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ARCHIVOS DE LA SOCIEDAD ESPAOLA DE OFTALMOLOGA

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Original article

Strabismus and diplopia after refractive surgery

a, R. Gmez de Liano-Snchez , R. Borrego-Hernando b , G. Franco-Iglesias c , c P. Gmez de Liano-Snchez , A. Arias-Puente d
a

Hospital Clnico San Carlos, Madrid, Spain Hospital del Tajo, Aranjuez, Madrid, Spain c Hospital Gregorio Marann, Madrid, Spain d Servicio de Oftalmologa, Fundacin Hospital Alcorcn, Madrid, Spain
b

a r t i c l e
Article history:

i n f o

a b s t r a c t
Objective: To evaluate factors that may decompensate a strabismus or lead to diplopia after refractive surgery. Methods: Retrospective study of 19 patients, who presented with binocular decompensation after refractive surgery. Mean age at surgery was 38.89 SD 10.26 (2763) years. Fourteen patients were myopic, 5 hyperopic, and 5 of them had a marked anisometropia. The photorefractive keratectomy procedure was used in 3 cases, laser-assisted in situ keratomileusis (LASIK) in 13, posterior chamber-IOL + LASIK in one of them, and bilateral IOL in 2 cases. Results: There was 0.12% prevalence of strabismus. All of our patients had a binocular pathology previous to the refractive surgery. After surgery, 11 patients had an esophoria or esotropia, 3 exophoria or exotropia, 2 vertical deviations, and 3 horizontal and vertical deviations. Several factors often worked simultaneously in the same patient, such as: residual accommodation, refractive overcorrection (hyperopia), visual instability or anisoacuity, high myopia and phoria decompensation, elimination of suppression, dominance change, and a presbyopic age. Conclusions: All of our patients had a previous binocular pathology. Binocularity may decompensate by several factors but mostly by myopic overcorrection, accommodation and visual factors, particularly in patients close to or in presbyopic age, in anisometropia and high myopia. 2011 Sociedad Espaola de Oftalmologa. Published by Elsevier Espaa, S.L. All rights reserved.

Received 25 January 2011 Accepted 23 December 2011 Available online 27 December 2012 Keywords: Refractive surgery Diplopia Strabismus Binocular vision Anisometropia

Please cite this article as: Gmez de Liano-Snchez R, et al. Estrabismo y diplopas tras la ciruga refractiva. Arch Soc Esp Oftalmol. 2012;87:3637. Corresponding author. E-mail address: rgomezdeliano@med.ucm.es (R. Gmez de Liano-Snchez).

2173-5794/$ see front matter 2011 Sociedad Espaola de Oftalmologa. Published by Elsevier Espaa, S.L. All rights reserved.

Document downloaded from http://www.elsevier.es, day 05/06/2013. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited.

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Estrabismo y diplopas tras la ciruga refractiva r e s u m e n

Palabras clave: Ciruga refractiva Diplopa Estrabismo Visin binocular Anisometropa Objetivo: Analizar los factores que pueden incidir en la descompensacin del estrabismo o aparicin de diplopa en pacientes sometidos a ciruga refractiva. Mtodos: Estudio retrospectivo de 19 pacientes remitidos por presentar descompensacin de la motilidad ocular y/o de la visin binocular tras ciruga refractiva. La edad media era 38,89 DS 10,26 anos (rango 27 a 63). Catorce pacientes eran miopes, cinco hipermtropes. Cinco de ellos presentaban anisometropa intensa. En tres casos la tcnica refractiva fue fotoqueratectoma refractiva, en trece de tipo Lasik, en uno LIO + Lasik y en dos LIO bilateral. Resultados: La prevalencia de diplopa posciruga refractiva fue 0,12% (5 de los 19 procedan de nuestro centro, sobre una base de datos de 4.135 pacientes sometidos a cirugia refractiva, al realizar el estudio). Todos tenan patologa binocular previa a la ciruga. Tras esta, once presentaban endoforia o endotropa, tres exoforia o exotropa, dos desviaciones verticales y tres horizontal y vertical. Las causas de descompensacin fueron: factor acomodativo residual, hipercorreccin refractiva en sentido hipermetrpico, inestabilidad visual, anisoagudeza, descompensacin de una foria en el estrabismo del miope magno, prdida de supresin, cambio de dominancia y presbicia. Frecuentemente varios factores actuaron simultneamente. Conclusiones: La aparicin de diplopa o estrabismo posciruga refractiva es poco frecuente. Varios factores pueden incidir en la descompensacin, fundamentalmente la hipercorreccin mipica y los factores acomodativos y visuales, especialmente en edad prsbita, en fuertes anisomtropes y miopes magnos. 2011 Sociedad Espaola de Oftalmologa. Publicado por Elsevier Espaa, S.L. Todos los derechos reservados.

