Had a couple of people pose good educated guesses as to what was happening with Ted, our Type A attorney from yesterday. Interestingly Ted’s intuition about what was happening with his own eyes underscores the importance of the doctor listening to the patient, particularly when there’s reason to believe that the patient is a good historian and perceptive about their own vision.
Ted asked me whether I thought the cataract that was developing in his right eye was contributing to his problems. Bingo! He had only been putting a contact lens over his left eye when needed to read. At all other times his uncorrected acuity was now a line better in the left eye than the right eye. His brain was confused, and his right eye was now trying to participate at near, but not very effectively when he wore the near vision contact lens on the left eye.
I suggested that Ted consult with a cataract surgeon and have the best monofocal IOL lens available implanted in the right eye following surgery. No fancy aspherics or multifocals — just the most pristine image possible to restore that eye to maximum distance clarity. Then his brain will resume preferring the left eye at near without any intrusion from the right eye, and without the binocular conflict of managing his decompensating esophoria.
As an aside, before seeing me this time Ted had consulted with our state’s Dean of eye muscle surgery to see if he could help him. The strabismologist said that EOM surgery wouldn’t be helpful, but that Ted should abandon monovision immediately because he’s seen patients run into all kids of trouble with it. This was a really good point, I explained to Ted, but with patients that hit presbyopia with perfectly normal binocular vision. Monovision may in some cases cause them to decompensate. Since Ted’s high esophoria was plaguing him, and monovision when he had two pristine crystalline lenses was a huge relief to him for years, it would be ideal to recapture it.