Diplopia in Medically and Surgically Treated Patients with Glaucoma

doi:10.1016/j.ophtha.2016.10.006

Ophthalmology

Volume 124, Issue 2, February 2017, Pages 257-262

Presented in part at: The Association for Research in Vision and Ophthalmology meeting, Denver, Colorado, May 5, 2015, and at the American Glaucoma Society, Coronado, California, February 28, 2015.

https://doi.org/10.1016/j.ophtha.2016.10.006 Get rights and content

Purpose

To report the prevalence, type, and cause of diplopia in medically and surgically treated patients with glaucoma.

Design

Cohort study.

Participants

A total of 195 adult patients with glaucoma treated in a glaucoma referral practice.

Methods

A total of 195 adult patients with glaucoma who had undergone surgical or medical management were prospectively enrolled. Forty-seven patients had undergone glaucoma drainage device (GDD) surgery (Baerveldt 350, Baerveldt 250 [Abbott Medical Optics, Abbott Park, IL], or Ahmed FP7 [New World Medical Inc, Rancho Cucamonga, CA]), 61 patients had undergone trabeculectomy, and 87 patients were medically treated. All patients completed the Diplopia Questionnaire to assess diplopia. We defined the presence of diplopia as “sometimes,” “often,” or “always” in distance straight ahead or reading positions on the Diplopia Questionnaire. A chart review was performed jointly by a strabismus specialist and a glaucoma subspecialist to characterize the type and cause of the diplopia.

Main Outcome Measures

Frequency, type, and cause of diplopia.

Results

Diplopia was reported in 41 of 195 medically and surgically treated patients (21%) with glaucoma. Binocular diplopia due to the glaucoma procedure was present in 11 of 47 patients (23%) after GDD (95% confidence interval, 12–38), which was significantly greater than in patients after trabeculectomy (2/61 [3%]; 95% confidence interval, 0.4–11; P = 0.002). The most common type of strabismus associated with binocular diplopia due to glaucoma surgery was hypertropia (10/11 GDD cases, 2/2 trabeculectomy cases). Monocular diplopia was found in a similar proportion of medically treated, post-trabeculectomy, and post-GDD cases (4/87 [5%], 4/61 [7%], and 2/47 [4%], respectively). Binocular diplopia not due to surgery was found in similar proportions of GDD, trabeculectomy, and medically treated cases (3/47 [6%], 5/61 [8%], and 10/87 [11%], respectively).

Conclusions

Diplopia may be under-recognized in medically and surgically treated patients with glaucoma, and standardization of ascertaining patient symptoms using the Diplopia Questionnaire may be useful in these patients. Diplopia was more commonly seen after GDD than trabeculectomy, typically a noncomitant restrictive hypertropia. The prevalence of monocular diplopia and binocular diplopia unrelated to glaucoma surgery was similar among medical and surgical groups. It is important to counsel patients on the higher occurrence of diplopia associated with GDD surgery.

Section snippets

Methods

Approval was obtained from the Institutional Review Board of Mayo Clinic, Rochester, Minnesota, and each patient gave informed consent before participating. All procedures and data collection were conducted in a manner compliant with the Health Insurance Portability and Accountability Act.

Patient Demographics

Patient demographics (age, gender, race/ethnicity) were similar across the 3 groups (Table 1), with the exception of the median time from surgery to evaluation of diplopia, which was longer in the trabeculectomy group (17 months; range, 1 month to 19 years) compared with the GDD group (9 months; range, 1 month to 9 years; P = 0.03) (Table 1).

Occurrence of Diplopia

Across the cohort of 195 medically and surgically treated patients, diplopia was reported in 41 (21%). Overall, diplopia was more common in the GDD group

Discussion

In our prospective study of medically and surgically treated patients with glaucoma using a standard diplopia questionnaire to collect data on symptoms of diplopia, we found the overall frequency of diplopia was 21%. Binocular diplopia due to surgery occurred in 23% of patients undergoing GDD placement and in 3% of patients undergoing trabeculectomy. Monocular diplopia and binocular diplopia not due to surgery were similar in medically treated patients and patients undergoing GDD placement or

Conclusions

Our data are limited by including only postoperative evaluations in surgical patients and including a referral population treated by multiple and other surgeons, leading to variable types of GDD and treatment history for glaucoma. Our study also is limited by using one point in time, evaluating diplopia at the patient's last follow-up examination. An additional potential limitation is that our study was not designed to address strabismus that was not associated with diplopia.

