Diplopia after glaucoma surgery

Evaluation of Diplopia Secondary to Seton Implantation Surgery: Ahmed Glaucoma Valve and Diplopia

Objectives:

To determine and evaluate the rate of diplopia after Ahmed glaucoma valve (AGV) implantation surgery.

Materials and Methods:

The records of patients who underwent AGV implantation in our hospital between the years of 2010 and 2017 were retrospectively reviewed. Patients who were referred to our strabismus department due to binocular diplopia after AGV implantation surgery were included. The details of postoperative day 1, day 7, day 15, and 1 month examinations were recorded. In the postoperative period, the onset time of diplopia complaints, diplopia type, and the presence of diplopia at distance and near fixation were noted. Ocular motility examination and deviation measurements were evaluated.

Results:

Ten (47%) of 211 patients who underwent AGV implantation in our hospital between 2010 and 2017 met the study inclusion criteria. Six of the 10 patients were men (60%) and 4 were women (40%). The mean age of the patients was 44.5 (34-63) years. Complaints of diplopia developed at a mean of 14.5±12.3 (1-30) days after AGV implantation. The prism measurements of the patients were found to be 8.4±1.4 prism diopters (PD) exotropia and 7.1±8.8 PD hypotropia. While 8 patients had diplopia only at near distance, 2 patients had diplopia at both distance and near. Three patients were treated with prismatic glasses, and their complaints of diplopia recovered spontaneously in 5.11±4.10 months. The other 7 patients were followed up without treatment, and their diplopia complaints resolved spontaneously in 6.11±4.40 months.

Conclusion:

Although most of the diplopia that develops after AGV implant surgery resolves without treatment, prismatic glasses might be considered as a treatment option in patients whose diplopia affects their daily lives.

Risk factors for strabismus following glaucoma drainage device implantation for refractory childhood glaucoma

BACKGROUND

Strabismus is common in children after glaucoma drainage device (GDD) implantation, but the risk factors for postoperative strabismus remain speculative. The purpose of this study was to investigate possible risk factors for strabismus following GDD implantation for refractory childhood glaucoma.

METHODS

The medical records of consecutive patients who underwent GDD implantation for refractory childhood glaucoma at Duke Eye Center from 2005 to 2016 were reviewed retrospectively. Pre- and postoperative motility and alignment, best-corrected visual acuity, and demographic and surgical data were extracted from the record for analysis.

RESULTS

A total of 81 patients (mean age, 7.9 ± 4.8 years) met inclusion criteria. The most common glaucoma type was glaucoma following cataract surgery (GFCS), and the most common GDD was a Baerveldt 250 mm² device. Before GDD surgery, 38 patients (47%) had documented strabismus. After GDD implantation, 25 (31%) had new or worsened strabismus, with vertical (16% of new/worsened), horizontal strabismus (exotropia, 48% of new/worsened; esotropia, 12% of new/worsened) and vertical and horizontal (24% of new/worsened) noted. New motility limitation occurred in 32 of 81 (40%) patients. Risk factors including age, type/location/number of GDD, revision, motility limitation, glaucoma type, asymmetric visual acuity, and visual impairment were not significantly associated with new or worsened post-GDD strabismus.

CONCLUSIONS

Children with refractory childhood glaucoma are at high risk for strabismus, which increases after GDD implantation; this study identified no clear risk factors for new or worsened post-GDD strabismus.

Strabismus surgery in the setting of glaucoma drainage devices in the pediatric population

PURPOSE

To evaluate outcomes of strabismus surgery performed subequent to or concomitant with glaucoma drainage device (GDD) implantation for refractory childhood glaucoma.

METHODS

The medical records of children who underwent strabismus surgery after or concomitantly with GDD implantation were reviewed retrospectively. Included were surgeries with motility and alignment data measured preoperatively and ≥3 months postoperatively. The following data were collected: demographics, visual acuity, glaucoma diagnosis, GDD type/location, pre- and postoperative sensorimotor/alignment measurements, and surgical details. Motor success was defined as ≤10^Δ horizontal and ≤4^Δ vertical residual heterotropia postoperatively.

RESULTS

A total of 25 children were included: 11 in the post-GDD group and 14 in the concomitant-GDD group. In the former, peri-GDD capsule dissection was required in 9 of 11 patients (82%). All cases had preoperative motility restriction or intraoperative scarring. Mean preoperative deviation (26.7^Δ ± 14.6^Δ) decreased by 41% postoperatively, with improved alignment in 7 patients (64%). No patients met strict motor alignment criteria for success. In the concomitant-GDD group, mean preoperative deviation (28.5^Δ ± 10.0^Δ) decreased by 39% postoperatively, with improved alignment in 11 of 14 patients (79%). Four patients (29%) met strict criteria for success. There were no surgical complications in either group.

CONCLUSIONS

Strabismus surgery in eyes with existing or planned GDDs for childhood glaucoma usually improves alignment but often does not result in success based on strict motor alignment criteria. Eyes with childhood glaucoma pose surgical technical challenges related to small orbits and exuberant GDD capsule-muscle scarring and postoperative challenges of poor vision and limited binocular function, that likely limit succcess.

Strabismus After Ocular Surgery

Many types of ocular surgery can cause diplopia, including eyelid, conjunctival, cataract, refractive, glaucoma, retinal, and orbital surgery. Mechanisms include direct injury to the extraocular muscles from surgery or anesthesia, scarring of the muscle complex and/or conjunctiva, alteration of the muscle pulley system, mass effects from implants, and muscle displacement. Diplopia can also result from a loss of fusion secondary to long-standing poor vision in one eye or from a decompensation of preexisting strabismus that was not recognized preoperatively. Treatment, which typically begins with prisms and is followed by surgery when necessary, can be challenging. In this review, the incidence, mechanisms, and treatments involved in diplopia after various ocular surgeries are discussed. [J Pediatr Ophthalmol Strabismus. 2017;54(5):272-281.].