Double vision after macular pucker vitrectomy

[tictactoe68]

I am a 43-year-old woman. I had a vitrectomy on January 18 to remove a macular pucker from my retina and for floaters left by a vitreous detachment. As my vision began to clear after surgery, I began seeing double.  I'm seeing separate images from each eye, but they are not "meshing" together when using both eyes. I do not have double vision when I cover either eye, it's only when I try to use my eyes together. Before surgery, my vision was distorted due to the macular pucker and I had an extremely large floater, but I was not seeing double.

My retina looks fine post-surgery and the retina specialist doesn't know why I have double vision. He sent me back to the optometrist who, after seeing me, said he believes my double vision is a processing problem. The optometrist said my vision was so compromised before the surgery that my brain can't put the images from each eye together. He prescribed prisms which I should be getting this week.

I'm trying to educate myself on what's happening and am finding little to none on "processing problems" such as mine. I'm also concerned there could be more at play here since I have Lyme disease and have a first degree relative with Grave's disease.

I'm not sure what to think. I'm trying learn more and figure out how I want to proceed. Any input is appreciated. Thank you.

[JodieJ]

I had the same problem following surgery to remove an epiretinal membrane (aka macular pucker).  Macular conditions and the surgery to correct them can cause changes in the photoreceptor distribution in the macula.  This results in changes in image size and/or shape.  When the size/shape of the images in each eye is too different your brain cannot fuse them, resulting in double vision.

A difference in image size is called aniseikonia.  I believe that your problem is retinally-induced aniseikonia.  There is little research in this area.  Dr. Gerard de Wit of the Netherlands has written the best papers on this topic (in English).  If you google his name, you can find his website.  I'd be happy to send you more information if you give me your email address in a personal message.

Treatment for this type of double vision has to be individualized.  In my own case, the image in my right (affected) eye was larger than the image in my left eye following retinal surgery.  Wearing a plus contact lens in my right eye under a minus glasses lens minified the image, and the double vision was eliminated.  I also had a second retinal surgery to remove pieces of the epiretinal membrane that had been left in my eye.  I've described my experience a number of times--check the archives of this site.

According the professional literature, prisms are not very helpful in cases of retinally-induced aniseiklonia.  But who knows, prisms might work for you.  In my opinion, your best strategy is to become educated about your condition.  Try to find an eye care professional who specializes in binocular vision who is willing to work with you.

[John C Hagan III, MD, FACS, FAAO]

Thank you JodieJ for your always helpful and authoratative responses.
JCH MD

[JodieJ]

Another recent post on this forum reminded me of something important that I omitted.  It is also possible that an injured eye muscle is causing your double vision.  In this case, there would not be a noticeable difference between the size/shape of the image in each eye.  Either prisms or eye muscle surgery would fix this problem.

[tictactoe68]

Thank you, Jodie. I've sent you a message and am reading you posts in the archives.

It sounds like retinally-induced aniseikonia could be the issue. Images from my right eye look slightly shorter and wider through my right eye with straight edges slightly bowed.

So, my next step is research and then addressing this with my doctors and/or finding another one familiar with this condition.

[John C Hagan III, MD, FACS, FAAO]

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[Ruth1246]

Hi Jodie my name is Ruth I live in New Zealand I had surgery for a epiretinal membrane 6 weeks ago the surgeon commented that he had difficulty removing the membrane which was very tough .I suspect this is perhaps when the damage to the retina occurred . I had a gas nibble in for two weeks once this went I have had the most terrible binocular double vision . The vision in the r operated eye is about 30 percent smaller and distorted then in the good eye .
I stumbled across this site when the double vision started and diagnosed myself with retinal induced aniseikonia which the eye surgeon has confirmed, Allthough he has not offered any advice except get prisms or wear a patch
I have been to optometrists prisms don't help I am seeing specialist again mon also have contacted Auckland university  vision science and have an appt with a Dr ken Robertson (Canadian) he seems to know about aniseikonia and also has designed lenses  .I have also been on Dr Gerard De Wit site  as second option. Any information u can pass on to me would be great  also if there are any other community members with this condition  in nz I would be happy to have them contact me . Cheers Ruth

[John C Hagan III, MD, FACS, FAAO]

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[JodieJ]

Your eye is still healing--hopefully your vision will improve.  You might want to consult another retinal surgeon to see whether a second surgery might improve your situation.

In my own case, partially correcting the image size difference between my eyes with a +3.5 contact lens worn under a -3.5 glasses lens eliminated my double vision.  Possibly this type of solution would work for you.

