Strabismus acquired though monovision contacts

Discussion in 'Contact Lenses' started by filmbuffchgo, Jul 21, 2005.

  1. filmbuffchgo

    filmbuffchgo Guest

    I am a woman in my 50's who began wearing monovision contacts about 9
    years ago. I began experiencing occasional episodes of horizontal
    diplopia during my 4th year of monovision under specific circumstances
    (mostly night driving and watching movies in a theater). The
    ophthalmologist I consulted dismissed my concerns, telling me that he
    experienced double vision himself when he wasn't feeling well. So I
    continued using monovision, although the episodes of diplopia increased
    in frequency during each of the next five years. I decided to stop
    using monovision this spring (against the advise of my optometrist),
    and that's when my real vision problems began! The episodes of diplopia
    occurred throughout the day (distance vision only), impairing my
    ability to function. After a couple of useless consultations with eye
    care professionals, I found an optometrist who diagnosed strabismus and
    prescribed prism glasses (OS 3BO OD 3BO). The prisms (which are quite
    heavy) eliminate almost all of the diplopia, but my depth perception is
    still impaired. The optometrist also suggested vision therapy, but he
    did not appear to be too optimistic about the probability of successful
    results. So I am now considering strabismus surgery. Despite my
    research, I cannot find a single study about treating someone with my
    history. In case it is relevant, I did not have strabismus as a child
    and have no family history of the disorder. My glasses prescription is
    OD-5.50-1.50x175 OS-6.00-1.00x175 ADD +2.00. Any
    information/suggestions for treatment would be greatly appreciated!
     
    filmbuffchgo, Jul 21, 2005
    #1
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  2. I assume the base out prism glasses were combined with the high minus
    spectacle correction. If that is true, then it sounds like they just
    didn't give you enough prism. Go to an O.D. who deals with binocular
    vision (or back to the prism prescriber) and have him/her measure
    exactly how much prism it will take to get you comfy, and get glasses
    with your minus AND that amount of prism in them. You'll do fine. BTW
    the glasses should NOT be that heavy. Base out prism in -6 lenses is
    almost a no brainer and should not make the glasses all that heavy.

    w.stacy, o.d.
     
    William Stacy, Jul 21, 2005
    #2
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  3. While you have prisms of 6^ total,there is no information as to the actual
    deviation readings at distance in primary position, and looking left, right,
    up and down. In addition, the angle at near is needed.

    This information would help tell something about the kind of acquired
    strabismus that you have. Monovision may have played a role, in causing a
    mild pre-existing deviation to "break down". In addition, it is not uncomman
    at this age to have minor deviations become symptomatic. Question is, is the
    angle stable?

    If the 6 prism is just enough for comfort, but the angle itself is actually
    much larger, would be nice to know. In general, the threshold for most strab
    surgery is about 15 prism. Is it possible to do single-muscle surgery for
    slightly smaller angles, but in general, if the total angle is only 6, most
    people would not operate.

    David Robins, MD
    Board certified Ophthalmologist
    Pediatric and adult strabismus subspecialty
    Member of AAPOS
    (American Association of Pediatric Ophthalmology and Strabismus)
     
    David Robins, MD, Jul 21, 2005
    #3
  4. filmbuffchgo

    filmbuffchgo Guest

    Actually, the base out prism glasses are combined with the +2.00 ADD to
    be worn over my (non-monovision) contact lenses. Despite several
    adjustments, the weight of the prisms constantly drag them down my
    nose, making it hard to find the reading correction at the bottom of
    the lens.

    Any suggestions for restoring my binocular vision, or am I stuck with
    the current status?
     
    filmbuffchgo, Jul 21, 2005
    #4
  5. filmbuffchgo

    Dr. Leukoma Guest

    I seriously doubt that your strabismus was entirely the cause of the
    monovision. I have prescribed monovision in thousands of cases without
    inducing strabismus. This will only happen if the patient has latent
    strabismus that is held in check by both binocular fusion and
    accommodation. Adult strabismus typically breaks down during
    presbyopia. Most people, however, will experience more problems at
    night because of the lack of peripheral visual cues.

