Eye Paralysis after Vitrectomy/Retrobulbar Block

[jw51]

I had a vitrectomy for a Stage III macular hole December 07 which was unsuccessful.  I had double vision right away as a result of paralysis of the superior rectus muscles.  It is now 9 weeks since the surgery and I have been wearing a patch because of the double vision.  I believe the paralysis is a result of the retrobulbar block  (and surgeon has also mentioned this may have happened).  Have you heard of this?  My surgeon of 25 years says he has never seen this as a complication. There is reference on-line to muscle paralysis as a risk.  I find it hard to believe that it is so rare that my surgeon has never seen it in his 25 years of practice.  Can you offer any advice?  jw

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

I cannot give you a medical opinion. You will need to make you own decision based on information obtained from your Eye surgeons.

JCH III MD

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

There are six muscles (extraocular muscles or EOM) that move each eye so the strabismus specialist needs to determine which one isn't working (there may be more than one). After that they can make surgical recommendations. Much of this type of surgery is successful.

The forced duction test is done under topical eyedrop anesthesia and consists of using a fine forceps on the eye and asking the person to look indifferent fields of gaze to see if the muscle is working. Also the eye is passively moved to see if there is any "entrapment" or scarring of an eye muscle that keeps it from moving properly.

Best of luck

JCH IIIMD

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

good plan.

JCH III MD

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

1, Some of my patients cleared with time (3-6 months) but at least half had to have eye muscle surgery.

2. You can go to a medical library associated with a hospital and they can get copies of the article  or you can go to the website of the medical journal and for a fee have their agent Elsevier print you a copy.

JCH III MD

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

Double vision following injection eye anesthesia is not at all rare. I have done research and published three scientific papers on the subject:


81. “Diplopia Cases After Peri-bulbar Anesthesia without Hyaluronidase”, Hagan III JC, Whittaker TJ, Byars SR Journal of Cataract & Refractive Surgery, 25:1560-61, 1999

82. “Diplopia and Ptosis Following Injection of local Anesthesia Without Hyaluronidase”, Jehan FS, Hagan III JC, Whittaker T, Subramanian M. Journal of Cataract & Refractive Surgery, 27:1876-1879, 2001


84. “Use of a Compounding Pharmacy Hyaluronidase for Ophthalmic Injection Anesthesia”, Hagan III JC, Hill WE. Journal of Cataract & Refractive Surgery, 27:1712-1714, 2001

You should not keep the eye patched all the time as it will lead to muscle contracture and also the eye will not attempt to start tracking again. I would ask for a referal to a strabismus/pediatric ophthalmologist for an eye muscle consult.

JCH III MD

[gordon2_4]

A related discussion, Double vision was started.

[jw51]

A related discussion, Strabismus Surgery was started.

[jw51]

Are you able to give me your opinion on this question I had asked you on a previous communication?  If so I would appreciate your answer.

In your opinion do you think that the strabismus/diplopia  this has left me is the cause of the macular hole surgery being unsuccessful?   Once the eye is straightened I have to decide if it is worth attempting another vitrectomy to deal with the macular hole.

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

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[PR777]

I had Vitrectom surgery on my right eye 2 weeks ago, opting for local, rather than general anesthesia.  When my patch came off the next day I had major double vision.  My surgeon explained that this complication only seems to effect patients not receiving general anethesia and that the frequency decreases in proportion to % of lydocaine in the local. (I can only repeat this info as a layman so please excuse!) Evidently, due to this complication, they have gradually decreased the concentration, and I am the first person to experience this result with the present lowest %they have used. He said it could take a week to a month for it to self-correct.  I wore an eye patch for a week (taking it off pe3riodically to excercise eye) and it is now 95% corrected.  It was suggested that I exercise and loosen up this muscle by using my finger in front of me to try and force it to focus a little bit better each sesson.  He also advised that I take 1 Aleve every 12 hours to reduce any inflamation.  Prior to surgery I began taking Lutein daily and have kicked up the dosage (by 1.5-2x) until my healing is complete. Eye drops 4x/day & ointment at night as well.  My blurriness is almost worse than before surgery but there is definitely something different about it.  Things definitely look brighter.  My surgeon told me that it can take several months for the eye to settle down enough for normal focusing and clarity.  It helped me understand things better when I was shown the scans of my healthy, vs. operative, eyes.  Guess there isn't instant gratification with this procedure, but I hope you begin to see improvement.  I feel strongly that the prodacol recommend to me had significant impact on my recovery from the double vision  Good luck...try the eye tracking excercises and push for a little improvement each time you do it.

