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Thread: Diplopia in upward gaze

  1. #1
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    Diplopia in upward gaze

    Wondering if anyone has ever encountered this, and if so, what was resolved it?
    This 73 year old Pt presents with the following Rx:
    OD: -2.25-0.50X164
    OS: +0.25-0.25X121
    +2.25 add OU
    Frame measurements:
    A=51 B=31 ED=51
    I put her in a trivex Ft 28 lens
    She has had corrective surgery and was given monovision, to aid in reading. Which caused the anisometropia. This is her first pair of glasses following surgery.
    So, the patient picks up her glasses, it takes her quite a bit of time to adjust to the new rx. She finally adjusts to the vision, but then comes back in to say that when she deviates from the center of the glasses in an upward gaze, she gets a double image. Optically, I understand why this is happening, but I'm not sure if there is a way to correct it.
    I know that typically one would prescribe slab off, but to my knowledge that is for diplopia at near.
    Anyone have any suggestions?
    Any input would be greatly appreciated.
    Also, we have fit this pt in CL,and she is very successful. She just wanted to have a pair of glasses as well. I have tried going over head movement techniques with her, but this doesn't seem like an acceptable solution to the pt.
    Last edited by VA Optician; 03-01-2013 at 11:09 AM.

  2. #2
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    You might suggest to her that the person to solve this issue for her is the surgeon. The contact lens/glasses combination is the next best solution, VA Optician.......
    Eyes wide open

  3. #3
    One eye sees, the other feels OptiBoard Silver Supporter
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    Quote Originally Posted by VA Optician View Post
    Wondering if anyone has ever encountered this, and if so, what was resolved it?
    This 73 year old Pt presents with the following Rx:
    OD: -2.25-0.50X164
    OS: +0.25-0.25X121
    +2.25 add OU
    Frame measurements:
    A=51 B=31 ED=51
    I put her in a trivex Ft 28 lens
    Good so far.

    She has had corrective surgery and was given monovision, to aid in reading. Which caused the anisometropia. This is her first pair of glasses following surgery.
    They did refractive surgery on a 73 year old? Mono? What were they thinking?

    So, the patient picks up her glasses, it takes her quite a bit of time to adjust to the new rx.
    Yup.

    She finally adjusts to the vision, but then comes back in to say that when she deviates from the center of the glasses in an upward gaze, she gets a double image. Optically, I understand why this is happening, but I'm not sure if there is a way to correct it.
    That's not normal, and I doubt the cause is strickly optical. At a minimum, she should see the prescribing doctor. I would recommend that she see a ped md or od. Be careful how you handle that.

    If you or your client care to be less circumspective, one could raise the OCs to the center pupil, if you haven't done so. There may be increased issues at near however. Use a hand held prism to confirm. However, the correct course of action is to get a doctor involved ASAP to rule out worst case scenarios.

    I know that typically one would prescribe slab off, but to my knowledge that is for diplopia at near.
    Anyone have any suggestions?
    Any input would be greatly appreciated.
    Also, we have fit this pt in CL,and she is very successful. She just wanted to have a pair of glasses as well. I have tried going over head movement techniques with her, but this doesn't seem like an acceptable solution to the pt.
    The primary concern is the diplopia. Get that resolved ASAP.
    Science is a way of trying not to fool yourself. - Richard P. Feynman

    Experience is the hardest teacher. She gives the test before the lesson.



