Decompensated strabismus after laser

in situ keratomileusis
Eileen Schuler, CO, Mark Silverberg, MD, Paul Beade, MD,
Ken Moadel, MD

ABSTRACT
We present a case of decompensated nerve IV palsy with vertical diplopia after bilateral
laser in situ keratomileusis. As the patient was given monovision, we believe diplopia
occurred with a decrease in vision in 1 eye and interruption of fusion. Although corrective
spectacles to restore equal vision at distance were prescribed, the patient needed a prism
to eliminate her double vision. We suggest a careful cover/uncover test and versions
assessment in all candidates for refractive surgery who want monovision correction and a
full ocular motility evaluation if there is any doubt about binocular issues. J Cataract Refract
Surg 1999; 25:1552–1553 © 1999 ASCRS and ESCRS

P atients having refractive surgery may report binocu-

lar diplopia induced by a decompensated strabis-
mus, especially when binocularity is interrupted by
monovision. We present a patient with no known his-
tory of ocular motility problems in whom diplopia oc-
curred after laser in situ keratomileusis (LASIK) in both
eyes.
Case Report
A healthy 48-year-old legal assistant was referred to our
strabismus clinic reporting vertical and torsional diplopia at
distance after bilateral LASIK. The patient did not report a
history of strabismus, diplopia, trauma, abnormal head pos-
ture, or orthoptic exercises.
Her preoperative best corrected visual acuity was 20/20
in each eye. Manifest refraction was ⫺3.00 ⫺3.00 ⫻ 180 in
the right eye and ⫺3.00 ⫺2.50 ⫻ 180 in the left. She was
intolerant of contact lenses and wanted monovision. She had
LASIK first in her dominant right eye to correct distance
vision. Three days later, her left eye was undercorrected for
near vision. Both procedures were uneventful.
The patient noted vague binocular discomfort at distance
immediately after the second surgery. Both patient and sur-
Accepted for publication May 28, 1999.
Reprint requests to Eileen Schuler, CO, 1016 Cliff Drive, #211, Santa
Barbara, California 93109, USA.
© 1999 ASCRS and ESCRS
Published by Elsevier Science Inc.
geon ascribed the discomfort to an inability to adapt. At the
patient’s insistence, she received spectacles 3 months later to
improve her distance vision for driving; however, she then
noticed constant vertical diplopia.
On examination, her uncorrected distance vision was
20/25 in her right eye (⫺0.50 ⫺1.00 ⫻ 155) and 20/50
(⫺1.25 ⫺1.25 ⫻ 180) in her left eye. On sensory testing at
distance (American Optical Vectograph slide and Worth
4-dot test), the patient noted vertical diplopia with and with-
out glasses. At near, her uncorrected visual acuity was 20/25 in
the right eye and 20/20 in the left. She demonstrated 40
seconds of arc on the Titmus stereo test and fusion on the
Worth 4-dot test at near (1/3 m).
An alternate prism cover test showed left intermittent
hypertropia of 16 prism diopters (PD) in primary position
at distance, which increased to 30 PD in right gaze and 16
PD in down gaze. The Bielschowsky test was positive on
left head tilt. The double Maddox rod test showed 5 de-
grees of extorsion in the left eye. Because of the large degree
of vertical fusional amplitudes, the diagnosis of a decom-
pensated left congenital superior oblique palsy was made.
A neurophthalmological evaluation concurred with our
findings.
The patient received a 4 PD base-down Fresnel prism
on the left lens of her spectacles to eliminate her double
vision. One month later, her prism was increased to 7 PD.
She wears her prism glasses for driving and the theater. At
work, she adopts a slight head tilt to the right and does not
use glasses.
0886-3350/99/$–see front matter
PII S0886-3350(99)00208-4
 CASE REPORTS: SCHULER
Discussion
Approximately 80% of 21 million American con-
tact lens wearers are between the ages of 18 and 44 years.
The presbyopic population is expected to double every 5
years until the year 2010.1 Monovision, correcting 1 eye
for distance and the other for near with contact lenses or
refractive surgery, is a promising alternative for the pres-
byopic patient. Many studies have shown that monovi-
sion is well tolerated in carefully selected patients. With