    Interesting that the strabismus is apparently esotropia. In a myope, I
    would have expected exotropia, convergence insufficiency, or divergence
    excess. Some vision therapy may be indicated at this point along with
    some adjustment of the prism, and/or the prescription.

    DrG
     
    Dr. Leukoma, Jul 21, 2005
    #5
  6. You could try some orthoptics/vision training, but eso is hard to help.

    Regarding your prism glasses, if they are made for over your mono
    contacts, then this is not a very good arrangement. I mean why bother
    with mono if you're wearing glasses over the contacts? Why not go full
    distance Rx and make the prism glasses bifocals? And they should NOT be
    heavy as you stated in the original post. In a reasonable sized frame,
    3^ lenses should be quite light, and could be made VERY light in Trivex.

    w.stacy, o.d.
     
    William Stacy, Jul 21, 2005
    #6
  7. I hope you meant "doubt your monovision was entirely the cause of the
    strabismus".

    w.stacy, o.d.
     
    William Stacy, Jul 21, 2005
    #7
  8. filmbuffchgo

    Dr. Leukoma Guest

    Of course I did. Thanks for sweeping up after me.

    Now, strabismus can be the cause of monovision if it causes amblyopia
    :)

    DrG
     
    Dr. Leukoma, Jul 21, 2005
    #8
  9. filmbuffchgo

    Dr. Leukoma Guest

    Of course I did. Thanks for sweeping up after me.

    Now, strabismus can be the cause of monovision if it causes amblyopia
    :)

    DrG
     
    Dr. Leukoma, Jul 21, 2005
    #9
  10. filmbuffchgo

    Dr. Leukoma Guest

    Of course I did. Thanks for sweeping up after me.

    Now, strabismus can be the cause of monovision if it causes amblyopia
    :)

    DrG
     
    Dr. Leukoma, Jul 21, 2005
    #10
  11. filmbuffchgo

    Neil Brooks Guest

    Google was hanging again, huh? ;-)
     
    Neil Brooks, Jul 21, 2005
    #11
  12. filmbuffchgo

    filmbuffchgo Guest

    If I had been aware of this site a couple of months ago, I would have
    been spared a lot of frustration and wasted money. I really appreciate
    the information I have received.

    I realize it's absurd to wear prism glasses over contact lenses. A
    previous consulation resulted in a prescription for 1BO in each eye; I
    was able to have the glasses remade at no charge. It would have been
    several hundred dollars to remake the bifocals.

    I don't have all the information that Dr. Robins requested. I do know
    that eye turns were measured at between 11 and 20 on different dates
    (worse at the end of the day). The optometrist seemed to feel that I
    was a candidate for surgery but suggested I do vision therapy first.
    This did not make much sense to me.

    Obviously, the monovision alone is not the reason for the breakdown of
    my alignment. I came across an interesting article by Burton Kushner
    in which changes in refractive management precipitated diplopia in
    adults with long-standing strabismus. Such changes commonly occur to
    treat presbyopia (e.g., monovision), which may account for the
    increased incidence of symptoms at this age. However, the article
    suggests that the diplopia can be eliminated by stopping the use of
    monovision when the symptoms begin. I feel angry that all of the
    practioners I saw over the past five years dismissed my complaints of
    diplopia (but documented them in my record) and kept pushing
    monovision. And it's frustrating that there doesn't seem to be much
    that I can do now to reverse the damage.
     
    filmbuffchgo, Jul 21, 2005
    #12
  13. filmbuffchgo

    Dr. Leukoma Guest

    It is entirely possible that these changes in your binocularity might
    have occurred without monovision. 20 diopters of esotropia is a
    surgical amount of strabismus, but 11 diopters might be within the
    range of feedback control.

    DrG
     
    Dr. Leukoma, Jul 21, 2005
    #13
  14. filmbuffchgo

    Neil Brooks Guest

    NB: I'm not an eye doctor, but am a strabismus patient of many years.

    I'm thinking Prism Adaptive Trials. Sounds like the OP /was/ a latent
    esotrope, but had the fusional amplitudes to maintain binocularity
    despite.

