Abstract
Purpose Vertical diplopia is an uncommon but disappointing complication of otherwise successful local anaesthetic cataract surgery. We studied strabismus patterns in a group of such patients to identify the nature and extent of extraocular muscle involvement.
Methods A retrospective review identified 15 cases of vertical diplopia following local anaesthetic cataract surgery between July 1994 and January 1998. Peribulbar anaesthesia was used in all cases and given by right-handed professionals.
Results All cases had otherwise successful cataract surgery (mean age 80.5 years; median pre-operative VA 6/18; median post-operative VA 6/9). The mean level of vertical diplopia was 7.2 prism dioptres (PD) in the primary position (range 2-25 PD). The left inferior rectus (lR) was paretic in 6 cases and restricted in 5 cases. The left superior rectus (SR) was not affected in any of the cases. The right IR was restricted in a single case. The right SR was paretic in 2 cases and restricted in a single case. None of the cases had clinical involvement of the oblique muscles. Eleven of the cases were managed successfully with prisms. Two of the cases required strabismus surgery.
Conclusions The incidence of left eye extraocular muscle involvement was greater than right eye involvement, although this did not reach statistical significance (73% vs 27%; P = 0.075). This may be due to the more difficult access of right-handed individuals giving left eye peribulbar injections with the needle tract being directed more closely to the muscle cone. The IR muscle is more commonly affected than the SR (80% vs 20%; p = 0.019). An equal incidence of paretic and restricted rectus muscle pathology was found in this study (53% vs 47%; p = 0.818). The exact aetiology of muscle injury is unknown but could be due to direct muscle or nerve trauma, anaesthetic toxicity, periocular haemorrhage or a combination of these.
Similar content being viewed by others
Article PDF
References
Rosenbaum AL . Strabismus following uncomplicated cataract surgery. Arch Ophthalmol 1997;115:253.
Hamed LM . Strabismus presenting after cataract surgery. Ophthalmology 1991;98:247–52.
Hamed LM, Lingua RW . Thyroid eye disease presenting after cataract surgery. J Pediatr Ophthalmol Strabismus 1990;27:10–15.
Catalano RA, Nelson LB, Calhoun JH, Schatz NJ, Harley RD . Persistent strabismus presenting after cataract surgery. Ophthalmology 1987;94:491–4.
Pratt-Johnson JA, Tillson G . Intractable diplopia after vision restoration in unilateral cataract. Am J Ophthalmol 1989;107:23–6.
Sharkey JA, Sellar PW . Acquired central fusion disruption following cataract extraction. J Pediatr Ophthalmol Strabismus 1994;31:391–3.
Burns CL, Seigel LA . Inferior rectus recession for vertical tropia after cataract surgery. Ophthalmology 1988;95:1120–4.
Hamed LM, Helveston EM, Ellis FD . Persistent binocular diplopia after cataract surgery. Am J Ophthalmol 1987;103:741–4.
Chapman JM, Abdelatif OM, Cheeks L, Green K . Subconjunctival gentamicin induction of extraocular toxic muscle myopathy. Ophthalmic Res 1992;24:189–96.
Kushner BJ . Case report. Ocular muscle fibrosis following cataract extraction. Arch Ophthalmol 1988;106:18–19.
Wylie J, Henderson M, Doyle M, Hickey-Dwyer M . Persistent binocular diplopia following cataract surgery: aetiology and management. Eye 1994;8:543–6.
Hunter DG, Lam Gc, Guyton DL . Inferior oblique muscle injury from local anesthesia for cataract surgery. Ophthalmology 1995;102:501–9.
de Faber JT, von Noorden GK . Inferior rectus muscle palsy after retrobulbar anesthesia for cataract surgery. Am J Ophthalmol 1991;112:209–11.
Hamed LM, Mancuso A . Inferior rectus muscle contracture syndrome after retrobulbar anesthesia. Ophthalmology 1991;98:1506–12.
Capo H, Roth E, Johnson T, Munoz M, Siatkowski RM . Vertical strabismus after cataract surgery. Ophthalmology 1996;103:918–21.
Rainin EA, Carlson BM . Postoperative diplopia and ptosis: a clinical hypothesis based on the myotoxicity of local anesthetics. Arch Ophthalmol 1985;103:1337–9.
Capo H, Guyton DL . Ipsilateral hypertropia after cataract surgery. Ophthalmology 1996;103:721–30.
Grimmett MR, Lambert SR . Superior rectus muscle overaction after cataract extractions. Am J Ophthalmol 1992;114:72–80.
Esswein MB, von Noorden GK . Paresis of a vertical rectus muscle after cataract extraction. Am J Ophthalmol 1993;116:424–30.
Hamilton SM, Elsas FJ, Dawson TL . A cluster of patients with inferior rectus restriction following local anesthesia for cataract surgery. J Pediatr Ophthalmol Strabismus 1993;30:288–91.
Munoz M . Inferior rectus muscle overaction after cataract extraction. Am J Ophthalmol 1994;118:664–6.
Ong-Tone L, Pearce WG . Inferior rectus muscle restriction after retrobulbar anesthesia for cataract extraction. Can J Ophthalmol 1989;24:162–5.
Carlson BM, Rainin EA . Rat extraocular muscle regeneration: repair of local anesthetic-induced damage. Arch Ophthalmol 1985;103:1373–7.
Carlson BM, Emerick S, Komorowski TE, Rainin EA, Shepard BM . Extraocular muscle regeneration in primates: local anesthetic-induced lesions. Ophthalmology 1992;99:582–9.
Porter JD, Edney DP, McMahon EJ, Burns LA . Extraocular myotoxicity of the retrobulbar anesthetic bupivacaine hydrochloride. Invest Ophthalmol Vis Sci 1988;29:163–74.
Altman DG . Practical statistics for medical research. London: Chapman and Hall, 1991:241–57.
Poland PJ, Hiatt RL . The correction of diplopia after cataract extraction. Ann Ophthalmol 1993;25:110–8.
Rao VA, Kawatra VK . Ocular myotoxic effects of local anesthetics. Can J Ophthamol 1988;23:171–3.
Corboy JM, Jiang X . Postanaesthetic hypotropia: a unique syndrome in left eyes. J Cataract Surg 1997;23:1394–8.
Author information
Authors and Affiliations
Additional information
Presented in part at the Annual Congress of the Royal College of Ophthalmologists, 1999
Rights and permissions
About this article
Cite this article
Pearce, I., McCready, P., Watson, M. et al. Vertical diplopia following local anaesthetic cataract surgery: Predominantly a left eye problem?. Eye 14, 180–184 (2000). https://doi.org/10.1038/eye.2000.50
Received:
Accepted:
Issue Date:
DOI: https://doi.org/10.1038/eye.2000.50
Keywords
This article is cited by
-
Inferior rectus muscle recession as a treatment for vertical diplopia following cataract extraction
Graefe's Archive for Clinical and Experimental Ophthalmology (2013)
-
Rectus muscle trauma complicating sub-Tenon's local anaesthesia
Eye (2001)