Double Vision After Cataract Surgery


It isn’t uncommon for patients to experience transient diplopia after cataract surgery.  This is more likely when the patient has a history of fragile fusion prior to the procedure.  From what I can gather, Nettie had no such history when she came to see me.

Her clinical history was that the double vision she was experiencing came about immediately after cataract surgery, and was worsening over time instead of improving.  She was advised that it apparently occurred due to the anesthetic injection to the eye in prepping her for surgery.  Subtenon administration is the safest among all the anesthetic injection methods . This involves making a 5mm cut on the conjunctiva and tenon, and then slipping a blunt cannula under the tenon.

SubtenonLA1

Nettie was one of the few unlucky patients who was experiencing myotoxic effects of anesthesia for cataract surgery resulting in lingering post-surgical diplopia due to EOM fibrosis.  She experienced a significant vertical strabismus and had 14 prism diopters of Fresnel prism in her glasses when she came to see me.  But she measured more than that, and was understandably displeased with the outcome of her cataract surgery and the need to wear glasses to see singly. But maintaining single vision was a fight, and each day brought growing discomfort.

I reviewed the options with Nettie, and although patients with large vertical misalignments can make improvements through vision therapy, I advised that a consult with a strabismus surgeon was in order.  It seemed to me that for a patient of Nettie’s age to overcome such a large vertical misalignment through vision therapy would be arduous.  I saw Nettie a few days after her EOM surgery, and although her eyes were chemotic and irritated, she was aligned and comfortably fused.  We’ll monitor her closely over the next months, and implement therapy to stabilize her outcome as needed.

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2 thoughts on “Double Vision After Cataract Surgery

  1. Dr. Press,
    Wonder what the acuity (sight) was prior to the surgery and if long standing there might have been suppression and a vertical phoria prior. OR, since I believe the muscle is 5.5 mm from the limbus could it that this muscle was nicked by the needle?
    At any rate I have never seen a problem as bad as the one you describe in 45 years of practice.
    Thanks for your expertise.
    August

  2. Good question, August. I had never seen one this bad either, but it is in the literature. The theory you have is plausible in some cases, but not this one. The surgeon confirmed when he operated that the muscle was extremely fibrotic when he went in to operate, and he was confident that it was more likely due to the diffuse myotoxic effect of the anesthesia. Here is a nice review of the variables involved: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1857604/

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