Management Of Diplopia Research Articles

Benefits and side effects of prisms in the management of diplopia in adults: a prospective study

To analyze the various factors affecting patient satisfaction with prism glasses in adults with diplopia. In this prospective case series, the benefits and side effects of prisms and factors affecting prism satisfaction were assessed by means of a questionnaire. A total of 134 patients were included. Overall, 58% of patients were highly satisfied, 22% were somewhat satisfied, and 20% were either neutral, somewhat dissatisfied, or very dissatisfied with prism glasses. Prior history of prism use, amplitude of prisms, comitancy of deviation, and type of lenses worn, had no influence on satisfaction rates. The extent of resolution of diplopia was highly correlated with prism satisfaction (P<0.001), improvement in depth perception (P<0.001), driving (P<0.001), and reading (P<0.008). Up to 22% of the participants noted "bothersome" side effects, including headaches, dizziness, eye strain and pulling (22%), alteration of depth perception (16%), visual distortion (13%), halos (8%), and weight of the prisms (6%). In this cohort of adults with diplopia, prisms were beneficial in treating diplopia of different etiologies, incomitance, and a wide range of deviations. The side effects experienced with prism glasses themselves accounted for patient dissatisfaction in our study.

Orthoptic Vision Therapy: Establishing a Protocol for Management of Diplopia Following Orbital Fracture Repair

Orthoptic Vision Therapy: Establishing a Protocol for Management of Diplopia Following Orbital Fracture Repair

Management of Diplopia.

Management of Diplopia.

Management of Diplopia and Oscillopsia

Management of Diplopia and Oscillopsia

Management of diplopia

Diplopia (seeing double) is an ophthalmologic complaint found mainly in elder patients. It can have both ocular and neurological causes. A careful history and clinical examination must detail the type of diplopia (monocular/ binocular), onset, and progression, associated and relieving factors. In case of monocular diplopia, refraction and biomicroscopic examination of the ocular media are mandatory. The cause of ocular misalignment for binocular diplopia must be determined and life-threatening conditions (such as posterior communicating artery aneurysm) must imply an immediate treatment. Management and treatment is always according to the specific cause of diplopia.

Management of diplopia with visual-field defects.

PURPOSE:The management of diplopia can be challenging in patients with a concurrent visual-field (VF) defect. We conducted a retrospective chart review to analyze and compare treatment outcomes for different types of VF defects.METHODS:A retrospective chart review.RESULTS:Seven patients with diplopia and VF defects were identified during the study. Four had bitemporal hemianopia, one had homonymous hemianopia, and two had a constricted central VF. A favorable or satisfactory outcome was achieved in all but two patients with bitemporal hemianopia.CONCLUSIONS:The hemifield-slide diplopia may develop in patients with bitemporal hemianopia or heteronymous altitudinal visual defects. Sensory abnormalities usually persist, even after elimination of ocular misalignment.

Goal-determined metrics to assess outcomes of esotropia surgery

To report outcomes of esotropia surgery with a goal-determined tool. A goal-determined outcomes analysis tool was devised to address a quality improvement initiative at Boston Children's Hospital. Surgeons preoperatively ranked four possible goals for intervention: enhancement of binocular potential, restoration of eye contact (reconstructive), management of diplopia, and resolution of torticollis. Criteria for success were goal specific; the primary outcome measure was surgical success at 2-4 months. Secondary outcomes included appraisal of risk factors and a comparison of outcomes with this methodology versus traditional criteria for success based on motor alignment. No patients were excluded based on diagnosis, systemic and ocular risk factors, or intervention performed. A total of 824 patients underwent esotropia surgery from 2006 to 2012 and returned for evaluation at 2-4 months' follow-up. Of these, 777 had sufficient documentation for inclusion: 372 procedures were performed primarily to improve binocular potential; 238, to restore eye contact; 124, to resolve diplopia; and 43, to remediate torticollis. Excellent (71%) or good (13.7%) results were obtained in 84% of cases. Without associated risk factors, 75% had excellent and 14% had good outcomes. Risk factors were present in 444 (57%). Success diminished with prior strabismus surgery (P = 0.004), preoperative angle ≥50(Δ) (P = 0.002), and surgery before 12 months of age (P = 0.003). Patients having surgery to remediate diplopia had the best outcomes (excellent, 79%; good, 8%). Preoperative ranking of goals allowed demonstration of better results than would have been reported with requirement of "traditional" motor alignment criteria (P = 0.009). Goal-determined methodology can be useful for monitoring outcomes of esotropia surgery in diverse populations.