Introduction
The appearance of diplopia or the decompensation of strabismus after refractive surgery is an infrequent complication. The rst case of accommodative esotropia after radial keratotomy was described in 1996.1 Subsequently other reports were published reporting patients with myopic anisometropia or decompensation of IV pair palsy.24 Kowal5 divided the risk of suffering diplopia as low, moderate and high risk. In previous studies we have analyzed binocular vision after refractive surgery in myopic6 and hypermetropic7 patients, nding slight alterations. The objective of this study is to analyze a consecutive series of patients who visited due to diplopia or strabismus after refractive surgery in order to analyze the strabological characteristics as well as the factors that could have inuenced binocular decompensation.

Subjects, materials and methods

Retrospective study of 19 consecutive patients who visited due to strabismus or diplopia after refractive surgery was carried out. Of these, 5 patients were treated for refractive surgery in our hospital and the remaining 14 were referred after diplopia. Table 1 shows the characteristics of the series. The mean age at surgery was 38.89 SD 10.26 years; it should be noted that 10 patients were over 40 years of age. Fourteen patients were myopic and 5 were hypermetropic. As regards refraction prior to refractive surgery, in the myopic patients (spherical equivalent) it was 7.48 SD 7.01 dioptres

(D) (+0.5 to 20 D) in the eye with the lowest refractive defect, and 12.31 SD 8.88 D (2 to 28) in the eye with the highest myopia. Refraction values of hypermetropic patients were +4.70 SD 1.61 D (+3.50 to +7.50) in the most hypermetropic eye and +4.05 SD 1.12 D (+3.25 to +6) in the eye with the lowest refractive defect. Five patients exhibited intense anisometropia (>9 D). The said table presents in detail the visual acuity of each eye. The term anisoacuity is utilized with increasing frequency in strabology to refer the visual acuity difference between both eyes for any reason (including others apart from amblyopia). The residual accommodative factor was assessed by comparing uncorrected ocular deviation with residual optic correction (residual hypermetropia and/or anisometropia). Table 1 shows the type of refractive surgery performed. Photorefractive keratectomy (PRK) in 3 patients (one unilateral), Lasik in 13 (3 unilateral) and bilateral lens surgery plus IOL in the anterior chamber in 3, one of which was subsequently intervened with Lasik. Five patients were intervened a second time with PRK (1 patient) or Lasik (4 patients). One case had a large corneal haze.

Results
On the basis of the number of patients who experienced decompensation and had been intervened in our hospital (5) in relation to the overall series of patients intervened since 1991 up to January 2004 (4135), the prevalence of the appearance of diplopia or strabismus after refractive surgery is 0.12%.

Table 1 characteristics of the series.

Patient Age Sex Preop. Sph. Eq. most ammetrope eye Preop. Sph. Eq. least ammetrope eye Preop. VA dominant eye Preop. VA nondominant eye 0.4 0.6 0.9 0.8 0.3 1 1 0.25 0.1 0.9 0.6 0.6 1 0.85 0.9 0.7 1 0.5 0.4 Refractive surgery Type of strabismus Postop. Sph. Eq. most ammetrope eye Postop. Sph. Eq. least ammetrope eye Postop. VA dominant eye Postop. VA non-dominant eye a r c h s o c e s p o f t a l m o l . 2 0 1 2; 8 7(1 1) :363367