    It seems possible-to-likely that monovision /could/ have played a
    role in the accelerating the degredation of fusional amplitudes (which
    is why I--a three-time strabismus surgery patient have refused
    monovision).

    Prism Adaptive Trials involve pushing steadily higher power prisms on
    you on the theory that you may actually have a higher deviation than
    you manifest. If you're manifesting between 11 and 20 diopters in
    primary gaze, you may well have 20-24d of total esotropia--some of
    which is compensated for by your residual fusional amplitudes.

    As Dr. G said -- 20d is definitely in the cut range. If you've /had/
    fusion in the past, and the surgical result is successful, it's very
    likely you'd regain ample fusion/steropsis again, but--as Dr. Robins
    said, it matters whether your deviation is stable in every direction
    or not.

    Also, I wore plano prism glasses over contact lenses for years.
    Nothing at all 'absurd' about it. If it works, you wear it, IMO.

    Good luck!
     
    Neil Brooks, Jul 21, 2005
    #14
  15. filmbuffchgo

    Dr. Leukoma Guest

    There is no way monovision would have "caused" 20 prism diopters of
    esotropia. However, it could have accelerated the decompensation,
    which would probably have occurred anyway due to the presbyopia.

    DrG
     
    Dr. Leukoma, Jul 21, 2005
    #15
  16. filmbuffchgo

    filmbuffchgo Guest

    Please review "Recently Acquired Diplopia in Adults with Long-standing
    Strabismus" by BJ Kushner, MD in Archives of Ophthalmology, Vol.119,
    No. 12, December 2001. I'm a psychologist, not an
    opthalmogist/optometrist, so I'd be very interesting in hearing your
    interpretation. (It's accessible online.) My reading suggests that
    monovision can indeed cause the breakdown of a stable alignment, and it
    is the monovision (not presbyopia) that triggers the symptoms. The
    article includes numerous case examples.
     
    filmbuffchgo, Jul 22, 2005
    #16
  17. filmbuffchgo

    Dr. Leukoma Guest

    I read the abstract, and the author is essentially saying the same
    thing, that a change in refractive status, refractive needs, or
    refractive management can bring about sudden onset diplopia in a
    patient with long-standing strabismus.

    It is likely that you had long-standing strabismus. Your refractive
    management brought about by your refractive needs probably triggered
    the diplopia. That is a slightly different spin than saying that the
    monovision caused the strabismus.

    You should know that I have also seen diplopia in such patients occur
    spontaneously, without any significant change in refractive management,
    simply because the accommodative-convergence relationship changed with
    the onset of presbyopia.

    I strongly believe that a thorough binocular vison workup is essential
    for any patient undergoing monovision or refractive surgery.

    DrG
     
    Dr. Leukoma, Jul 22, 2005
    #17
  18. Can amblyopia be trigered at this age?

    Roland Izaac
     
    Philip D Izaac, Jul 22, 2005
    #18
  19. filmbuffchgo

    Dr. Leukoma Guest

    Conventional wisdom says that refractive amlyopia cannot be induced at
    this age...however, I seem to remember some obscure article arguing
    that it can. All I know is I haven't seen it.

    DrG
     
    Dr. Leukoma, Jul 22, 2005
    #19
  20. No, just aided and abetted it ....

    One treatment not mentioned is BOTOX - a non-surgical injection way of
    helping regain the alignment IF there is some fusion potential to hold the
    alignment once it is straight. Is done in the office by some strabismus
    specialists, takes very little time, and less risk than surgery. However,
    for it to work, it has to cause a large exotropia (eye angled out) with
    diplopia that may require a patch for more than several weeks.

    And as mentioned, PAT (prism adaptation testing) to find if there is a
    latent esotropia that is hidden, which might change the proposed treatment,
    as surgery would want to be done for the total (non-hidden) angle, as Neil
    Brooks mentioned.


    David Robins, MD
    Board certified Ophthalmologist
    Pediatric and adult strabismus subspecialty
    Member of AAPOS
    (American Association of Pediatric Ophthalmology and Strabismus)
     
    David Robins, MD, Jul 22, 2005
    #20
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