Contralateral Superior Oblique Posterior Tenotomy (SOPT): A Primary Treatment for Diplopia in Downgaze Following Blowout Orbital Fracture

ABSTRACTPurpose: Superior oblique posterior tenotomy (SOPT) is a recognized surgical treatment to weaken the depressor effect of the superior oblique muscle without causing excyclotropia. We analyzed its use in the management of diplopia in downgaze due to contralateral blowout orbital fracture.Methods: We performed a retrospective case note review of patients that had undergone an SOPT as a primary surgical option in the management of diplopia in down gaze caused by contralateral blowout orbital fracture. The study covered a 17-year period from 1993 and 2010. These cases had diplopia maximal to the side of the orbital blowout. Pre- and postoperative orthoptic measurements were compared. Surgical complications were noted.Results: Five patients who fulfilled the entry criteria were identified. The mean follow-up period was 15.2 months (range 6–20 months). Preoperatively, the median |dev| was 2 prism diopters (PD) in primary position (range, 0–2) and 8 PD in downgaze (range, 2–18). At the final follow-up, the median |dev| in primary position was 0 PD (range, 0–2) and 2 PD in downgaze (range, 0–12). There were no significant differences pre- and postoperatively in both the primary position (p = 0.19) or in downgaze (p = 0.25) despite the large reduction in deviation size. Two patients needed a second procedure following SOPT. No patients complained of torsion, not in the primary position or in downgaze following the surgery.Conclusion: Contralateral SOPT can be a useful and simple primary treatment option for patients with moderate vertical deviations in downgaze to the same side of the orbital fracture. Larger deviations may require second surgeries. SOPT does not cause iatrogenic excyclotorsion and avoids surgery to a potentially much scarred inferior rectus area.

Diplopia in blow out fractures

Sir, We read with interest the article by Ceylan OM et al.,[1] entitled ′Management of diplopia in patients with blow out fractures′. We would like to congratulate them on their report, and their excellent results regarding diplopia management. We would like to make a few comments on the report. Diplopia in orbital fracture might result from various causes[2] and because patients' complaints are often too subjective for meaningful comparisons, objective ways to evaluate diplopia are required.[3] To better study the effect of surgery, it is desirable to quantify the amount of diplopia. Reports have utilized quantitative evaluation of binocular visual field (BVF)[2] testing, Hess test (Hess area ratio),[3] and electronystagmography[4] equipment, as newer and innovative measures to quantify diplopia. We appreciate that Ceylan OM et al., utilized Hess screens and BVF, and would like to know if they applied any quantitative value to these tests. We understand that 6 patients were treated additionally with strabismus surgery or prisms for residual diplopia. We were interested in knowing if the persistent diplopia was less than, or equal to the initial diplopia measured prior to wall repair, and if there was any improvement in the diplopia post orbital repair in these patients. Though the mean time between trauma and strabismus surgery is mentioned as 10.5 months, the mean time between secondary strabismus surgery and the initial orbital wall reconstruction is not. We were interested in knowing how long should we wait after the primary orbital repair the surgery take place before opting to operate for residual diplopia. The study states that 7 patients underwent strabismus surgery. Even though the average deviation is mentioned as 14 prism diopters, the direction of deviation is not mentioned. Since the study mentions inferior-rectus recession as the commonest surgery, we infer that most of them had hypotropia in primary gaze. We would like to know if there is a difference in outcome between horizontal and vertical deviations. We wondered if the authors considered strabismus operation in the unaffected eye to resolve diplopia. We also wanted to know if there were any cases of diplopia in down gaze post strabismus surgery. The study mentions that primary gaze diplopia was eliminated in 73.9% of patients with no complication related to use of the Medpore® (Stryker Company, USA) implant. They also mention the possibility of flap tear in 2 of the patients. We would like to suggest, doing further investigation to find out the cause for the residual diplopia found in 26.1%, post wall repair. Various reports suggest the benefits of a post operative multi-positional high resolution MRI in such situations, to rule out mesh related complications.[5]

Prisms are Effective in Resolving Diplopia from Incomitant, Large, and Combined Strabismus

