Double vision after cataract surgery

[wpalmer]

After cataract surgery I have occasional but annoying double vision when looking at distant road signs.  The two images  come together after a fraction of a second.  My surgeon says this is due to a retina problem.  He says the cataract surgery went perfectly.  My retina doctor has no comment.  What should I do?

[Michael J Kutryb, MD]

Make sure you don't have strabismus (eyes out of alignment).  This can be easily checked for in office.  Ask retina doctor if double vision is due to a retinal problem.  If not, you sholld next be measured for new glasses and have cover/uncover or maddox rod testing done to see if you have a slight misalignment of eyes (turning slighty in or out) which can sometimes be corrected with prism in glasses.  Ask your doctor to show you why the eyes see double.  If he can't make your eyes see double in the office - it may be like you said an occasional annoyance (I've seen it many times before) and could then be due to fatigue, medications, or other temporary symptoms.  Usually if I can't make the eyes see double in office and it occurs only rarely - it's not a major problem.  Have it checked out and make sure to report exactly how, how long, how often, it happens.

MJK MD

[wpalmer]

Thanks, a big help.  In my ealier inquiry I did not add that I had a vitrectomy for epiretinal layer stripping six months prior to the cataract surgery.  The cataract formed in reponse to the retinal surgery, evidently a common complication.  I have gained two Snellen lines from the retinal surgery so must regard it as a success, but I want to pursue the double image problem, and I thank you for your help in that regard.

Who does the strabismus testing -- retina doctor, cataract surgeon, or optometrist?

[JodieJ]

Your double vision problems may well be related to residual retinal damage (i.e., a change in the retinal receptor distribution), especially if you notice a difference in image size between your eyes.  This condition (called retinally-induced aniseikonia in the medical literature) can cause various symptoms, including double vision, headaches, photophobia, excessive tearing, and depth perception problems.  It's been my experience that the diagnosis is often overlooked, with symptoms incorrectly attributed to other causes.  I suffered from an eye that teared continuously for more than a year following a vitrectomy with epiretinal peeling, for which various dry eye remedies were prescribed without benefit by my retinal surgeon, my cataract surgeon, and my optometrist.  I ended up diagnosing retinally-induced aniseikonia on my own using online information sources, but then finding treatment was another challenge.

I'll summarize my treatment experience for you.  I initially contacted every ophthalmologist in my area who specialized in strabismus and was continuously told that the doctor didn't treat aniseikonia.  The local optometry school attempted to measure my aniseikonia using existing testing methods.  Unfortunately, because the degree of aniseikonia is not uniform across the retina, the tests didn't work very well, and it was concluded that my aniseikonia was "unclassifiable" and "untreatable."  There is an aniseikonia treatment program at the Ohio State University College of Optometry, and for $2000 they reportedly do a good job at measuring and treating aniseikonia that is not related to retinal problems.  One of the optometrists there suggested during a phone consultation that I put Magic Tape on my glasses lens to blur the vision in my affected eye, but this just didn't work for me.  What did work involved vision testing over the Internet by a Dutch Ph.D., Gerard de Wit, using new testing methodology he developed himself.  His website is at www.opticaldiagnostics.com.  Based on my test results, Dr. de Wit prescribed a contact lens/glasses combination that provided the image size correction I needed.  This immediately stopped my eye from tearing and made my binocular vision more comfortable.

If your problem does involve retinally-induced aniseikonia, I'd be happy to answer any questions you might have concerning treatment.  

  

[wpalmer]

Thanks for your very complete and helpful comments.  I live in the OSU area and will look up the Optometry problem you report.  My right (vitrectomy operation) eye does have a slightly larger image than the left eye.  My double vision does not bother me except when driving, and then it bothers me all the time and is very annoying.  I am four weeks away from the cataract operation and six months from the epiretinal layer stripping.  I see my optometrist in a couple days.  I will keep this forum posted.

[JodieJ]

Dr. David Robins (a board-certified strabismus surgeon in California) has posted on the Google newsgroup sci.med.vision that prism correction does not work for double vision related to retinally-induced aniseikonia, since the size distortion is not uniform across the retina.  He referred to the condition as being "not uncommon" in his posts.  He recommended slightly blurring the vision in the affected eye.  But I suspect that an image size correction by means of glasses/contacts might work better, without a loss of vision.

There is a Yahoo aniseikonia support group, where you can find additional information.  You can also download Gerard de Wit's professional publications from his website.  They are quite technical but provide state-of-the-art detail about measuring and correcting retinally-induced aniseikonia.  (You might want to bring in a couple of them to your optometry appointment.)

Paradoxically, as retinal surgeons are becoming more adept at saving vision, I suspect that symptoms related to retinally-induced aniseikonia are becoming more prevalent.  I'm hoping that this will lead to an increased awareness of the condition, as well as a greater availability of treatment.    

[wpalmer]

I saw my optometrist today.  He measured the double vision by the cover/uncover method and has prescribed a small degree of prism correction.  We shall see.  Thanks again for your comments.

[JodieJ]

I hope that the prism eliminates your double vision and makes your vision with both eyes comfortable.  If you continue to experience problems, your best bet would be an optical correction (probably iseikonic glasses) to equalize the image size between your eyes.  (The difference in image size is undoubtedly what's causing your problem, by making it difficult for you to fuse the images in each eye in certain situations.)  An optical correction might be achieved by changing the base curves or center thickness of your lenses.  It's not difficult to do but, unfortunately, few eye care providers know how to measure the needed size correction and then prescribe the iseikonic lenses.  The resources I mentioned above should be helpful.  Best wishes.

[wpalmer]

I will let you know how the prism correction works.  If no relief I will go the OSU optometry route for the iseikonic lens.  Thanks again for all your insightful comments.

[JodieJ]

I hope the prisms work for you.  If not, you might consider online aniseikonia testing, which worked extremely well for me.  It's hundreds of dollars cheaper than OSU, and you don't have to wait several months for an appointment.  (Dr. de Wit would need to work with your eye care provider to prescribe the best correction for you.)  BTW, the OSU optometry school uses an older version of Dr. de Wit's aniseikonia test.  The latest version of the test (currently available online only) is customized to measure retinally-induced aniseikonia, which is not uniform across the retina.  Best wishes.