On the basis of our

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Postoperative Complications in the Primary Tube Versus Trabeculectomy Study During 5 Years of Follow-up
2022, Ophthalmology
Citation Excerpt :
It is noteworthy that the incidences of diplopia and persistent corneal edema were similar after tube shunt implantation and trabeculectomy with MMC. A cross-sectional study using a standardized questionnaire found that diplopia was more common after tube shunt surgery than after trabeculectomy.11 Restrictive strabismus after tube shunt surgery may develop because of muscle scarring or a mass effect from a large bleb.12–15
To describe postoperative complications encountered in the Primary Tube Versus Trabeculectomy (PTVT) Study during 5 years of follow-up.
Multicenter randomized clinical trial.
A total of 242 eyes of 242 patients with medically uncontrolled glaucoma and no previous incisional ocular surgery, including 125 patients in the tube group and 117 patients in the trabeculectomy group.
Patients were enrolled at 16 clinical centers and randomly assigned to treatment with a tube shunt (350-mm² Baerveldt glaucoma implant) or trabeculectomy with mitomycin C (MMC, 0.4 mg/ml for 2 minutes).
Surgical complications, reoperations for complications, visual acuity, and cataract progression.
Early postoperative complications occurred in 24 patients (19%) in the tube group and 40 patients (34%) in the trabeculectomy group (P = 0.013). Late postoperative complications developed in 27 patients (22%) in the tube group and 32 patients (27%) in the trabeculectomy group (P = 0.37). Serious complications producing vision loss and/or requiring a reoperation were observed in 3 patients (2%) in the tube group and 9 patients (8%) in the trabeculectomy group (P = 0.11). Cataract progression was seen in 65 patients (52%) in the tube group and 52 patients (44%) in the trabeculectomy group (P = 0.30). Surgical complications were not associated with a higher rate of treatment failure (P = 0.61), vision loss (P = 1.00), or cataract progression (P = 0.77)
A large number of surgical complications were observed in the PTVT Study, but most were transient and self-limited. The incidence of early postoperative complications was higher following trabeculectomy with MMC than with tube shunt surgery. The rates of late postoperative complications, serious complications, and cataract progression were similar with both surgical procedures after 5 years of follow-up. Surgical complications did not increase the risk of treatment failure, vision loss, or cataract progression.
Management of strabismus related to infantile glaucoma: Case series
2021, Archivos de la Sociedad Espanola de Oftalmologia
Evaluar las diferentes estrategias de tratamiento del estrabismo, sus complicaciones y resultados quirúrgicos en pacientes con glaucoma de la infancia.
Se analizaron las historias clínicas de 7 pacientes con glaucoma de la infancia que requirieron tratamiento quirúrgico de estrabismo. Se analizaron las variables edad en el momento de la cirugía de estrabismo, tipo de glaucoma, cirugías de glaucoma, tipo de estrabismo, su tratamiento y resultados posquirúrgicos.
De los 7 pacientes incluidos en nuestro estudio, 4 fueron sometidos a cirugía de estrabismo, 2 recibieron tratamiento con toxina botulínica y uno requirió ambas técnicas. Un 71,42% de los pacientes tenía glaucoma congénito primario, un 14,28% una disgenesia de segmento anterior y un 14,28% glaucoma secundario. Fueron intervenidas 4 exotropías y 3 endotropías. La principal dificultad fue el manejo de la conjuntiva y las ampollas filtrantes.
El estrabismo constituye una complicación frecuente asociada al glaucoma de la infancia. La estrategia de tratamiento del estrabismo en estos pacientes debe ser individualizada. En nuestra serie, el tratamiento del estrabismo mejoró el alineamiento ocular. La cirugía debe considerarse de elección, teniendo en cuenta la importancia de proteger la conjuntiva y no interferir en las cirugías de glaucoma. La toxina botulínica es una opción útil en niños cuando se requieren tratamientos conservadores.
To evaluate the different modalities of treatment of the strabismus related to infantile glaucoma, its complications, and results.
The clinical history of 7 patients with infantile glaucoma which required strabismus surgical treatment were analyzed. Age at onset of glaucoma, type of glaucoma, glaucoma surgeries, type of strabismus, strabismus surgical treatment and postoperative results were studied.
Four patients required strabismus surgery, two were treated with botulinum toxin and one required both. Primary congenital glaucoma was the most common (71,42%), 14,28% had an anterior segment dysgenesis and 14,28% had secondary glaucoma. Regarding strabismus, 4 patients had exotropia and 3 had esotropia. The main difficulty involved the management of the conjunctiva and the filtering blebs.
Strabismus is a frequent complication in infantile glaucoma. The management of these patients should be individualized. In our case series, treatment of strabismus improved eye alignment. Surgery should be the mainstay of treatment while preserving the conjunctiva and interfere the less with glaucoma surgeries. Botulinum toxin is a reasonable option when conservative treatment is needed.