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19

45 29 31 28 29 28 41 32 29 51 51 45 40 41 27 35 45 63 49

F M M M F F F F M F F F M F M F F M M

22 3.75 3.5 4.25 14 3.25 2 11 15 7.5 28 12.5 3.25 4.5 5.35 7.5 2.5 25 21

20 3.5 3.25 3.5 4 3.25 2 0.75 0.5 6.5 16 11.5 3 4 4.25 6 2 13 19

0.5 1 1 1 1 1 1 1 1 0.9 0.7 1 1.2 0.95 1 0.9 1 0.8 0.6

P-B L-B L-B L-B L-B L-B L-B L-U L-U L-B IOL + LB L-B L-B L-U P-B L-B P-U IOL-B IOL-B

Vertical + FD XT ET ET ET FD FD ET ET ET VERT + ET VERT ET + F ET XT ET XF VERT VERT + ET

5 1 1.5 0.5 5 0.25 0.75 1.5 3 0.5 0.75 3 0.5 1 0.35 3.75 2.5 2 0.75

3 1.5 1.75 1.5 1 1 1.5 0.75 0.5 1.25 0.25 1.25 0.75 4 0.25 3 0.75 0.5 0.75

0.6 1 1 1 1 1 1 1 1 1 0.7 1 1.2 0.95 1 0.8 1 1 0.8

0.3 0.4 0.9 0.8 0.4 0.5 1 0.25 0.1 1 0.6 0.6 1 0.85 0.7 0.7 0.9 0.8 0.6

Sp. Equ.: spherical equivalent; L-B: Lasik bilateral; L-U: Lasik unilateral; IOL-B: bilateral intraocular lens; IOL-U: unilateral intraocular lens; P-B: bilateral photorefractive keratectomy; P-U: unilateral photorefractive keratectomy; Postop.: post-surgery; Preop.: pre-surgery; VERT: vertical strabismus.

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Table 2 Type of strabismus after refractive surgery.

Endodeviations Accommodative residual endotropia Decompensated microtropia in anisometrope (1 + hypercorrection) VA modication and dominance change Hypercorrection toward hypermetropia Signicant haze Exodeviations Decompensated exophoria (1 hypercorrection of one myopic) Exophoria decompensation with monovision Vertical strabismus High bilateral myopia + decompensation. Vertical phoria High bilateral myopia + vertical phoria High bilateral myopia + anisometropia + dominance change + probable lowering of the heavy eye 11 3 3 2 2 1 3 2

the non-dominant eye and the dominance changed. Patient 17 was intervened in one eye only to obtain singular vision and the phoria was decompensated. In addition, 10/19 were over 40 years old. Treatment of strabismus or diplopia was as follows: 7 patients were corrected with spectacles, 4 with refractive reintervention, 3 with prisms although they declined their use, and 5 required botulin toxin treatment or strabismus surgery.

Discussion
1 5 3 1 1

The type of binocular alteration which led to the rst visit was strabismus in 8 cases, diplopia in 3 and strabismus with diplopia in 8 cases. The type of strabismus exhibited by patients was endotropia or endophoria (11/19). Three patients had exophoria/exotropia, 2 patients exhibited vertical strabismus (hypotropia in myopia magnus) and 3 exhibited vertical and horizontal deviation (Tables 1 and 2). The time at which symptoms appeared was variable and referred vaguely by some patients. Eighteen referred to a period between the rst days up to 2 months, and one patient referred diplopia after 8 months although she exhibited astenopia symptoms since refractive surgery. All the patients of the series exhibited previous binocular pathology. Prior to refractive surgery they had strabismus or micro-strabismus (13/19), one phoria (8/19), one ambliopia (10/19), or astenopia (2/19). Five patients of this series suffered signicant anisometropia of 10 D or more. Nine out of 14 myopic patients had over 6 D and 4 had over 16 D. Even though it was not possible to determine with certainty the reason of the decompensation in each case, the causes were multiple (Tables 2 and 3). The most frequent factor was hypermetropic residual refraction either due to myopic hypercorrection or regression of the hypermetropic correction. The second most frequent factor was visual instability expressed by patients as variable visual acuity through a period of several days which affects each eye in a different manner. An additional factor was the change of dominance and monovision for several reasons: 4/19 cases were unilateral surgeries, patient 14 (Table 1) was intervened for hypermetropia only in

Table 3 Factors that inuenced the binocular decompensation* ).

Final refraction (hypermetropia) Corrected myopics Hypermetropic remission Hypercorrection of hypermetropics Visual instability Dominance change and monovision

12 7 4 1 4 4

Several factors inuenced in some patients.

