diplopia after macular pucker surgery

Eighteen months ago I was diagnosed with a macular pucker. The retina specialist  (Ben Z. Cohen in Manhattan) said there was nothing to be done at that time because it was not bad enough. Last month my vision had deteriorated to 20/60 corrected (-9.5 diopters uncorrected).so he recommended surgery.  I also had a cataract which needed to be removed first.

I had simultaneous cataract/macular pucker surgery on Jan. 14 on my right eye, at which time a +10 diopter monocular lense was implanted. This brought my uncorrected vision to 20/100.  With new glasses my vision is now 20/40 in each eye.  I have considerable distortion when using only the right eye. which is manifested by letters on a page moving up and down  The edges of the letters are well defined, but distorted.  When using both eyes together there is no distortion of the letters. "vaseline spots" appear randomly on the page, but they are gradually disappearing.
Vertical lines appear wavy when using only the operated eye. Also, I see a double image when using both eyes together.  The image is displaced vertically with a horizontal tilt, from the real image.

It is a real adventure looking in a mirror, almost like a fun house mirror where my reflection is elongated, with my head appearing above the mirror, then shrunk with my head appearing to come out of the mirror.

The cataract surgeon confirmed double vision and said I may need a prism lense to resolve the double vision.

Three days ago I received a shot of Avastin from the retinal surgeon. He is not especially communicative so I am not at all clear as to what is going on.  I saw the OCT of my retina, which showed a bulge.  I suspect there is some edema, for which I was given the Avastin.

My questions are:

How long before the double vision resolves, and will the Avastin help?
Has anyone had any similiar experiences?

Thanks for any comments

Gary

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

Generally prism lens do not help this problem because it is not true double vision but monocular  ghosting caused by macular distrortion (metamorphopsia).  One of our reliable posters Jodi J has this problem and has written on it expertedly in many posts. The problem is also often made worse by the brain trying to fuse images of different sizes.

You can use the archives and search feature to pull up the many discussions of macular membrains (ERM).  Avastin is not very helpful for this problem.

JCH MD

[JodieJ]

After re-reading your post, it's not clear that your double vision is related to your ERM.  There are a couple of other possibilities.  (1) You mentioned that a +10 IOL was implanted in your right eye, which suggests that you were previously very nearsighted.  If you have not had cataract surgery on your left eye, then the difference in refractive error between your eyes might be causing your double vision.  (2) It's also possible that an eye muscle was injured by the local anesthesia injection during your surgery.  This can cause double vision, which might resolve on its own.  Otherwise, prism or eye muscle surgery can solve the problem.  Dr. Hagan is an expert about this.

Is there an image size difference between your eyes?  (Try looking at a distance object, covering one eye and then the other.)  I have personal experience with this condition, and I have a lot of information to share if this turns out to be your problem, too.

[Gary44]

I thank you and Dr. Hagen for your comments.

Yes, the operated eye sees a larger image.

It appears from what I have read that I have a combination of binocular ghosting, as well as true double vision, depending on distance, size , and background.

I have also read about Ansekonia, currently the only symptom I have are diplopia and distorted space perception, but if this were to continue I might very well develop nausea and nervousness.

The diplopia/ghosting has become worse since I got new glasses last Friday which improved my vision to 20/40 in the operated eye so the distortions are much clearer.

The diplopia has become so distracting that I put a piece of Scotch tape on my eyeglass lense, which blocks everything but light, but at least there is no more diplopia.

I am seeing the retinal MD tomorrow.  Do you have any thoughts of questions I should ask him?

Your comments are very much appreciated.

Thanks,

Gary

[Gary44]

One other symptom that I forgot to mention.  If I tilt my head back, the double image resolves into a single image.  Does this suggest that a prism might correct this diplopia?

Thanks,

Gary

[JodieJ]

Do you have an IOL in your left eye, or is it still very nearsighted without correction?  A difference of more than 3 diopters in uncorrected vision between your eyes can cause double vision, which can't be corrected with ordinary glasses.

If we can rule out the above situation, then it is likely that your double vision is caused by macular changes related to the ERM and/or the surgery to peel it.  In this case, we are in uncharted waters  To the best of my knowledge, there is no research currently being conducted in the USA relating to this topic.  It sounds like you've been reading Gerard de Wit's opticaldiagnostics website.  The more you know about retinally-induced aniseikonia, the better. You may well be stuck orchestrating your own treatment.

I don't think that it is likely that you will develop additional symptoms such as nausea.  (Certainly don't focus on this!)  Since your double vision developed after your surgery, I think that it is VERY important to determine whether or not there is still ERM in your eye.  It would be easy to identify ERM in Spectralis OCT images, although your doctor should be able to identify ERM during a retinal exam.  (This turned out to be the source of my double vision.  It is actually not that uncommon for some ERM to remain in the eye post-surgery.)  In this case, a second surgery to remove the remaining ERM might eliminate your double vision.  I'm not sure what it means that you can fuse an image by tilting your head back.

Not everyone with retinal aniseikonia develops double vision.  Having a phoria (a benign condition) seems to make people more vulnerable.  In my own case, my double vision was eliminated by wearing a minus glasses lens over a plus contact lens (as described in the optical diagnostics website.)

I have a number of professional papers to send you.  Please send me your email address in a personal message.  (Only the abstracts of these papers are available free online, but I'll post the citations on request.)