1. Treating diplopia in a patient S/P RD surgery Presented by Justin Smith, OD Pediatric Resident, NECO

2. Abstract Longstanding binocular diplopia caused by large angle exotropia resulting from scleral buckle surgery for bilateral retinal detachments. The patient reports near total reduction in diplopia after a careful refraction and prescribing appropriate horizontal prism. Longstanding binocular diplopia caused by large angle exotropia resulting from scleral buckle surgery for bilateral retinal detachments. The patient reports near total reduction in diplopia after a careful refraction and prescribing appropriate horizontal prism.

3. Pt. History 74 y.o. Caucasian male 74 y.o. Caucasian male Myopic astigmatic presbyope Myopic astigmatic presbyope RD in both eyes, surgical correction 1986. RD in both eyes /c scleral buckle surgery 1990. RD in both eyes, surgical correction 1986. RD in both eyes /c scleral buckle surgery 1990. Sx of diplopia S/P RD surgery. Sx of diplopia S/P RD surgery. PMHx: Unremarkable PMHx: Unremarkable PFHx: DM (father) PFHx: DM (father) Allergies: Amoxicillin Allergies: Amoxicillin ROS: general health is stable ROS: general health is stable Social Hx: Former Economics professor, drives, enjoys bird watching. Social Hx: Former Economics professor, drives, enjoys bird watching.

4. Reason for Visit Patient presents with complaint of intermittant diplopia which prevents him from using his binoculars when bird watching. Patient presents with complaint of intermittant diplopia which prevents him from using his binoculars when bird watching.

5. Examination Findings ccDVA: OD:20/32 (-2) OS:20/50 OU:20/32 (-2) (Lighthouse illuminated chart) ccDVA: OD:20/32 (-2) OS:20/50 OU:20/32 (-2) (Lighthouse illuminated chart) ccNVA: OD:20/30 OS:20/50+ OU:20/40 ccNVA: OD:20/30 OS:20/50+ OU:20/40 PERRL –APD PERRL –APD EOMS: FESA EOMS: FESA FCF: inferior restriction almost to midline OD, Full OS FCF: inferior restriction almost to midline OD, Full OS CT: 30 Alt XT CT: 30 Alt XT Maddox rod: 18 BI, 2BU OS Maddox rod: 18 BI, 2BU OS No ptosis No ptosis

6. Ocular Health Anterior seg: mild bleph OU, arcus OU, NSC OU Anterior seg: mild bleph OU, arcus OU, NSC OU Undilated fundus eval unremarkable Undilated fundus eval unremarkable IOP: 10,11 (OD,OS) NCT@9:30am IOP: 10,11 (OD,OS) NCT@9:30am

7. Visual Fields HVF 30-2 Threshold HVF 30-2 Threshold OD: Outside Normal Limits 2’ to large inferior absolute scotoma (obeys horizontal raffe, not complete hemianopia, spares macula) OD: Outside Normal Limits 2’ to large inferior absolute scotoma (obeys horizontal raffe, not complete hemianopia, spares macula) OS: Borderline /c general reduction OS: Borderline /c general reduction

8. Refractive Error Lensometry: OD:-2.00-2.50x058 4.5BD OS:-1.50-2.50x13011BI +2.75add Lensometry: OD:-2.00-2.50x058 4.5BD OS:-1.50-2.50x13011BI +2.75add Ret: OD:-1.00-1.25x060 OS:-1.50-1.00x130 Ret: OD:-1.00-1.25x060 OS:-1.50-1.00x130 Subj: OD:-0.50-2.50x60 20/30 OS:-1.00-2.50x135 20/30 +2.50add Subj: OD:-0.50-2.50x60 20/30 OS:-1.00-2.50x135 20/30 +2.50add

9. BV workup Versions not commitant superiorly Versions not commitant superiorly Stereo @ D: 3 min of arc Stereo @ D: 3 min of arc Stereo @ N: none, showing left suppression Stereo @ N: none, showing left suppression Jump Ductions: B.O. x/14/4 B.I. x/14/8 Jump Ductions: B.O. x/14/4 B.I. x/14/8 Unable to test phorias, vergences due to suppression Unable to test phorias, vergences due to suppression