I accidently discovered another option that might work in your case.  I use an Acuvue 1-day moist contact, which is so comfortable that I've occasionally forgotten to remove it at night.  More than once, I've inserted a second +3.5 contact lens and gone the entire day wearing 2 contacts in the same eye!  Amazingly, this seemed to make little (no?) difference in my vision, although I was using only my "good" eye to see.  This suggests that wearing the wrong prescription in your operated eye (using either a contact lens or glasses) might eliminate your double vision and give you comfortable binocular vision.

Dr. de Wit's paper (Retinally Induced Aniseikonia) has some other suggestions that have been helpful to others--it's not clear what would work for you.  Feel free to contact me through a personal message if you have more questions.  Unfortunately, it's been my experience that the eye care professionals in my area had little to offer me--maybe you'll have better luck in New Zealand.

[Ruth1246]

Thankyou Jodie for your reply as I said I have an appt with a specialist optometrist at the Auckland university on tues and will take you suggestions along with me also Dr De Wits paper on aniseikonia I wil post a comment and let u know how I get on . Many thanks Ruth Do u buy the Acvue I day moist contact on line I only had glasses for reading prior to my surgery

[JodieJ]

You're so fortunate to have a specialist optometrist available to help you.  You might want to print out the information about the Aniseikonia Inspector test from Dr. de Wit's website.  I believe that your optometrist could get a free trial of this software (and perhaps a consultation about using the test results to get a prescription for minimizing the image size difference between your eyes.)

I'm sure that your optometrist will know all about ordering contact lenses in your area, and s/he will probably have samples of the major brands in stock.  There are several good 1-day contacts available now.  My eyes are somewhat dry, and I cannot wear some brands of contacts comfortably for more than a couple of hours.  However, I can wear two 1-day Acuvue moist lenses in the same eye all day (not recommended).  It would probably also be possible to give you comfortable vision with glasses alone.  Keep us posted!

[John C Hagan III, MD, FACS, FAAO]

JodieJ: Thanks again for sharing your experience and research. JHaganMD

[Ruth1246]

hi Jodie Yes I intend taking the information an the aniseikonia inspector with me on tues. and I am lucky to have someone in Nz he is about 3 hours from me at the university of Auckland .Whenthis first happened I managed to stumble over your site and got on to Dr De Wits stuff from there it hen did a nz search for retinally induced aniseikonia specialists  in nz and his  was the only name popped up .the Auckland university school of optometry and vision science runs  teaching clinics at the university and so I ph and got an appt with him.Ken Robertson is Canadian he apparently developed the Robertson technique of measuring dynamic aniseikonia and designed iseikonic lesses you can google him  I feel incredibly lucky as I suspect he is probably the only one in nz. Will let you know how I go

[JodieJ]

You are incredibly lucky!  I live in a large metropolitan area (Chicago), and I have yet to encounter an optometrist who is knowledgeable about retinally-induced aniseikonia.  A couple of optometrists actually became hostile when I attempted to explain the concept of field dependency.  I did see a very enlightened local neuro-ophthalmologist who used correction techniques similar to those of Dr. de Wit.  However, the ophthalmologists I contacted who specialized in binocular vision actually refused to see me when they learned that my problems were retinally induced.

NZ is apparently more advanced in this area than we are in the US.   It sounds like you are in good hands.  

[Ruth1246]

Hi I went to see the eye specialist  who was very apologetic said he only ever come across this once in his professional life and didn't know what to advise me .he had written and phoned Ken Robertson in Auckland also he took copies of Gerard De Wits paper on retinal induced aniseikona and the info on the aniseikonia inspector . I attended the appt with Ken Robertson who was helpful he also was aware of Gerard De Wit  Ken is trying to make me some lenses at this stage for driving did say that it would be atrial and error exercise but was happy to hang in there . My major problem at the moment is constant headaches despite taking panadol 2  every 4 hours do u have any suggestions I am trying to work and finding this a real struggle with the headaches  any suggestion will be appreciated . Ruth Solly

[JodieJ]

Yes, getting the right correction will involve a trial and error process.

Do you have glasses now?  I'd suggest trying to wear a foil on the inside of the lens for your affected eye that would blur your vision so that you'd be relying on your good eye.  This is a much better solution cosmetically than wearing an eye patch.  Your optometrist should have foils available in a range of powers.

I don't know the extent to which my own experience would generalize to others, but wearing the wrong prescription in my bad eye provided comfortable vision.  Through some type of neuroadaptive process, my brain automatically screened out the distorted image in my bad eye.  It seemed like I was seeing out of both eyes, and I wasn't aware of the loss of depth perception.  (Apparently, there are many visual cues for judging depth.)  This wouldn't work for viewing 3-D movies, but my vision seemed to be fine for driving.  (In the 3rd edition of "The Fine Art of Prescribing Glasses Without Making a Spectacle of Yourself" by Milder & Rubin, the authors prescribe glasses with the wrong script in one eye for a physician who suffered a badly botched LASIK procedure in one eye--and it worked just fine.)

