To see views enlarged, click on the individual pictures...

This 81-year-old woman had bilateral cataract extraction with placement of an intraocular lens and then treatment of a secondary membrane in the left eye.  Both procedures on the left eye were done with local anesthesia.  Immediately after the second procedure on the left eye the patient noted double vision.  She presented as shown two months after the last procedure with a left hypotropia, limited elevation of the left eye, and increased depression in the left eye.  There is also a small left exotropia but normal horizontal versions in the left eye.  The patient has 20/25 vision in each eye in the distance.

1.	The double vision reported by the patient would most likely be described as the second image being:
	c -- With a left exotropia and hypotropia the second image of the object of regard would be less clear since it is seen by peripheral retina.  The peripheral retina is temporal and inferior meaning the object would be seen by the patient as being to the right and above the object of regard.
2.	The most likely cause for the vertical diplopia is:
	d -- This left hypotropia is most likely due to the toxic effect of the local anesthetic being injected into the left inferior rectus.  This is an occasional complication of local anesthesia for this type of surgery.  It has been shown that in some (most) cases there is a transient weakness of the inferior rectus followed by a fibrosis and shortening, leading to a mechanical hypotropia with limitation of elevation and overaction of the inferior rectus in downgaze.
3.	Treatment for this condition:
	c -- The best treatment of this condition is a weakening of the offending muscle, the left inferior rectus.  The surgery can be done with local or even topical anesthesia using either a fixed or an adjustable suture.   This surgery can be done on a patient at any age as long as they can tolerate the simple muscle surgery.  Since the patient sees very well after the cataract surgery, she is not a good candidate for prism therapy that would require the wearing of glasses.

See Strabismus Minute  Vol. 1, No. 22 "Diplopia after Cataract Surgery"