Treatment for Central-Peripheral Rivalry-Type Diplopia ("Dragged-Fovea Diplopia Syndrome")

An Update on Dragged-Fovea Diplopia Syndrome

Dragged-fovea diplopia syndrome (DFDS) is a type of binocular double vision caused by a displacement of the fovea in one or both eyes due to retinal disorders including epiretinal membranes or other maculopathies. DFDS induces diplopia through a mismatch between peripheral motor fusion and central (foveal) fusion. It can be diagnosed by utilizing the Lights on - Lights off test. While there is no cure, there are treatments for DFDS including monocular occlusion or blurring (tape, lenses, IOL), Bangerter filter, and Fresnel prisms. While this syndrome has been identified in the literature by multiple names including central-peripheral Rivalry (CPR)-type diplopia, macular diplopia, and foveal displacement syndrome, this article works to summarize the current known characteristics, diagnostic tests, and treatment for this syndrome.

Characteristics and type of strabismus associated to macular diplopia. Treatment outcomes

OBJECTIVE

To study the clinical characteristics of macular diplopia, treatment, and outcome.

METHODS

Retrospective descriptive study of cases referred to the ocular motility section of a tertiary hospital with diplopia, diagnosed with macular diplopia between 2022-23. The etiology of the macular pathology and the type of associated strabismus were recorded. The result was considered good if the diplopia improved or was eliminated with the medical or surgical treatment. Follow-up time from the onset of diplopia until data collection was recorded.

RESULTS

a total of 19 cases comprised the sample (63.2% women), mean age: 67.16 years. Amblyopia (21.1%), high myopia (47.4%), epirretinal membrane (ERM) (36.8%), neovascular membrane (26.3%), macular hole (10.5%), and lamellar (15.8%), and age macular degeneration (5.3%) were registered. The 47.4% had vertical diplopia, horizontal: 5.3 and 47.4% mixed. The mean horizontal deviation was: 7.3 PD (prism diopters) and vertical: 6.22 PD. Ocular extorsion was observed in 26.3%, and intorsion: 5.3%. Torticollis was present in 15.8%. The treatment consisted of strabismus surgery + Botox (15.8%), strabismus surgery (47.4%), medical treatment with Fresnel prims or Scotch cellophane (36.8%). A 68.4% presented a good result at the end of the study. The mean follow-up was 55.58 months.

CONCLUSIONS

Misregistration of macular photoreceptors is the most common cause of binocular diplopia in patients with ERM or other macular pathologies. Most complains of vertical or mixed diplopia. Sensorimotor evaluation of these patients should be thorough. Early diagnosis prevents unnecessary prescription of prism glasses. Surgical and/or medical treatment achieves good results in most cases.

Supraequatorial displacement with lateral rectus myopexy for treatment of myopic sagging/heavy eye

PURPOSE

To describe the outcome of the patients diagnosed of sagging/heavy eye associated to myopia, that were operated on with the supra-equatorial displacement with LR myopexy.

METHODS

A retrospective study of 9 cases between 2017-2023. The following data were analyzed: horizontal and vertical deviation, diplopia, amblyopia, ductions, ocular torsion, sensorial test, macular pathology, and the orbital magnetic resonance. Treatment was considered Successful if the diplopia was improved or eliminated and a final vertical deviation (VD) ≤5 prism diopters (PD).

RESULTS

The mean age (SD) was: 62.11 (4.6) years (100% women). A total of 88.88% presented diplopia. The mean preoperative hypotropia was: 11.33 PD (SD 3.16), and the mean final VD 3.44 PD (SD 3.05). After surgery, the hypotropia was overcorrected in one case, under corrected in 5, and orthophoria was achieved in another three. The technique was associated with surgery of another rectus muscle in 4 subjects. The mean follow-up time after surgery was 34 months (SD 34.62). Six of the 9 patients improved with a vertical deviation ≤5 PD. In 3 patients, the diplopia was eliminated, while in 5 it remained intermittent (three with macular pathology).

CONCLUSION

Supra-equatorial displacement with LR myopexy for treatment of myopic sagging/heavy eye, is a therapeutic option if hypotropia is less than 12 PD or the Yokoyama technique is not indicated. A good result was obtained in most cases, although diplopia could only be totally suppressed in three, and another five remained intermittent.