Strabismus After Ahmed Glaucoma Valve Implantation
2021, American Journal of Ophthalmology
Citation Excerpt :
Other smaller studies of the Baerveldt implant have retrospectively reviewed between 30 and 182 subjects and reported a rate of diplopia ranging from 1.4% to 37%.2,9–14 In 2017, Sun and associates15 enrolled 195 glaucoma patients in a prospective study that assessed the presence of diplopia using the previously developed Diplopia Querstionnaire.16 In this series, 47 of the patients underwent glaucoma drainage device surgery (Baerveldt n = 35 and AGV n = 16), and 11 (23%) of them subsequently experienced new-onset diplopia postoperatively.
Most reports of strabismus after glaucoma drainage device implantation study larger devices and rarely note the incidence of strabismus after Ahmed glaucoma valve (AGV) implantation. It is unknown if the pattern of strabismus is similar with smaller devices. We investigated characteristics of strabismus after AGV implantation.
Retrospective review.
Institutional study of 732 patients at our institution undergoing AGV implantation between 2013 and 2018. Rate and characteristics of strabismus were the primary outcome; age, gender, and location of AGVs were also analyzed.
We identified 29 patients who developed new-onset strabismus postoperatively after initial AGV implantation, for 4% incidence of strabismus. Twenty-one (72%) of these had diplopia. AGVs were implanted superotemporally in 21, superonasally in 5, inferotemporally in 1, and inferonasally in 2. Three patients were esotropic, 11 were exotropic, 4 had hypertropia, 2 had hypotropia, and 9 patients had combined horizontal/vertical strabismus (esotropia/hypotropia [n = 1] or exotropia/hypertropias [n = 8]). Exotropia was the most common type of strabismus in both the superotemporal and superonasal (60%) AGV groups. Superotemporal AGVs were more commonly associated with ipsilateral hypertropia (43%) than superonasal AGVs. Treatments included strabismus surgery (n = 14), prisms (n = 6), or an occlusive lens (n = 1).
In the largest single-center series of patients undergoing initial AGV implantation, the overall incidence of postoperative strabismus was 4%. This is comparable to strabismus incidence following implantation of other types of glaucoma drainage devices, even larger devices. The possibility of this complication should be discussed with patients prior to surgery.
Pickwell’s Binocular Vision Anomalies
2021, Pickwell's Binocular Vision Anomalies
Risk factors for strabismus following glaucoma drainage device implantation for refractory childhood glaucoma
2019, Journal of AAPOS
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.
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.
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.
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
2019, Journal of AAPOS
Citation Excerpt :
Diplopia was rare in this study (4%), and most subjects had poor vision in at least one eye. Although these sensory challenges likely diminished our likelihood of achieving traditionally defined surgical success, these traditional standards may have also been of less significance for our study population than for patients with good fusional potential and preoperative diplopia.3,6,16 In the concomitant-GDD group, most subjects had surgery on only the lateral rectus adjacent to the GDD being implanted.
To evaluate outcomes of strabismus surgery performed subequent to or concomitant with glaucoma drainage device (GDD) implantation for refractory childhood glaucoma.
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.
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.
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.

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: Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

: J.M.H.: Support – National Institutes of Health Grant EY024333; Research to Prevent Blindness, New York, New York (an unrestricted grant to the Department of Ophthalmology, Mayo Clinic); and Mayo Foundation, Rochester, Minnesota. None of the funding organizations had any role in the design or conduct of this research.

: Author Contributions:

: Conception and design: Sun, Leske, Holmes, Khanna

: Analysis and interpretation: Sun, Leske, Holmes, Khanna

: Data collection: Sun, Leske, Holmes, Khanna

: Obtained funding: Holmes

: Overall responsibility: Holmes, Khanna

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Original articleDiplopia in Medically and Surgically Treated Patients with Glaucoma

Purpose

Design

Participants

Methods

Main Outcome Measures

Results

Conclusions

Section snippets

Methods

Patient Demographics

Occurrence of Diplopia

Discussion

Conclusions

Ophthalmology

Surv Ophthalmol

J AAPOS

Ophthalmology

Ophthalmology

Ophthalmology

Ophthalmology

Ophthalmology

Ophthalmology

Ophthalmology

Original article
Diplopia in Medically and Surgically Treated Patients with Glaucoma