Patient Prism Woes

[Jubilee]

I have a gentleman that has diplopia for years. He had an eye trauma at 17, a retinal detachment and lens rupture at 19 (with no IOL) and had cataract surgery in Summer of last year. He used to wear RGPs but doesn't want to go that route.

His RX when we first saw him in May 05 was:
OD +12.75 -0.25 x 017 V:70
OS +0.75 -0.50 x 090 V:20 +1
+2.00 ADD

At that time we referred him to an OMD to have Cat Surgery and possible IOL.

He came in for 1st follow up with us in Sept 05. His rx at time was:

OD -2.25 -4.25 x 025 5BU V:25 -4 (when pushed)
OS +0.75 -0.50 x 090 5BD V:20 +1
+2.00 Add
He held off on filling RX to give more time to heal per OMD.

In Dec he presented the rx was:
OD pl -2.00 x 180 6BU 4BI V:20 -2
OS +1.00 -0.75 x 114 6BD V:20 +1
+2.25
Patient was pleased with vision out of both eyes, but while diplopia was better than in past, he still wasn't able to get a fused image.

Remade in Feb with altered prism of
OD 3BU 4BI
OS 3BD 4BI
with a notation made that there still will be some diplopia but less.

Patient said this is much better, and when he uses just one of his eyes, he gets a great crisp picture. The problem is if he tries to ues both eyes at same time, the right image is still up about 15 degrees of the left.

The gentleman is getting frustrated because now that he can see out of right eye, he wants to be able to use it. It isn't as easy to ignore now :)

Any ideas on what can be done to help fuse these images together? He doesn't notice a difference in the placement of the images when using distance or reading.

He just doesn't want to give up on that hope we created for a clear image from both eyes.

Many Thanks!

Cassandra

[eyegirl]

I noticed his prism vertically went from 10 to 12 to 6 total prism diopters.
If he's not complaining of horizontal diplopia - only vertical diplopia.
Have him see the doctor again for a possible increase or decrease of vertical prism. Does he fuse in ANY gazes?

I recommend seeing someone who specializes with adult strabismus. It's always those vertical strab's that are tough to please.

May want to try fresnel over the right eye first to see how it goes.
Good Luck

I have a gentleman that has diplopia for years. He had an eye trauma at 17, a retinal detachment and lens rupture at 19 (with no IOL) and had cataract surgery in Summer of last year. He used to wear RGPs but doesn't want to go that route.

His RX when we first saw him in May 05 was:
OD +12.75 -0.25 x 017 V:70
OS +0.75 -0.50 x 090 V:20 +1
+2.00 ADD

At that time we referred him to an OMD to have Cat Surgery and possible IOL.

He came in for 1st follow up with us in Sept 05. His rx at time was:

OD -2.25 -4.25 x 025 5BU V:25 -4 (when pushed)
OS +0.75 -0.50 x 090 5BD V:20 +1
+2.00 Add
He held off on filling RX to give more time to heal per OMD.

In Dec he presented the rx was:
OD pl -2.00 x 180 6BU 4BI V:20 -2
OS +1.00 -0.75 x 114 6BD V:20 +1
+2.25
Patient was pleased with vision out of both eyes, but while diplopia was better than in past, he still wasn't able to get a fused image.

Remade in Feb with altered prism of
OD 3BU 4BI
OS 3BD 4BI
with a notation made that there still will be some diplopia but less.

Patient said this is much better, and when he uses just one of his eyes, he gets a great crisp picture. The problem is if he tries to ues both eyes at same time, the right image is still up about 15 degrees of the left.

The gentleman is getting frustrated because now that he can see out of right eye, he wants to be able to use it. It isn't as easy to ignore now :)

Any ideas on what can be done to help fuse these images together? He doesn't notice a difference in the placement of the images when using distance or reading.

He just doesn't want to give up on that hope we created for a clear image from both eyes.

Many Thanks!

Cassandra

[Matthew]

Do you have a trial lens set? Play around with the prism untill he can fuse (if that is possible) Then talk to your doctor with your findings.

[Dave Nelson]

the ocular muscles atrophy after a lengthy period of little or no use, like any other muscle in the body. There is little or no stimulus to converge or align when acuities are reduced or absent. With acuities now much improved, the ocular muscles are "in recovery." You may consider a regimen of gradually reduced fresnel prisms to until the muscles strengthen, or at least until the condition stabilizes, and the prism required is consistant. You may consider a referal to an orthoptist, (usually via an ophthalmologist as already suggested.)
I suspect with the remarkable acuities you indicate he is able to acheive, his outlook for an improvement in ocular alignment and stability is very good. All the best to you and the patient.

[drk]

The first step is to get a diagnosis of the patient's muscle problem. Why does he have a problem, and what is it? Diagnosis before treatment, you know.

[chip anderson]

I have seen aphakic patients (in contact lenses) have an eye that was obviously turned out, straighten up while I watched after putting contacts on in a few minites. Others took a few days to a few weeks. This appearently depends on how long the patient had been with poor vision while the cataract developed and how long post surgery the fitting was done. What the outlook in spectacles would be in this situation, I don't know.
Another pearl: An aphakic eye cannot have residual astigmatism with a rigid lens.

Chip