[Disorders of the visual system following vitreoretinal and macular surgery]

The visual system is highly complex. Monocular or binocular disorders can develop, for example during tractive alterations of the macula, such as in epimacular membranes, and result in symptoms, such as double vision, aniseikonia or metamorphopsia. These symptoms are also observed following vitreomacular or vitreoretinal surgery, especially after treatment of large retinal detachment involving the macular area using pars plana vitrectomy or scleral buckle surgery but also as a result of vitreomacular interventions, such as membrane peeling in epimacular gliosis. Some patients have preoperatively existing latent conditions, which are not explicitly addressed during routine preoperative diagnostics. For patients and surgeons it is worth noting that these troublesome symptoms are often manifested in patients with good restoration of best corrected visual acuity following vitreomacular surgery. In such cases, patients tend to be dissatisfied with the surgical result despite good visual acuity. Treatment of postoperative metamorphopsia, aniseikonia and double vision is often difficult. In clinical studies, the maximum depth of tractive retinal folds has been described as a reliable morphological biomarker for the occurrence of metamorphopsia in epimacular gliosis. As metamorphopsia tends to postoperatively resolve slowly and even persist in ca. 30% of cases, this biomarker can have an impact on preoperative consulting and postoperative monitoring. Persistent binocular discomfort is often treatable by exact refraction correction and by applying a vertical and, if necessary, a horizontal prism. This often requires patience on the part of both the patient and the physician but is mostly successful due to fusion and adaptability.

Binocular Interference vs Diplopia in Patients With Epiretinal Membrane

Importance

Patients with epiretinal membrane (ERM) sometimes close 1 eye for improved vision, but associations have not been rigorously studied.

Objective

To evaluate associations with monocular eye closure in patients with ERM, and to report binocular interference (closing 1 eye to improve visual quality).

Design, Setting, and Participants

Retrospective medical record review of an adult strabismus clinic at a tertiary referral center. Patients with ERM referred from retina clinicians between June 2010 and October 2019 who completed the Adult Strabismus (AS)-20 questionnaire, including the question: "I cover or close one eye to see things better." Two groups were identified: (1) patients reporting eye closure sometimes or more, and (2) patients reporting no eye closure (as control patients).

Main Outcomes and Measures

Frequencies of (1) central-peripheral rivalry (CPR)-type diplopia (dragged fovea diplopia); (2) binocular interference (monocular eye closure but no diplopia or strabismus); and (3) other, associated with monocular eye closure. Visual acuity, metamorphopsia, aniseikonia, and AS-20 quality of life domain scores (self-perception, interactions, reading function, and general function) compared between binocular interference, CPR-type diplopia, and control patients.

Results

A total of 124 patients with ERM (58 of 124 were women [47%]; mean [SD] age, 70 [9] years) reported monocular eye closure. Associations were binocular interference in 36 (29%; 95% CI, 21%-38%), CPR-type diplopia in 34 (27%; 95% CI, 20%-36%), and other (primarily strabismus) in 54 (44%). Compared with control patients with ERM (n = 11), patients with ERM and binocular interference had worse quality of life on AS-20 reading function (95 vs 62; mean difference, 22 points; 95% CI, 7-27 points; P = .007) and general function (89 vs 68; mean difference, 23 points; 95% CI, 13-34 points; P = .01) domains. Compared with CPR-type diplopia, patients with binocular interference had poorer worst-eye visual acuity (median 0.50 vs 0.30 logMAR [20/63 vs 20/40]; mean difference, 0.13 logMAR; 95% CI, 0.00-0.25 logMAR [20/20 to 20/35]; P = .03), and a larger interocular difference (0.46 vs 0.19 logMAR [20/58 vs 20/30]; mean difference, 0.15 logMAR; 95% CI, 0.03-0.28 logMAR [20/21 to 20/38]; P = .004).

Conclusions and Relevance

Study findings suggest that binocular interference, manifesting as monocular eye closure (without diplopia or strabismus), is a distinct entity affecting quality of life in patients with epiretinal membrane.

Central Mini-tenotomy and Environmental Modifications to Correct "Macular Diplopia" due to Sickle Cell Retinopathy in a Resource-limited Setting

Epiretinal membrane causing binocular diplopia, also denoted "macular diplopia," is a well-established entity, which is often difficult to treat. Mini-tenotomy is a surgical procedure to treat diplopia due to small-angle deviations. In this case report, we describe the successful management of a patient with "macular diplopia" secondary to sickle cell retinopathy using a central mini-tenotomy of the left superior rectus muscle and environmental adaptations to diminish peripheral retinal fusion.