Two More Causes of Following cataract surgery Diplopia Convergence - - PowerPoint PPT Presentation

12/2/2016 1

Two More Causes of Diplopia

Creig S Hoyt MD MA San Francisco

Other Causes Discussed

• Following cataract surgery
• Convergence abnormalities
• Divergence abnormalities
• Excluded- CN palsies, thyroid orbitopathy

Following cataract surgery

• Reduced but not eliminated with topical

anesthesia

• Myotoxicity most likely cause in cases with

retrobulbar or peribulbar anesthesia

• Previous strabismus/amblyopia most likely

cause in cases with topical anesthesia

Convergence abnormalities

• Convergence insufficiency is common/benign
• Convergence paralysis implies neuro problem
• Beware of the older patient who progresses

from insufficiency to paralysis

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Divergence abnormalities

• Divergence insufficiency in young patients

implies neuro problem- subclinical 6th nerve

• Divergence insufficiency in older patients with
• r without myopia is usually benign

Case Number One

• 36 year old complains of double vision with

slight horizontal and vertical displacement that overlaps the other image. The second image is described as “faint”.

• What is the diagnosis?

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Differences in Pictures

• Presence or absence of cyclotorsion!
• Is the second image “faint”?
• Do the images overlap?
• How confusing is the double vision?

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Monocular Diplopia

• Second image- “faint” or “ghost”
• Overlap the rule; complete separation rare
• Little or no cyclotorsion
• Persists with occlusion of fellow eye
• Disappears with pinhole

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Monocular Diplopia

• Most common cause of diplopia in general

eye practice — 25% of diplopia cases

• Most common cause — refraction problem

not just astigmatism errors

• Other causes — cornea, lens, retina

Case Number Two

• 46 year old man – sudden onset diplopia
• 16 PD ET; 2 PD right HT with OA IO
• Ductions and versions — no limitations
• OD 20/25 +2.00 + 1.50 x 067
• OS 20/20 +.50 + .25 x 101
• Otherwise unremarkable exam

Monofixation Syndrome

• Stable less than 8 PD horizontal deviation
• Good fusional vergence amplitudes
• Facultative suppression scotoma non-fixing
• Peripheral fusion with low grade stereo
• Inability to convert to bifoveation with Tx

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Etiology of MFS

• Previously treated strabismus
• Anisometropia with strabismus
• Unilateral macular lesion
• Primary or idiopathic- FH is important

MFS IS NOT STABLE

• 10% per decade after 40 yo develop diplopia
• Fusional vergence amplitudes decrease
• May be related to accommodation change
• Often have small vertical

Case Number Two

• 46 year old man – sudden onset diplopia
• 16 PD ET; 2 PD right HT with IO OA
• Ductions and versions — no limitations
• OD 20/25 +2.00 + 1.50 x 067
• OS 20/20 +.50 +.25 x 101

Case Number Two

• 46 year old — early presbyopia
• Horizontal deviation with small vertical deviation

with inferior oblique overaction

• Ductions and versions – no limitations
• Anisometropia
• No history of strabismus or amblyopia Tx

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CONCLUSIONS

• 1. Monocular diplopia is most common cause
• 2. Monofixation syndrome is NOT stable
• 3. Divergence insufficiency: adults – benign
• children - beware

CONCLUSIONS

• 4. Convergence insufficiency is common
• 5. Convergence paralysis – think Parkinson’s
• 6. Cataract surgery, topical anesthesia

reduces diplopia risk but does not eliminate