What are the next steps for a patient experiencing diplopia (double vision) following strabismus surgery, with an unusual spasm when changing focus, possibly voluntarily induced by the patient?

From the Guidelines

For a patient experiencing diplopia after strabismus surgery with unusual spasms during focus changes that appear potentially voluntary, I recommend a comprehensive follow-up evaluation including detailed orthoptic assessment and prism measurements. This approach is supported by the most recent guidelines for adult strabismus management, as outlined in the 2024 adult strabismus preferred practice pattern 1. Schedule an urgent appointment within 1-2 weeks to distinguish between expected post-surgical adaptation and complications. In the meantime, temporary prism glasses or patching the affected eye for limited periods (2-3 hours daily) may provide symptomatic relief. Consider prescribing cycloplegic drops like cyclopentolate 1% once daily to reduce accommodative spasm if appropriate, as suggested by the management of strabismus and diplopia in various studies 1. Reassure the patient that post-strabismus surgery diplopia often resolves within 4-6 weeks as the brain adapts to the new eye alignment. The unusual spasms may represent convergence spasm, accommodative issues, or potentially functional (non-organic) elements, which require different management approaches. During the follow-up, perform forced duction testing to check for mechanical restrictions and assess for muscle slippage or other surgical complications. Patient education about normal recovery expectations and distinguishing between true diplopia and awareness of physiologic diplopia is essential for reducing anxiety and improving outcomes.

Some key points to consider in the management of this patient include:

• The importance of a detailed sensorimotor evaluation, assessment of refractive status, and dilated fundus examination in the diagnosis and management of adult strabismus 1.
• The potential for fixation switch diplopia, especially in patients with a history of monofixation and suppression, and the need for management by an ophthalmologist with expertise in binocular function abnormalities 1.
• The role of prism correction, occlusion, and strabismus surgery in the management of diplopia and strabismus, including the use of adjustable sutures and the potential for multiple surgeries 1.
• The need for close communication with other healthcare providers, including those managing glaucoma, to ensure comprehensive care and minimize complications 1.

By prioritizing a comprehensive evaluation and individualized management approach, we can optimize outcomes for patients with diplopia after strabismus surgery, minimizing morbidity, mortality, and improving quality of life.

From the Research

Next Steps for Diplopia Following Strabismus Surgery

The patient experiencing diplopia (double vision) following strabismus surgery, with an unusual spasm when changing focus, possibly voluntarily induced by the patient, may consider the following options:

• Botulinum toxin injections and prism therapy: As reported in 2, botulinum toxin injections to both lateral rectus muscles along with a small prismatic correction in spectacles can be effective in eliminating paradoxical diplopia and permitting some binocular fusion.
• Ocular occlusion, monovision optical correction, prism glasses, strabismus surgery, and chemodenervation: These treatment options, as discussed in 3, can help alleviate diplopia by enabling the patient to ignore the image from the misaligned eye, altering the light pathways, or restoring ocular alignment.
• Fresnel membrane prisms: The use of Fresnel membrane prisms, as described in 4, can provide relief from diplopia in patients with fourth and sixth cranial nerve palsies, restrictive motility, or convergence insufficiency.
• Combined Bangerter filter and Fresnel prism: For patients with binocular diplopia due to maculopathy, a combination of Bangerter foil and Fresnel prism, as reported in 5, may be an effective treatment option.
• Prism correction with physiotherapeutic procedures: As shown in 6, prism correction combined with physiotherapeutic procedures, such as oculomotor muscles motility training and orthoptic exercises, can lead to improved binocular vision function and regression of diplopia.

Possible Treatment Outcomes

The treatment outcomes for diplopia following strabismus surgery may vary, but the following have been reported:

• Relief of diplopia: Many patients experience relief from diplopia with the use of prism correction, botulinum toxin injections, or other treatment options.
• Improved binocular vision: Treatment can lead to improved binocular vision function, including simultaneous perception, fusion, and stereopsis.
• Increased ocular range of motion: Physiotherapeutic procedures can help increase the ocular range of motion and reduce horizontal and vertical deviation angles.