[Ruth1246]

Hi Jodie I i made my self up a lense a week or so ago out of some clear   baroque glass i do stained glass as a hobbie which does work  blurres the image but i can still see out of that eye and it allows me to drive I have it stuck in with sticky tape certainly worked better than the ones the local optometrist made up for me. Ithink some of my headache problem is that I have been trying to go without glasses in an attempt to get the brain to suppress the distorted image in my r eye headache is much better today as I had my glasses on all day this may be a helpful suggestion for others while they are waiting to get to see a specialist optometrist thank you so much for all your help and suggestions  Ruth Solly

[Ruth1246]

Hi Jodie thank you so much for all your help and advice will let u know how my driving glasses turn  out once they arrive ,again many thanks for all your help cheers Ruth Solly

[JodieJ]

This type of correction often involves some tweaking, but I really believe that you can come up with something that works for you.  I'm always available if you have questions.

[Ruth1246]

Thanks Jodie i really appreciate all your suggestions and support idon't know anyone else with this condition and it seems difficult for others to understand how disabling and distressing it is  so it was great for me to get support from you.  Many thanks Ruth  I will keep in touch and let u know how things go with me .

[Ruth1246]

Jodie can u tell me if the retinal induced aniseikonia I am experiencing is a result of the epiretinal membrane or from the surgery to remove it . I didn't have any double distorted vision before the surgery . I had a look  on the net but couldn't really find anything . If it is due to the surgery I can get some help through acc ( accident compensation ) to help with all the lenses that I have to pay for that don't seem to help the problem .   Thanks Ruth.

[JodieJ]

I can't give you a definitive answer.  My situation is similar to yours--I had no image size difference between my eyes (causing my double vision) before ERM surgery.  In my case, I believe that the problem was caused by pieces of ERM left in my eye by my surgeon (who was very much aware of this but never informed me.)  Apparently, the remaining ERM continued to exert traction on my macula resulting in a changed photoreceptor distribution, which produced an image size difference and double vision.  I suspected that there was a problem with my surgery and consulted several respected local retinal surgeons, all of whom told me to "go home and live with it."  (Apparently, it takes special skills to remove small pieces of ERM, and this was beyond the ability of retinal surgeons in my area.)  In any case, Dr. de Wit's correction eliminated my double vision.  Three years later I traveled to Memphis, Tennessee, where Dr. Steve Charles easily removed the remaining ERM.  Afterwards, I got about a 50% improvement in my image size difference.  I corresponded with some British researchers, who speculated that the delay between my surgeries caused some permanent damage to my macula, and I was very unlikely to get further improvement.

I think that you could make a very strong case that your surgery caused your double vision.  Let me know if I can help you with that.  Possibly, a second retinal surgery might help your situation.  

[Ruth1246]

Thanks for your reply after reading your other replies I did ask my retinal surgeon if there would could be any membrane left behind and would he be able to tell he assured me he would as I have had several scans done on my eye. I will however think about getting a second opinion from another retinal specialist.AlsoI think i will put in a claim for medical .misadventure Again Jodie Thankyou so much for your advice and support  Ruth Solly.

[JodieJ]

Since you didn't have double vision before surgery and you do now, I think that it's fair to conclude that something about your surgery caused your double vision.  I tried investigating this issue in the medical literature, but even the retinal specialists seem to be in the dark.  My first theory was that ERM left in the eye was the cause.  However, apparently some people who develop double vision after ERM surgery don't still have ERM.  In any case, this is not a hot research topic.    

[Luvtoski]

Hi Jodie and Ruth !
I too had ERM surgery 1 1/2 years ago.  I did not have double vision prior to surgery but had a small amount after surgery that I seem to be slowly adjusting to.

The objects in my surgery eye are now a bit larger and in a little different
position than my non-surgery eye so the images, giving the perception of a double image.  My theory is that the surgeon's tugging on my retina when pulling off the ILM layer especially, upset the layers in my retina.  

The specific layers that now have a missing spot (visible on the OCT results post surgery)   is the IS/OS junction which is the photoreceptor layer that Jodie refers to.  If this layer is upset and disrupted, it is likely to cause distortion, etc.  When one thinks of how thin the retina layers are, it is logical that the surgery tugging at the ERM and ILM might disrupt it.

Just my thoughts, I would be interested in Jodie's opinion on it.
Good luck with your decisions, and keep on researching !!!