To assess the effectiveness of prisms in the management of diplopia in patients with incomitant, large, and combined strabismus. Data were collected retrospectively from the medical records of 64 patients who were prescribed prisms for symptomatic diplopia due to restrictive strabismus. The main outcome measure was resolution of diplopia (diplopia score 1 or 2). Data on the number of patients who continued wearing prisms versus those who opted for surgery were derived based on follow-up records. Among 64 patients, 72% of patients reported complete or partial resolution of diplopia after prism use. In patients who were prescribed =10 PD (n=18) and those with oblique prisms (n=18), 67% and 50%, respectively, reported resolution of diplopia. More patients with vertical prism reported improvement in double vision symptoms (83%) than those who were prescribed horizontal prism (70%, p=0.04). During follow-up, 73% of the cohort continued using prisms while 23% of patients opted for strabismus surgery. Prisms are an effective modality and should be considered in the initial or interim management of patients with diplopia from complex ocular misalignments.

Effectiveness of Prisms in the Management of Diplopia in Patients Due to Diverse Etiologies

To study the effectiveness of prisms in the management of diplopia from different etiologies and over a broad range of ocular misalignment. In this retrospective cohort study, resolution of diplopia in 94 patients who were prescribed prisms was studied. Among 94 patients, 88% reported complete or partial resolution of double vision (95% confidence interval: 84.1% to 95.6%) with highest improvement noted in the divergence insufficiency and skew deviation group (100%) compared to 64% improvement noted in patients with convergence insufficiency. More than 85% of patients who were prescribed greater than 10 diopters of prism and those with oblique prism prescriptions also reported resolution of diplopia. Eighty-nine percent of the cohort continued with prism use and 11% opted for strabismus surgery. In this study, prisms were effective in alleviation of diplopia over a broad range and for different etiologies of double vision.

Nonsurgical Management of Diplopia After Retinal Surgery

For those who manage strabismus in adults, the patient with diplopia following retinal surgery presents a challenge. Mechanical and sensory factors may combine to preclude single binocular vision, and neutralizing the patient's strabismus may not be sufficient to permit resolution of their diplopia. This paper reviews the issues involved and discusses some potential solutions.

Nonsurgical Management of Diplopia

Diplopia is a potential undesirable outcome of nearly any ocular surgery. In some cases, the unexpected strabismus and diplopia resolve quickly without intervention, especially if due to swelling or minor insult from the surgical procedure. When double vision persists, effective treatment may be more elusive in patients in which the strabismus is the result of a restrictive process. The sudden onset of the strabismus makes treatment more challenging. Frequently these patients will require surgical intervention. Where possible, patients may be managed with nonsurgical treatments until the time of surgery or indefinitely if successful and acceptable to the patient.Diplopia has been documented as a result of restrictive strabismus following vitreoretinal surgery, glaucoma surgery, orbital decompression surgery, strabismus surgery, orbital surgery, conjunctival surgery, cataract surgery, blepharoplasty, and others.The treatment of diplopia after ocular surgery is complicated by the incomitance and torsion that may be associated with restrictive strabismus as well as the variability of the deviation during healing. Nonsurgical treatment options include prisms or occlusion. Fresnel prisms are used primarily, but occasionally the prism is ground into the spectacles. Occlusion of the involved eye may be partial or complete, using a “pirate” patch, adhesive patch, Bangerter foil, tape, or related method.

Nonsurgical Management of Diplopia After Orbital Decompression Surgery

Orbital decompression is frequently performed in patients with thyroid eye disease. The indication for an orbital decompression in most patients is threatened visual loss from corneal exposure or optic neuropathy. One of the more common complications associated with orbital decompression is the development or worsening of diplopia. Often times, surgical intervention for strabismus is delayed after orbital decompression and in these cases, nonsurgical management of diplopia is invaluable to the patient. Nonsurgical management can include occlusion therapy, prism therapy, or even botulinum toxin injections into the extraocular muscles.

When the patient sees double and the doctor sees nothing

Relevance: Diplopia can be distressing to both the patient and the clinician. Though some cases are straightfoward, there are those that present with no obvious cause, those in which the symptoms are not consistent with the clinical signs, and those that seem to defy relief with all but occlusion. These are the types of cases that bring a busy clinic to a grinding halt! They take time, patience, and sometimes creativity. Enter the orthoptist. This workshop will cover the diagnosis and management of diplopia and related binocular visual symptoms whose cause is either not readily apparent, or unusual.

