look to as it is there in all directions of gaze. It is intermittent, I don't wake up with it, but by nighttime it is almost constant.

I used to have eagle-eye perfect vision. Around age 44 I began to need reading glasses. Used pharmacy readers for awhile and then went to the optometrist and got progressives due to vanity. When the diplopia first appeared I brushed it off thinking I was just overly tired. My schedule would whip anyone. I first noticed the diplopia at night. Bright objects like lights begat 3 images. One below and one above and to the right extending out from the main image. Needless to say it was very confusing. Still I thought I was just tired as my job involved alot of reading and computer use. This went on for a few months and appeared more often so I sought help.

Long story short, I've seen many doctors, O.D's and M.D.'s, over nearly 2 years, including the neuro guys. Research on the internet scared me into thinking I could have some horrible affliction like MG, MS, thyroid disease, brain tumor, cataract, etc. I've had many prescription changes, including trials of prism lenses, rigid gas permeable contact lenses, toric soft contacts. I've tried artificial tear drops and even miosis (pupillary restriction) inducing drops yet my diplopia persists. I had all kinds of tests, nothing obvious presented.

Finally the last specialist I was referred out to at the university eye institute found a possible cause by using a piece of testing equipment called Wavefront. This machine detected irregular astigmatism. It is a higher order aberration (zernike polynomial) which is undectable by other than this sophisticated machine. My diplopia is not due to dry eyes. I've spent alot of money and alot of time trying to find a cause and cure. At least I have a cause for mine now. Unfortunately it is not curable so I must live with diplopia. I've also had quite an education doing research on the internet, trying to help my doctors help me. The doctors have nothing left to offer me toward a fix. I have now given up my quest for a cure and am retiring from my job.

In retrospect the first clue to the ultimate cause was that my diplopia was improved when looking through a pinhole. That was the clue that indicated this was a refractive error. Does yours improve or go away when you look through a pinhole? Perhaps through my experience you can save yourself some time and alot of frustration. See if the pinhole test works, if it does, then have your doctor decide if you should be tested with the Wavefront machine to rule in or rule out some kind of odd refractive error. Sorry my outcome is not cheery good news.

[Chris Ryser]

so I sought help.

.........................Sorry my outcome is not cheery good news.

Has anybody suggested you should get off the progressive lenses? If they are not 100% adjusted to you pupil height in the frame you are wearing your rpoblem would be multiplied. By having normal straight top bifocals this could be easier adjusted to accommodate your vision.

[drk]

Good post.

In my post above with my patient, I tried (and am continuing to try) to get a wavefront analysis of her vision. Higher order aberrations are like prescriptions that we cannot measure, since they are so subtle and irregular.

Newer wavefront devices now have the ability to determine whether the irregularity is with your cornea or lens. Generally speaking, acquired refractive errors/ higher order aberrations are more likely to come from the lens changing. If that is the case, an intraocular lens is a possibility.

Higher order aberrations used to be a diagnosis of exclusion (if then), where everything else that could go wrong had to be excluded first. With the improved technology and improving access to it, we ought to be able to look for these things more easily and sooner.

As to the pinhole test, it is axiomatic that it would reduce the ghost image, so while it's somewhat worthwhile, it's not specific to any particular refractive problem. I'm sure it would disappear for her with a pinhole.

[sheltie57]

LensCrafters, I think, has a 30 day, no question refund policy. Get your glasses there (hope they're having a sale) and if they don't work, return them for a refund.

You mean that they will take them back? I didn't realize that. Are most optical stores like that?

[sheltie57]

If you are an avid reader at home, properly made single vision reading glasses will make long periods of reading much more pleasant. If this describes your situation try the readers first; the cost could be as little as $100, less if you have an old frame that's suitable and serviceable.

Hope this helps

single vision reading glasses = bifocals?
Sorry...I'm not quite up on the proper terms.

And yes, I am an avid reader. I think that has definitely been part of the reason I'm so frustrated.

Tonight I did notice something else. I was on the computer while talking with my sister on the phone. I was playing a computer game for some time, maybe an hour. Of course, my vision continued to deteriorate until I finally gave up. When I sat down to watch tv, I noticed that not only was there vision problems with the left eye, I now had the same thing in the right eye. I have had this happen every so often. I'm thinking it likely is when I push the limits but sometimes I just say, hang it. I'm tired of not being able to do what I want.

