Eye alignment

[irishdrumrboy]

Good morning,
I’ve had this problem with my eyes for just about as long as I can remember. Basically, when I look right with both eyes, one of them wanders, depending on which one I focus. Naturally, my vision goes double when this happens. It doesn’t happen looking left, only right. I’ve grown accustomed to compensating by shutting one eye or just turning my head (like when driving, etc..) My forward and left vision is fine and I experience no double vision looking forward or looking left. I finally got good eye insurance, so I decided after many years to get it checked out. The eye doctor prescribed me eyeglasses with prisms. My question is about the prisms: It seems to me that the prisms are simply tricking my eyes. Now when I look right, my vision doesn’t go double, but my eye still wanders. This is not at all what I wanted. I want them to line up properly. I guess I am just fishing for a second opinion on my options. Will the prisms eventually help with this? Does this sound like something only surgery will fix? Is this something that can’t be fixed?
I would like to also add that when I cover each eye, I have full range of motion and vision in the eye I'm not covering. I've also not had any incidents (that I know of) that may have caused nerve damage, ie.. head trauma, stroke, etc...

Thanks in advance.

[John C Hagan III, MD, FACS]

Hello, Irish drummer boy: Eye alignment disorders/diseases are called 'strabismus' by Ophthalmologists. If the misalignment is the same in all directions it is called a 'commitant' deviation; if the misalignment varies in different directions, or (as in your case) is present in only certain directions it is an 'incommitant' deviation. Misalignment problems are either vertically or horizontally (as in your case) misaligned or both. If the eye are deviated towards one another ('cross eyed) it's an esotropia or convergent strabismus; if the eyes deviate away from one another it's a divergent or exotrophia ('wall-eyed'). Thus you have an incommitant deviation, probably a esotrophia. (I would have to examine you to be certain).

Commitant deviations are usually due to problems with the control centers ('fusion centers') in the brain and are usually present at birth or develop in childhood. Incommitant deviations are usually due to weaknesses of one or more of the 6 extra-ocular muscles that move each eye (12 all totaled). While they can be present at birth they are more likely to develop in adults and may be caused by trauma, diseases, injuries, etc. Because the nerves that elevate the eyelids and that make the pupil larger and smaller are located near the control centers for the extra-ocular muscles incommitant strabismus may be associated with a droopy eyelid, and pupils that don't work right.

Of the 6 extraocular muscles that move each eye four move the eye up and down (superior rectus, inferior rectus, superior oblique and inferior oblique) and two move the eye horizontally (medial rectus, lateral rectus).

When you look to the right you're using your right lateral rectus and the left medial rectus. Your description of your problem would implicate one of these two muscles as the cause of your problem. It would also be important to know if when you look right or left whether your upper and lower lids in either eye move up or down. A not infrequent cause of a problem like yours is called 'Duane's Syndrome', a second would be a left lateral rectus palsy.

Prisms glasses do not work well on incommitant strabismus. You need to see a Pediatric Ophthalmologist. They are the strabismus experts of the profession of Ophthalmology. They have extra training in eye muscle problems; although most of their patients are kids almost all of them do adult strabismus.

Because you used your eye care insurance and were given prisms, I suspect you saw an optometrist. A Pediatric Ophthalmologist is a physician (MD) that has been to medical school and taken an extended Residency (EyeMD).  Because you have a medical problem your evaluation should be covered under your HEALTH insurance. You can check with your insurance carrier to confirm this or you can call the Pediatric Ophthalmoloist you're going to see and confirm that they participate in your plan. Almost all major cities have Pediatric Ophthalmologists and they can also be found in the Department of Ophthalmology of all medical schools and on the faculty of most Children's Hospitals.

Many of the important diagnostic findings in strabismus are very subtle and even you may not have noticed things that are important to the Pediatric Ophthalmologist in making a diagnosis and giving you your medical and surgical options.

Good Luck

JCH MD Irish Eye Surgeon

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