The prevalence of diplopia or strabismus after refractive surgery is considered to be very low in our study (0.12%), and with an exploration of ocular motility as well as adequate surgical planning it could be even lower. However, frequently patients referred temporal astenopia in the rst few months after surgery. The onset of symptoms has been highly variable. If the patient has taken legal action, the reference is even more confusing. In some occasions, the initial distortion is confused with vertical diplopia. Seven out of 19 patients referred progressive diplopia or strabismus. Studies carried out by our group revealed that refractive surgery alters binocular vision at least temporarily both in myopic6 and in hypermetropic patients,7 and in patients at risk or with poor refractive-visual results it could be the factor that determines decompensation. Previous alteration of binocular vision is also an important risk factor for post surgery cataract diplopia.8 The patients who decompensated more frequently were the large myopic. Nine out of 14 myopic patients had over 6 D and 4 over 16. These patients experienced frequent binocular alterations and in the course of several years developed restrictive horizontal and vertical alterations, mainly the greater myopic cases, which attain greater importance after 40 years of age. Refractive surgery has a signicant inuence due to visual acuity modications, aniseiconia and smaller dominance changes that denitively break the unstable fusion they had. An additional risk subgroup was that of anisometropics. Five patients had signicant anisometropia (10 D or more). This involves decompensation risk after refractive surgery.5,9,10 It is convenient to perform a binocular study prior to refractive surgery and in specic cases to assess the situation with contact lenses. In these cases, decompensation has been variable: unilateral surgery (4 patients) can produce quantitative image differences in contrast sensitivity as well as in other factors. Changes in dominance, residual aniseiconia and fusion alterations are factors that had inuence in other patients. These data lead us to ponder the risk of single vision treatment in patients with binocular pathology.4,11,12 A signicant percentage of patients in presbytic age was found (10/19 patients were over 40). Diminished fusional capacity, related to diminished accommodation capacity, must be added to the factors described above. In what concerns the nal refractive condition, postsurgery hypermetropia was observed in 12 of 19 patients. Seven myopic patients were hyper-corrected which partially destabilized ocular motility.

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Other technical factors such as corneal opacities could also have played a role in the nal result. Treatment of oculomotor alterations sometimes improves in time with the remission of myopic hyper-correction. Meanwhile optic correction was prescribed (7 patients) although they declined their application. In others, ocular dominance balance was sought and 4 were re-intervened due to residual refraction. Thirty-eight required prisms and 5 botulin toxin or strabismus surgery. Diplopia or strabismus after refractive surgery has appeared generally in patients with underlying buying binocular pathology. Several factors could play a role in the decompensation, notably myopic hyper-correction, residual hypermetropia and visual instability as well as dominance changes. The most frequent type of deviation is endophoria or endotropia, followed by vertical and exotropia strabismus. Treatment for strabismus or a residual diplopia is varied and comprises correcting the residual defect with spectacles or refractive re-intervention, prescribing prisms, botulin toxin injection or strabismus surgery.

Conict of interests
No conict of interest has been declared by the authors.

references

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2. Mandava N, Donnenfeld ED, Owens PL, Kelly SE, Haight DH. Ocular deviation following excimer laser photorefractive keratectomy. J Cataract Refract Surg. 1996;22:5045. 3. Kim SK, Lee JB, Han SH, Kim EK. Ocular deviation after unilateral laser in situ keratomileusis. Yonsei Med J. 2000;41:4046. 4. Schuler E, Silverberg M, Beade P, Moadel K. Decompensated strabismus after laser in situ keratomileusis. J Cataract Refract Surg. 1999;25:15523. 5. Kowal L. Refractive surgery and diplopia. Clin Exp Ophthalmol. 2000;28:3446. Snchez R, Arias Puente A, Ragai Kamel N, 6. Gmez de Liano Snchez P, Rodrguez Gmez Moreno ML, Gmez de Liano Snchez J. Visin binocular tras la ciruga fotorrefractiva. Acta Estrabolgica. 1996;25:1858. 7. Gmez-de-Liano-Sanchez R, Piedrahita-Alonso E, Arias-Puente A. Visin binocular tras ciruga refractiva en pacientes hipermtropes. Arch Soc Esp Oftalmol. 2006;81:10714. 8. Domingo Gordo B, Merino Sanz P, Arrebola Velasco L, Acero A, Luezas Morcuende JJ, Gmez de Liano Snchez P. Pena Diplopa post-ciruga de catarata: causas y tratamiento. Arch Soc Esp Oftalmol. 2000;75:5817. 9. Holland D, Amm M, Decker W. Persisting diplopia after bilateral laser in situ keratomileusis. J Cataract Refract Surg. 2000;26:15557. 10. Krzizok T, Kaufmann H, Schwerdtfeger G. Binokulare probleme durch aniseikonie und anisophorie nach katarakt operation. Klin Monatsbl Augenheilkd. 1996;208:47780. 11. Wright KW, Guemes A, Kapadia MS, Wilson SE. Binocular function and patient satisfaction after monovision induced by myopic photorefractive keratectomy. J Cataract Refract Surg. 1999;25:17782. 12. Jain S, Arora I, Azar DT. Success of monovision in presbyopes: review of the literature and potential applications to refractive surgery. Surv Ophthalmol. 1996;40:4919.