[jw51]

Dr. Hagan, saw the specialists this week.  Slowly being weened off prednisolone but continuing drops for the pressure.  They are now thinking that it is the inferior rectus muscle that is prohibiting the eye going up instead of the superior rectus muscle being involved in the paralysis.  Seeing another specialist to determine this next month who does some sort of test with forceps to determine which muscle.  Can you give me any insight into what to expect and how this is done.  I believe a type of anesthesia is used.

In your opinion do you think that the strabismus/diplopia  this has left me is the cause of the macular hole surgery being unsuccessful?   Once the eye is straightened I have to decide if it is worth attempting another vitrectomy to deal with the macular hole.

I look forward to hearing from you.
jw51

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

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[jw51]

I am seeing an eye md and a neuro-opthamologist next week - eye md has been away - I see him regularly but in the meantime have my optometrist check the pressure.  Seeing neuro-opthamologist for second time next week also.  In the meantime I am asking for your advice as a specialist.  Your assistance is appreciated.

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

I cannot tell you about the choice of medicines but I can tell you that you should be under the care of an ophthalmologist Eye MD and NOT AN OPTOMETRIST. Your problem is miles above their skill level.

PUSH HARD to see an Eye MD immediately.

JCH III MD

[jw51]

I now have high pressure (27/28) in both eyes and use xalatan, prednisolone, apo-timop and pms-brimonidine for the operated eye only.  Also lots of pain and aching in both eyes - extra strength tylenol (2x a day gives some relief).

Seeing specialist next week but in meantime optometrist is checking pressure and looking into me using the xalatan at night in good eye.  Any suggestions why pressure is high in good eye also when it is not being treated?  Could the prednisolone be the cause by somehow being absorbed by the good eye.  Do you think the prednisolone should be stopped?

Diplopia and strabismus still bad - trying to get used to using glasses with a prism patch for some relief.

jw51

[jw51]

Surgeon on holiday so will call his office tomorrow.  I am going to stop the Cosopt.  I have allergies to sulfa drugs (surgeon knows) and was prescribed this.  On reading the literature from pharmacy it says not to take if allergic to sulfas.  Also lists serious side effect other than swelling is unexplained weight gain which I have noticed.

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

That is the sort of question that should be answered by your surgeons. As a generalization Xalatan and cosopt are pretty well tolerated.

JCH IIIMD

[jw51]

I have been on eye drops non-stop since the surgery in December and have noticed recently that one side of my face (the side of the eye being treated) is puffy and swollen in the cheek area. The other side is fine.  The last two weeks I have been using cosopt and xalatan to treat high pressure.  Could this be the reason.  I had used atropine which was stopped two weeks ago and tobradex which was stopped last week and now I use prednisolone.

jw51

[jw51]

Thank you Dr. Hagen for letting me know this is not rare.  It is hard to convince my surgeon of that.  

The eye is not aligned properly and has not been since the day after the surgery and with the double vision I keep it patched.  As I said the macular hole repair was not successful so I am seeing a very blurry imagine with that eye - it is on top of what my normal eye sees and has a slant to it.  The surgeon and neuro-opthamologist have told me wearing the patch this does not present a problem.  The eye is looking down and because of superior rectus paralysis the eye does not lift up.  It has complete motility and the field acuity tests are normal.  I am being referred to two strabismus specialists and also have an orbit CT-scan done next week.  They want to rule out any type of tumour behind the eye that could be causing the problem . . . . ?????

What is the outcome for others who have experienced this.  Does the muscle start eventually working on its own and if so how long does it take or is the solution surgery to straiighten the eye?  As I said my surgeon has never seen this happen before?  I have yet to find someone on-line who has experienced this personally?

Thank you for your assistance and how can I print off your articles. JW51