Today’s guest blogger is Ms. Annie Hao.  Annie was born and raised in China until her family moved to Japan in 1997 where she attended elementary school. In 2000, she came to America and finished her schooling in Pittsburgh, PA.  She attended  Michigan State University in Ann Arbor and received her Bachelor of Science in Physiology. She is currently a 3rd year student at Southern College of Optometry in Memphis, TN.  Upon graduation, Annie intends to complete a private practice residency in vision therapy and eventually practice vision therapy in a group practice setting. In her free time she likes to run, read. and cook.

A 61-year-old white male presented with a chief complaint of double vision and a history of having difficulty with glasses. He reported being uncomfortable with driving and said he could not see road signs well enough.  The history revealed that he had worn vertical prism for the past 25 years. For the past 6 years his glasses “haven’t been right” and he presumed that it was due to the change in his eye doctor and moving away from New York.  He reported being involved in a car accident when he was a teenager which may have affected the muscles of his right eye.  He also has a history of Meniere’s disease, an inner ear disease that affects balance and hearing.

Upon examination he was found to have a moderate vertical deviation, with a tendency of the right eye to turn upward.   While trying to determine his spectacle prescription, he reported double vision and vertical prism was required to help move the images from each eye closer together.   He saw two lines of letters and the lines were almost level, but one of the lines was tilted.  Further testing demonstrated that, in addition to the vertical deviation, he also had a cyclo deviation which was causing the images to be rotated or tilted away from each other.

Among all causes of double vision, the prevalence of a cyclorotation or torsional deviation is very low; however symptoms, when noticed, can have a major negative impact on a patient’s quality of life.  These symptoms include but are not limited to double vision, dizziness, and difficulties in negotiating stairways, steps, and street curbs. Simple horizontal or vertical spectacle prisms used to treat other causes of double vision are insufficient to relieve these symptoms because they do not address the rotational aspect of the deviation.   Surgical intervention for cyclodeviations is an option; however surgery for cyclodeviations is more complex, and many patients wish to avoid surgery if possible. Dr. Paul Harris suggested another treatment option for this patient: monovision.  This involves modifying the patient’s spectacle prescription so one eye sees clearly at distance and the other eye sees clearly at near.  Whether the patient is looking at something far away or close up, the non-preferred eye is slightly blurred.  This makes it easier to ignore this 2nd image and thus eliminates the double vision.  Dr. Harris has worked with many patients with similar diagnoses and has found that monovision therapy is an effective treatment option to relieve double vision for patients who are unable to attain fusion (eye alignment) through traditional methods.

After these treatment options were discussed, the patient chose monovision as the preferred treatment option. When he received his glasses, the patient reported significantly improved comfort when driving and double vision was no longer an issue.

A careful history and examination are the important keys to uncovering a cyclovertical deviation and improving the patient’s quality of life.  Sometimes thinking “outside the box” can help determine an effective treatment option for a particular patient.  In this case, blurring the image from one eye made it much easier to avoid binocular vision and eliminate the double vision.  Although cyclovertical deviations are fairly rare, their detection and treatment with monovision spectacles can give great relief to the patient and satisfaction to the doctor.

The vertical deviation and cyclorotation deviation can be seen in this cheiroscopic tracing.  The patient looks through the instrument with both eyes open and copies the pattern, first with the right eye and the right hand, then with the left eye and the left hand.  The vertical displacement and the outward tilt of the 2 drawings represents the vertical and cyclorotational components of the misalignment.

Cheiroscopic tracing with vertical and cyclo deviation