10. Differential Dx Under-corrected exotropia secondary to R/D surgery Under-corrected exotropia secondary to R/D surgery Increase in existing exotropia secondary to swelling of Hydrophilic explant Increase in existing exotropia secondary to swelling of Hydrophilic explant Less likely: Less likely: –Third nerve palsy –Medial rectus palsy –Duane’s –Ocular myopathy –INO –Dysthyroid eye disease –Divergence Excess

11. Hydrophilic Explants A brand of scleral buckle explants used to treat retinal detachments has been shown to be hydrophilic and can swell over time causing diplopia in patients who did not exhibit diplopia s/p surgery. A brand of scleral buckle explants used to treat retinal detachments has been shown to be hydrophilic and can swell over time causing diplopia in patients who did not exhibit diplopia s/p surgery. Removal of the explants, where appropriate, has been shown to resolve the diplopia.(Leibovich, 2005) Removal of the explants, where appropriate, has been shown to resolve the diplopia.(Leibovich, 2005)

12. Diagnosis Under-corrected Large angle exotropia 2’ to scleral buckle surgery from RD OU /c Sx of diplopia Under-corrected Large angle exotropia 2’ to scleral buckle surgery from RD OU /c Sx of diplopia Central suppression OS under clinical binocular testing conditions Central suppression OS under clinical binocular testing conditions Inferior field loss OD 2’ to retinal detachment Inferior field loss OD 2’ to retinal detachment

13. Diagnosis Scleral buckle surgery can result in diplopia in 5- 7% of cases. (Fison, 1987) Scleral buckle surgery can result in diplopia in 5- 7% of cases. (Fison, 1987) In approximately 80% of those cases binocular single vision is restored after the use of prism, removal of the explant, or strabismus surgery. In approximately 80% of those cases binocular single vision is restored after the use of prism, removal of the explant, or strabismus surgery. In the case of the patient described, diplopia had persisted for over 17 years post surgery despite the use of prism. It is possible that the exotropia had increased over time, possibly due to swelling of the explant. Thus, close monitoring of the patient is important. In the case of the patient described, diplopia had persisted for over 17 years post surgery despite the use of prism. It is possible that the exotropia had increased over time, possibly due to swelling of the explant. Thus, close monitoring of the patient is important.

14. Treatment options VT VT Ophthalmic prisms Ophthalmic prisms –Give reversed prism to put image far from fovea –Continue to refine current prism correction Botulinum toxin Botulinum toxin Surgery to remove scleral buckles Surgery to remove scleral buckles Strabismus surgery Strabismus surgery –Adjustable sutures Monocular occlusion Monocular occlusion –Give pt old Rx where OD is fogged

15. Plan Pt. given Rx: OD -0.50-2.50x060=1BD, 9BI OS -1.00-2.50x135=1BU, 9BI +2.50add F/U in 3 wks to check visual Sx with new spectacles UUUUpon return visit, symptoms were almost totally resolved, except on extreme horizontal gaze. Pt was able to use his binoculars without experiencing diplopia.

16. Conclusions In some cases, diplopia can continue to be managed with success using prism, even after many years of seemingly intractable symptoms. In some cases, diplopia can continue to be managed with success using prism, even after many years of seemingly intractable symptoms. Splitting prism between lenses not only improves cosmetic appearance of spectacles but also can improve functionality of spectacles. Splitting prism between lenses not only improves cosmetic appearance of spectacles but also can improve functionality of spectacles.

17. References: 1. Diplopia after retinal detachment surgery. PN Fison, AH Chignell, Br J Ophthalmol. 1987 Jul;71(7):521-5 2. Role of optometric vision therapy for surgically treated strabismus patients. RS Garriott, CL Heyman, MW Rouse, Optom Vis Sci. 1997 Apr;74(4):179-84 3. Strabismus after retinal detachment surgery. AK Farr, DL Guyton Curr Opin Ophthalmol. 2000 Jun;11(3):207-10 4. The Differential Diagnosis of Diplopia. A Finlay, City University London Department of Optometry and Visual Science 2000 Oct. 5. New onset diplopia: 14 years after retinal detachment surgery with a hydrogel scleral buckle, I Leibovitch, J Crompton and D Selva British Journal of Ophthalmology 2005; 89:640