Management of diplopia limited to down gaze
B. J. Kushner
Department of Ophthalmology and Visual Sciences, University of Wisconsin, Madison, USA.
OBJECTIVE: To evaluate the usefulness of various optical and surgical
treatment modalities in the treatment of patients who were symptom free in
the primary position of gaze yet had symptomatic diplopia in the reading
position (down gaze at near). PATIENTS AND METHODS: A retrospective chart
review was conducted to identify all patients with presbyopia I have
treated who were symptom free in the primary position but had diplopia in
down gaze associated with vertically incomitant strabismus. Of 51 patients
identified, 32 were symptomatic in down gaze due to a hypertropia
associated with a unilateral inferior rectus muscle underaction. Twenty-two
of these patients had previously undergone recession of the affected
inferior rectus muscle for treatment of thyroid eye disease; four patients,
for correction of entrapment secondary to blow-out orbital fracture; and
four patients, for treatment of superior oblique muscle palsy. Two patients
had undergone prior surgery for superior oblique myokymia. Eight patients
had horizontal diplopia associated with an A pattern, and eight patients
had horizontal diplopia associated with a V pattern. Three patients had
vertical and horizontal diplopia after partial recovery from third-nerve
palsy. RESULTS: The treatment modalities were varied and individualized.
Treatment consisted of optical management (20 patients), surgical
management (21 patients), or a combination of both (10 patients). These
treatment modalities resulted in comfortable single binocular vision for
reading in 41 of the 51 patients. Successful optical treatment consisted of
Fresnel prisms (four patients), slab-off prisms (two patients),
single-vision readers (seven patients), switch to nonprogressive bifocal
lenses (three patients), and a high bifocal segment (16 patients).
Successful surgical modalities included posterior fixation of the
contralateral inferior rectus muscle (10 patients), surgery for A- or V-
pattern strabismus (five patients), or bilateral inferior rectus muscle
recession (six patients). CONCLUSION: Diplopia in the reading position
frequently can be alleviated with a systematic approach that includes both
optical and surgical modalities.