Management of diplopia in patients with blowout fractures

Purpose:To report the management outcomes of diplopia in patients with blowout fracture.Materials and Methods:Data for 39 patients with diplopia due to orbital blowout fracture were analyzed retrospectively. The inferior wall alone was involved in 22 (56.4%) patients, medial wall alone was involved in 14 (35.8%) patients, and the medial and inferior walls were involved in three (7.6%) patients. Each fracture was reconstructed with a Medpore® implant. Strabismus surgery or prism correction was performed in required patients for the management of persistent diplopia. Mean postoperative follow up was 6.5 months.Results:Twenty-three (58.9%) patients with diplopia underwent surgical repair of blowout fracture. Diplopia was eliminated in 17 (73.9%) patients following orbital wall surgery. Of the 23 patients, three (7.6%) patients required prism glasses and another three (7.6%) patients required strabismus surgery for persistent diplopia. In four (10.2%) patients, strabismus surgery was performed without fracture repair. Twelve patients (30.7%) with negative forced duction test results were followed up without surgery.Conclusions:In our study, diplopia resolved in 30.7% of patients without surgery and 69.2% of patients with diplopia required surgical intervention. Primary gaze diplopia was eliminated in 73.9% of patients through orbital wall repair. The most frequently employed secondary surgery was adjustable inferior rectus recession and <17.8% of patients required additional strabismus surgery.

眼窩壁骨折における複視症例の扱いについて

眼窩壁骨折における複視症例の扱いについて

Diplopia and eye movement disorders

Diplopia—seeing double—is a symptom with many potential causes, both neurological and ophthalmological. Accurate diagnosis and appropriate plans of management can be achieved with careful history taking and clinical examination. In...

Ophthalmic complications of childhood medulloblastoma.

To study the ophthalmic complications and sequelae in children surviving medulloblastoma in order to assess the need for therapeutic intervention by the ophthalmologist. We identified all children attending the Leeds General Infirmary and St. James' University Hospital for treatment of medulloblastoma in the period January 1990 to March 1997, and the notes of all surviving patients were reviewed. Those patients who had not had an ophthalmic assessment within the last 6 months were recalled for examination. Twenty-four surviving patients underwent full ophthalmic assessment. The follow-up period ranged between 6 months and 7 years (range 3.6 yr): 66% had ocular symptoms at presentation; 25% developed ocular complications following treatment; 50% were left with ocular sequelae; 41% percent required ophthalmic intervention (25% medical/orthoptic intervention; 16% surgical intervention). Early (preferably preoperative) referral to the ophthalmology department is important in order to ensure appropriate management of diplopia, preservation of binocular single vision, and prevention of amblyopia in younger children.

Management of Diplopia Limited to Down Gaze

Objective: To evaluate the usefulness of various optical and surgical treatment modalities in the treatment of patients who were symptom free in the primary position of gaze yet had symptomatic diplopia in the reading position (down gaze at near). Patients and Methods: A retrospective chart review was conducted to identify all patients with presbyopia I have treated who were symptom free in the primary position but had diplopia in down gaze associated with vertically incomitant strabismus. Of 51 patients identified, 32 were symptomatic in down gaze due to a hypertropia associated with a unilateral inferior rectus muscle underaction. Twenty-two of these patients had previously undergone recession of the affected inferior rectus muscle for treatment of thyroid eye disease; four patients, for correction of entrapment secondary to blow-out orbital fracture; and four patients, for treatment of superior oblique muscle palsy. Two patients had undergone prior surgery for superior oblique myokymia. Eight patients had horizontal diplopia associated with anApattern, and eight patients had horizontal diplopia associated with aVpattern. Three patients had vertical and horizontal diplopia after partial recovery from third-nerve palsy. Results: The treatment modalities were varied and individualized. Treatment consisted of optical management (20 patients), surgical management (21 patients), or a combination of both (10 patients). These treatment modalities resulted in comfortable single binocular vision for reading in 41 of the 51 patients. Successful optical treatment consisted of Fresnel prisms (four patients), slab-off prisms (two patients), single-vision readers (seven patients), switch to nonprogressive bifocal lenses (three patients), and a high bifocal segment (16 patients). Successful surgical modalities included posterior fixation of the contralateral inferior rectus muscle (10 patients), surgery forA- orV-pattern strabismus (five patients), or bilateral inferior rectus muscle recession (six patients). Conclusion: Diplopia in the reading position frequently can be alleviated with a systematic approach that includes both optical and surgical modalities.