[sheltie57]

In retrospect the first clue to the ultimate cause was that my diplopia was improved when looking through a pinhole. That was the clue that indicated this was a refractive error. Does yours improve or go away when you look through a pinhole? Perhaps through my experience you can save yourself some time and alot of frustration. See if the pinhole test works, if it does, then have your doctor decide if you should be tested with the Wavefront machine to rule in or rule out some kind of odd refractive error. Sorry my outcome is not cheery good news.

I've been for so many tests, I'm trying to remember if he did the pinhole one with me. It seems very familar, but I don't remember if I saw clearer. How do I do this myself to check?

BTW....thank you for sharing this with me. :)

[socal]

Has anybody suggested you should get off the progressive lenses?...

Chris,
Nobody has suggested a change out of progressives. Still, I did get out of them for awhile when doing the trials of the contact lenses but the end result of those trials was no improvement in the diplopia. Next time I have a checkup I shall ask the docs if they feel I could be helped by a trial of the old style lined type. Thanks.

[socal]

I've been for so many tests, I'm trying to remember if he did the pinhole one with me. It seems very familar...

Sheltie,

I know just how you feel. I've had so many tests it makes me tired just thinking of everything I've been through. The pinhole was a handheld object, kinda like the thing you hold over your eye when testing one eye at a time. A black spoon like thing. Only this thing had a bunch of small perforations in it. Like I said, I'm not a doctor but I've been to plenty and tried to learn and research to help them help me along the way. I'm just guessing but maybe if you put a small hole in a piece of paper and looked through that into the distance it might simulate the same thing?

Your story seems so similar to mine. Not one of the 4 docs I saw in my area and neither of the 2 pediatric neuro-ophthalmology specialists I saw could find anything wrong with eyes or my nerves or muscles or such. In fact one of them basically accused me of being a headcase. It was the second neuro-guy and his crowd of white-coated specialists in training at the university that put their heads together and finally suggested I be tested with the wavefront. The machine seems to be a fancier piece of equipment and isn't available just anywhere. Probably too costly just yet for the regular office. Still it can see stuff the doctor can't pick up visually and caught my problem. I had previously had the corneal topography test but it didn't show up on that one. That machine is a bit more common. You might want to call your doc and see if he knows where one of the wavefront machines is located in your area.

I'm wondering too, since this diplopia came on shortly after the onset of presbyopia, if the lack of accomodation due to the aging lens might have something to do with it. Maybe I had this my whole life and never knew it because my brain told my muscles how to move my lens to compensate. With the loss of elasticity (for lack of better words) it finally manifested? Maybe that is why it appears rapidly after visually intense tasks like reading or when I am tired. I can't accomodate for it easily anymore? It has slowly worsened over time since it first appeared, perhaps this is related to aging. Who knows whether it will continue to progress to where I have this 100% of the time. I hope not but the trend sure looks that way.

Betwen all the different docs that examined me my prescription fluctuated alot. As I look back it was as if they were correcting for one astigmatism warp direction one time and for another the next, chasing it around. My prescription was changed alot over very short periods of time (1-3 months between new glasses). Perhaps this should have been another clue to the irregular astigmatism? Who knows? Guess it doesn't really matter much for me at this point.

[Spexvet]

You mean that they will take them back? I didn't realize that. Are most optical stores like that?

Not most. We, for instance, allow changes (frame or lens style) with no financial penalty in the first 60 days.

[Spexvet]

Tonight I did notice something else. I was on the computer while talking with my sister on the phone. I was playing a computer game for some time, maybe an hour. Of course, my vision continued to deteriorate until I finally gave up. When I sat down to watch tv, I noticed that not only was there vision problems with the left eye, I now had the same thing in the right eye. I have had this happen every so often. I'm thinking it likely is when I push the limits but sometimes I just say, hang it. I'm tired of not being able to do what I want.

This is another indication that it is dry eyes. People tend to blink less as they stare a the computer.

[Robert Martellaro]

single vision reading glasses = bifocals? Sorry...I'm not quite up on the proper terms. And yes, I am an avid reader. I think that has definitely been part of the reason I'm so frustrated.

vvvvvvvvvvvvvvvvvvv