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    Quote Originally Posted by Robert Martellaro View Post
    That's not normal, and I doubt the cause is strickly optical. At a minimum, she should see the prescribing doctor. I would recommend that she see a ped md or od. Be careful how you handle that.
    I work for the prescribing doctor. We sent her back to MD because we thought there may be a muscular problem, letter sent to MD:
    "Refraction Confirmed the spectacle Rx as correct. Cover testing in central gaze did not reveal gross strabismus/ phoria. However, in superior Gaze, I noted a right Hypertrophia. There was no pain on EOM testing, but there was the possibility of very subtle EOM restriction on Superior gaze OS"
    No abnormalities were found by MD Evaluation


    Quote Originally Posted by Robert Martellaro View Post
    If you or your client care to be less circumspective, one could raise the OCs to the center pupil, if you haven't done so. There may be increased issues at near however. Use a hand held prism to confirm. However, the correct course of action is to get a doctor involved ASAP to rule out worst case scenarios.
    I personally have checked the OC heights and they are spot on. I am concerned about bringing the OC up any higher, because it may give her diplopia upon central gaze. But may try prism over glasses to confirm this.
    Last edited by VA Optician; 03-01-2013 at 01:21 PM.

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    Quote Originally Posted by uncut View Post
    You might suggest to her that the person to solve this issue for her is the surgeon. The contact lens/glasses combination is the next best solution, VA Optician.......
    We sent her back to the Surgeon, there are no abnormalities.

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    Quote Originally Posted by VA Optician View Post
    We sent her back to the Surgeon, there are no abnormalities.
    What I actually meant is that this "problem" the person has is an infliction created by the surgeon, so the surgeon should be made to deal with the consequences of their handiwork!, and come up with the solution that is satisfactory to the patient!
    Eyes wide open

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    Master OptiBoarder Darryl Meister's Avatar
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    If I'm following the thread correctly, it sounds like the patient has a problem with the ocular motility of her left eye, particularly in upgaze, which the doctor may need to address (it could be due to cranial nerve palsy or something). This issue may appear to be exacerbated by her spectacle correction, because the left eye must rotate farther up than the right eye to fixate objects above the center of the lens due to the additional minus power in the right lens.

    Best regards,
    Darryl
    Darryl J. Meister, ABOM

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    Doh! braheem24's Avatar
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    Solutions to your issue through eyeglasses...

    Smaller b
    Higher oc
    Higher fitting seg
    Make sure any vertical prism is bd in the higher plus.

    Or... Raise the o.c. ou only And use a slab-off.

    Lastly, don't waste your time with an MD unless he's one of the gifted ones or did a residency in pediatrics.

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    What's up? drk's Avatar
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    99% chance that this is diplopia from prismatic imbalance from ill-advised 2D monovision. Agree that the surgeon is goofy, if this was planned.

    You can measure the diplopia in upgaze with the glasses on and a maddox rod. If it's around 2^ BU OD then bingo.

    To be sure, you put a contact lens in the right eye and measure the angle of deviation in cardinal positions of gaze. It could be a compounded effect, as Darryl surmises.

    The solution is to cut the minus in the myopic eye. About one diopter of new aniso correction is about all people can take.

    Surgical monovision is a *****. It's ill-advised. Maybe a 1/2 or a full diopter, but more than that and you get this kind of stuff.

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    Quote Originally Posted by drk View Post
    99% chance that this is diplopia from prismatic imbalance from ill-advised 2D monovision. Agree that the surgeon is goofy, if this was planned.

    You can measure the diplopia in upgaze with the glasses on and a maddox rod. If it's around 2^ BU OD then bingo.

    To be sure, you put a contact lens in the right eye and measure the angle of deviation in cardinal positions of gaze. It could be a compounded effect, as Darryl surmises.

    The solution is to cut the minus in the myopic eye. About one diopter of new aniso correction is about all people can take.

    Surgical monovision is a *****. It's ill-advised. Maybe a 1/2 or a full diopter, but more than that and you get this kind of stuff.
    Agreed with DRK good call!!! And I can't believe doing refractive surgery on a 73 year old! What was her rx before the surgery??

  11. #11
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    Rarely is another surgery on top of the first surgery a good idea...especially from the same surgeon. Ditto on the aniso caused by too much monovision. I also would cut the minus and maybe raise the OCs a mm assuming SV lenses. Often with these folks, you cannot keep them in MFs very well.

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