the increasing popularity of refractive surgery in this age
group, it is becoming the option of choice. Although it
has been argued that monovision reduces stereopsis,2
the clinical implications of disrupted binocularity vary
significantly.
Reports of ocular deviations following refractive
surgery are rare. Mandava et al.3 report a case in which
the diplopia associated with an intermittent exodevia-
tion appeared 9 months after photorefractive keratec-
tomy in 1 eye. Marmer4 described a patient with a
history of strabismus surgery who had a decompensated
esotropia in between a 2-stage radial keratotomy proce-
dure. To our knowledge, diplopia secondary to decom-
pensated heterotropia has not been reported with
LASIK. This patient is noteworthy for the rapid evolu-
tion of her symptoms and the relative inability to restore
her binocularity using optical correction.
The disruption of the patient’s fusion initially arose
in the 3 days between the first and second surgery. Once
her strabismus decompensated, diplopia ensued because
of the relative disparity in distance visual acuity. At near,
she retained single vision with excellent binocularity be-
cause of her large fusional amplitudes and nearly equal
vision.
Several poignant issues are raised by this patient.
First, as she was intolerant of contact lenses, would a
preoperative “monovision trial” with spectacles have
elicited her symptoms? To date, there is no standard
method of determining patient acceptance of monovi-
sion. Refractive surgeons vary widely in their preopera-
tive assessments. Second, could binocularity have been
restored if this patient immediately had a third refractive
procedure or corrective spectacles to restore perfect dis-
tance acuity in the left eye upon the patient’s mention of
persistent binocular discomfort? Either the 3 days be-
J CATARACT REFRACT SURG—VOL 25, NOVEMBER 1999
tween the 2 surgeries or perhaps the 3 months between
the second procedure and spectacle correction caused
her to fully decompensate. However, the evolution of
congenital superior oblique palsies is not predictable.
Diplopia is an infrequent complication of refractive
surgery but is extremely frustrating for both patient and
physician. The incidence of binocular problems is likely
to increase with the higher demand of baby-boomers for
monovision. Studies, although few, indicate that for
most patients, monovision is well accepted with little to
no sacrifice of binocularity.5 The main issue confronting
the refractive surgeon is how to properly and rapidly
identify patients at risk for binocular discomfort, diplo-
pia, or both. Methods currently used are version assess-
ment, cover testing, and mere history-taking. It has been
recommended1,6 that a trial of monovision contact
lenses may be the best way to identify patients who will
do well. We believe that at least a cover/uncover test
should be performed on all patients who are considering
refractive surgery. We are currently studying the best
way to assess potential binocular problems before sur-
gery. A full preoperative strabismus evaluation is recom-
mended if the refractive surgeon has doubts about
binocular issues.
References
1. Jain S, Arora I, Azar DT. Success of monovision in
presbyopes: review of the literature and potential appli-
cations to refractive surgery. Surv Ophthalmol 1996;
40:491⫺499
2. Du Toit R, Ferreira JT, Nel ZJ. Visual and nonvisual
variables implicated in monovision wear. Optom Vis Sci
1998; 75:119⫺125
3. Mandava N, Donnenfeld ED, Owens PL, et al. Ocular
deviation following excimer laser photorefractive keratec-
tomy. J Cataract Refract Surg 1996; 22:504⫺505
4. Marmer RH. Ocular deviation induced by radial keratot-
omy. Ann Ophthalmol 1987; 19:451⫺452
5. Wright KW, Guemes A, Kapadia MS, Wilson SE. Binoc-
ular function and patient satisfaction after monovision in-
duced by myopic photorefractive keratectomy. J Cataract
Refract Surg 1999; 25:177⫺182
6. Maguen E, Nesburn AB, Salz JJ. Bilateral photorefrac-
tive keratectomy with intentional unilateral undercor-
rection in an aircraft pilot. J Cataract Refract Surg
1997; 23:294⫺296
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