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 Table of Contents    
LETTER TO THE EDITOR
Year : 2016  |  Volume : 9  |  Issue : 3  |  Page : 196-198  

Orthoptic relevance of refractive correction in the phakic plane in unilateral high refractive errors in adults


Department of Ophthalmology, King George's Medical University, Lucknow, Uttar Pradesh, India

Date of Web Publication14-Oct-2016

Correspondence Address:
Siddharth Agrawal
Department of Ophthalmology, King George's Medical University, Lucknow 226 003, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-620X.192383

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How to cite this article:
Agrawal S, Singh V, Yadav A, Katiyar V. Orthoptic relevance of refractive correction in the phakic plane in unilateral high refractive errors in adults . Oman J Ophthalmol 2016;9:196-8

How to cite this URL:
Agrawal S, Singh V, Yadav A, Katiyar V. Orthoptic relevance of refractive correction in the phakic plane in unilateral high refractive errors in adults . Oman J Ophthalmol [serial online] 2016 [cited 2019 Jul 15];9:196-8. Available from: http://www.ojoonline.org/text.asp?2016/9/3/196/192383

Sir,

Anisometropia is the condition in which the two eyes have unequal refractive power. A disparity in focus and the difference in clarity and size of the image on retina results in the impairment of fusion, often leading to strabismus. [1] Ocular deviation associated with anisometropia in adults is a common presentation in strabismus practice. Half-hearted efforts, if at all, are made for refractive correction before ocular alignment as it is largely believed that the deviation remains largely unchanged with use of glasses. [2]

Refractive correction by means other than spectacles has been known to significantly improve the quality of vision, enhance binocular functions, and also have a positive impact on ocular deviations. [3],[4] We report a series of three patients proving the orthoptic relevance of surgical refractive correction in unilateral high refractive errors in young adults. The patients underwent surgery after informed consent.

The first patient was a 21-year-old male who presented to our strabismus clinic for cosmetic correction of the left exotropia (LXT) of 35 prism diopters (PD) [Figure 1]a. His uncorrected visual acuities (UCVA) were 0.0 (logarithm of the minimal angle of resolution) right eye (RE), and 1.34 left eye (LE). LE improved to 0.78 with + 8D sphere. A diagnosis of severe anisohypermetropic amblyopia LE with sensory LXT was made. [5] Surprisingly, a momentary control of XT was noted during subjective improvement which we attributed to improved visual acuity (VA) in LE and some preexisting binocularity. His control was even better (Newcastle control score 5/7) with contact lens (CL). [6] LE amblyopia therapy trial for 3 months showed no change in best-corrected VA (BCVA) or ocular deviation. Binocular functions could not be elicited by any standard test. As the patient desired permanent solution, refractive surgery followed by ocular alignment for residual deviation was planned. A clear lens extraction with multifocal intraocular lens (refractive-diffractive multifocal intraocular lens (IOL) (iDIFF, Intra Ocular Care Pvt. Ltd., Vadodara, Gujarat, India) implantation was done in LE, due to nonsuitability for implantable collamer lens (ICL) (anterior chamber depth = 2.432 mm). [7] Our decision to implant a multifocal IOL (MFIOL) was influenced by the patient's motivation to be spectacle free and possibly greater pseudo-accommodative effort. [8] Postoperatively, he was controlling the XT most of the times (NCS 5/7) [Figure 1]b. Postoperative UCVA and BCVA were 0.60. Binocular functions (160 s of arc on randot stereo test) were observed. [9] The patient was comfortable, and strabismus surgery was deferred.
Figure 1: (a) Preoperative photograph of case 1 showing exotropia (35 prism diopters). (b) Postoperative photograph of case 1 after clear lens extraction with multifocal intraocular lens implantation with control of exotropia

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The second patient was a 20-year-old, male medical student who presented with difficulty in enjoying binocular vision while looking through a microscope. He had undergone a repair of corneal penetrating injury with lens aspiration and in the bag-IOL implantation LE 8 years back. His RE was emmetropic with a UCVA of 0.0. LE had a UCVA of 1.30 and BCVA of 0.30 with 8.0 D sphere. He had a leukoma adherans about 3.5 mm away from the center at 10 O' clock which made him intolerant to CL [Figure 2]a. He showed LE suppression with standard tests and desired binocular vision. Sulcoflex® (Rayner Intraocular Lenses Limited, East Sussex, United Kingdom) piggyback IOL was implanted, and the patient had a postoperative UCVA and BCVA of 0.3 [Figure 2]b and c. He demonstrated a binocularity of 100 s of arc on randot stereo test and a fusional range of − 4-+4 on the synoptophore. [8]
Figure 2: (a) Preoperative photograph of case 2 showing leukoma adherans. (b) Postoperative photographs of case 2 after piggyback intraocular lens implantation. (c) Postoperative photographs of case 2 after piggyback intraocular lens implantation

