Intractable Diplopia After Strabismus Surgery in Adults

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Abstract
THE POSSIBILITY of diplopia occurring after strabismus surgery has been recognized since its description by von Graefe1 in 1854. If diplopia persists after surgery and particularly if it was not anticipated preoperatively, it can be disconcerting to both the patient and the surgeon. In some circumstances, diplopia after strabismus surgery is a predictable occurrence. For example, if a visually mature patient with acquired strabismus has diplopia prior to surgery and if the surgery is not successful in realigning the eyes, one would expect that diplopia would persist postoperatively. Also, there are some situations in which a patient without previous diplopia may predictably see double after strabismus surgery if the postoperative motor alignment is not satisfactory. Common examples include persistent surgical overcorrection in an adult with exotropia2-5 or persistent overcorrection in an adult patient with a decompensated paresis of the fourth cranial nerve; such patients typically do not have strong vertical vergence to compensate for a hypotropia of the previously hypertropic eye.6 In both of these circumstances, the presence of diplopia after surgery can be attributed to an unsuccessful attempt to surgically realign the eyes. Much less commonly, adults with a constant strabismic deviation(but no preoperative diplopia) may experience diplopia after surgery despite successful realignment of the eyes to the desired position (whatever that position may be for the particular patient). With this troublesome type of diplopia, the patient cannot fuse the images using prisms, nor can the second image be hidden in a suppression scotoma, unless the diplopic image is shifted optically to its original preoperative location on the retina of the deviating eye. This differs from the more common type of diplopia, which is simply due to an unsatisfactory postoperative alignment. In this latter situation, the use of prisms to simulate the desired outcome or further surgery to accomplish the desired ocular alignment will eliminate the diplopia; in the former, the diplopia cannot be eliminated.

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