What are the treatment options for binocular vision disorders?

Treatment Options for Binocular Vision Disorders

Treatment of binocular vision disorders is symptom-directed and aims to reduce diplopia, restore binocular vision, and reconstruct ocular alignment through a stepwise approach starting with observation and optical management, progressing to prism correction, fogging techniques, and ultimately surgical intervention when conservative measures fail. 1

Initial Assessment and Conservative Management

Observation and Monitoring

• Patients with mild or occasional symptoms, or those opposed to treatment, should be monitored without immediate intervention. 1
• This approach is appropriate when symptoms do not significantly impact quality of life or daily function. 1

Refractive Correction

• Proper sphere-cylindrical correction is the first-line treatment, as adequate refractive correction can reduce heterophoria and binocular vision disorders. 2
• Refractive correction is particularly important in fixation switch diplopia, where attempting to "switch" fixation back to the dominant eye through refractive optimization can gradually reduce diplopia. 1
• Patients will experience less diplopia if dominance is re-established in the previously dominant eye. 1

Optical Management with Prisms

Prism Correction

• Prism lenses represent a primary non-surgical treatment option for binocular diplopia, aiming to restore the largest area of single binocular vision. 3
• Prisms can reduce symptoms in patients with binocular central diplopia and various forms of strabismus. 4
• In cases where fixation cannot be switched back due to permanent vision loss, vision in the newly dominant eye should be optimized with refractive correction and prisms. 1

Fogging Techniques

Monocular Fogging

• Fogging one eye is the most successful long-term treatment for binocular central diplopia, as it eliminates foveal conflict by creating a central scotoma. 5
• Fogging can be achieved through Bangerter foils, Scotch Satin tape, or occlusive contact lenses. 5, 4
• Combination therapy with small prism plus Bangerter foil may be effective in selected cases. 5

Occlusion as Last Resort

Complete Occlusion

• When fixation switch diplopia cannot be alleviated by other means, occlusion must be contemplated as a last resort. 1
• This is reserved for cases where all other conservative measures have failed. 1

Surgical Intervention

Strabismus Surgery

• Eye muscle surgery is indicated when conservative measures fail and there is a significant angle of misalignment with demonstrated ability to relieve diplopia through prism correction. 1, 3
• Surgery may be considered if improved binocular alignment reduces symptoms not completely addressed by fogging or optical correction. 4
• For divergence insufficiency, sagging eye syndrome, and strabismus fixus, surgical treatment is warranted when diplopia, inability to make eye contact, or severe ocular misalignment prevents proper eye examinations. 1

Retinal Surgery

• Surgical peeling of epiretinal membranes can be effective for treating binocular central diplopia in some patients, but carries risk of creating new diplopia in others. 4
• This should be approached with caution and coordinated between retina and strabismus specialists. 5

Specialized Management by Disorder Type

Fixation Switch Diplopia

• Management requires an ophthalmologist with expertise in longstanding childhood strabismus and abnormalities of binocular function, with orthoptists assisting in examination and nonsurgical management. 1
• Patients have excellent prognosis if fixation can be switched back to the dominant eye. 1

Binocular Retinal Diplopia

• For retinal disease causing diplopia (epiretinal membranes, subretinal membranes, foveal ectopia), coordinated care between retina specialists and strabismus specialists is essential. 5
• The prevalence increases with age, affecting 2% under age 60 and 12% over age 70, with 16-37% developing binocular diplopia. 1, 5

Convergence Insufficiency and Heterophoria

• Convergence insufficiency (prevalence 19%) and simple esophoria/exophoria require proper refractive correction as initial management. 2
• Accommodative and fusional vergence abnormalities should be addressed through appropriate optical and vision therapy interventions. 6, 7

Critical Pitfalls to Avoid

• Never assume all "double vision" complaints represent true diplopia—many patients describe blurred vision or visual distortion rather than true image separation. 5
• Do not perform strabismus surgery for binocular central diplopia without addressing the underlying retinal distortion, as this will fail to resolve the condition. 5
• Avoid procedures or refractive corrections that result in fixation switch to the nondominant eye in patients with history of monofixation. 1