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A 21-year-old female who came for cosmetic correction of the left XT was the third patient. Her UCVA was 1.0 RE and 1.5 LE. She had left XT of 30 PD with no variability or incomitance [Figure 3]a. BCVA of RE was 0.0 with − 4.5 D sphere; LE was 1.1 with − 20.0 D sphere. Both eyes had myopic degeneration with no staphyloma or treatable lesions. LE amblyopia therapy trial for 3 months caused no change in VA or ocular deviation. Simultaneous macular perception without fusion was present. Refractive correction followed by ocular alignment was planned. The patient underwent implantable Collamer lens (visian implantable Collamer lens (ICL) - STAAR Surgical, CA, USA) implantation simultaneously in both eyes (−6.5 D RE, −23.0 D LE). Postoperatively, the uncorrected VA improved to − 0.1 RE. The BCVA in LE was 0.6 (20/80) with − 0.75 D Sphere. She was orthophoric for distance and near with fusion with a limited range [Figure 3]b.
Figure 3: (a) Preoperative photograph of case 3 (with contact lenses) showing left exotropia (30 prism diopters). (b) Postoperative photograph of case 3 after bilateral implantable Collamer lens implantation with control of exotropia

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[Table 1] and [Table 2] summarize the clinical details of the cases.
Table 1: Preoperative details with the intervention done


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Table 2: Postoperative orthoptic details (12-week postprocedure)


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These cases highlight the following points:

  • Refractive correction closer to the nodal point improves VA. [10] A clearer and lesser aniseiokonic image would stimulate and enhance binocularity
  • For high refractive errors, glasses create significant peripheral distortion. Surgical correction of the refractive error provides the patient with a larger distortion-free peripheral field and stronger stimulus for fusion [11]
  • A greater accommodative effort would help in controlling the XT. Greater pseudo-accommodative effort with MFIOL in the 1 st case and enhanced effort by phakic IOL in the 3 rd case would play a role.
These cases demonstrate orthoptic relevance of surgical refractive correction in unilateral high refractive errors in young adults as an essential part of their initial management.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Czepita D, Goslawski W, Mojsa A. Occurrence of anisometropia among students ranging from 6 to 18 years of age. Klin Oczna 2005;107:297-9.  Back to cited text no. 1
    
2.
Barrett BT, Bradley A, Candy TR. The relationship between anisometropia and amblyopia. Prog Retin Eye Res 2013;36:120-58.  Back to cited text no. 2
    
3.
Kirwan C, O'Keefe M, O'Mullane GM, Sheehan C. Refractive surgery in patients with accommodative and non-accommodative strabismus: 1-year prospective follow-up. Br J Ophthalmol 2010;94:898-902.  Back to cited text no. 3
    
4.
BenEzra D, Cohen E, Karshai I. Phakic posterior chamber intraocular lens for the correction of anisometropia and treatment of amblyopia. Am J Ophthalmol 2000;130:292-6.  Back to cited text no. 4
    
5.
Singh V, Agrawal S. Visual functions in amblyopia as determinants of response to treatment. J Pediatr Ophthalmol Strabismus 2013;50:348-54.  Back to cited text no. 5
    
6.
Buck D, Hatt SR, Haggerty H, Hrisos S, Strong NP, Steen NI, et al. The use of the Newcastle Control Score in the management of intermittent exotropia. Br J Ophthalmol 2004;88:233-5.  Back to cited text no. 6
    
7.
Fernandes P, González-Méijome JM, Madrid-Costa D, Ferrer-Blasco T, Jorge J, Montés-Micó R. Implantable collamer posterior chamber intraocular lenses: A review of potential complications. J Refract Surg 2011;27:765-76.  Back to cited text no. 7
    
8.
Tan N, Zheng D, Ye J. Comparison of visual performance after implantation of 3 types of intraocular lenses: Accommodative, multifocal, and monofocal. Eur J Ophthalmol 2014;24:693-8.  Back to cited text no. 8
    
9.
Wang J, Hatt SR, O'Connor AR, Drover JR, Adams R, Birch EE, et al. Final version of the Distance Randot Stereotest: Normative data, reliability, and validity. J AAPOS 2010;14:142-6.  Back to cited text no. 9
    
10.
Pascal JI. Retinal image in axial and refractive ametropia. Br J Ophthalmol 1955;39:380-1.  Back to cited text no. 10
    
11.
Agrawal S, Singh V, Jain A. Corrrection of exotropia by implantable collamer lens. Indian J Ophthalmol 2013;61:685.  Back to cited text no. 11
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