Watch for phorias: a cautionary tale


My fusion trouble started insidiously. When we obtained a new slit lamp a few years ago, I immediately noticed I had trouble fusing images when viewing the fundus — sometimes I’d see two optic nerves instead of one. I had no issues with anterior segment slit lamp exams or cataract surgery. But, it was affecting my life in other ways; sometimes I’d view late-night TV through one eye to avoid diplopia.

In time, my fusion difficulties began to affect my surgical abilities, like implanting glaucoma drainage devices. I stopped being a surgeon and became a patient.


Exams revealed a 5-diopter hyperphoria. Apparently, I had this for years, with old photos showing a slight compensatory head tilt. My radial keratectomy from years ago and subsequent photorefractive keratectomy gave me monovision, which possibly enhanced the dissociation. A pediatric surgeon recommended prisms, which helped, but fusion on posterior segment exams was variable. Besides, I’d already undergone two refractive surgeries to avoid wearing glasses.

Although the prior surgeon counseled that I defer surgery, I wanted a second opinion. I looked for the best strabismus specialist in the country, which led me to Kellogg Eye Center in Ann Arbor, Mich. Being a 58-year-old ophthalmologist in a pediatric waiting room is a unique experience. But the staff at Kellogg were gr-r-reat! (Let that sink in. It’ll come to you.) Despite my constant craving for Frosted Flakes, I got to observe a clinic full of orthoptists, techs and residents while they measured me and while I waited for Steven Archer, MD.

He looked over the results and concluded that surgery was a reasonable option. He was doing a newer procedure, a partial inferior rectus tenotomy, in which you cut the muscle insertion most of the way and recess just that small corner. It would only be a 10-minute procedure, with the odds of it fixing my problem between 70% and 80%.

Despite his very conservative approach (he recessed less than usual just to be safe), I overcorrected and now had an opposite-side vertical phoria, which was a bit worse since I’d acclimated to the old phoria for decades. Hey, no one expected a perfect outcome on an ophthalmologist with OCD! I went back, had a procedure done on the other eye, and am now the proud host of two nicely fusing eyeballs.


Why relate this story? For one, my life is so much better. I can easily fuse images again at the slit lamp. Watching TV at night with both eyes open is amazing.

But for two, a reminder: You have patients like me in your exam rooms. Watch for phorias. They are a real problem. Treat them with prisms if that gives a satisfactory result, but don’t forget surgical options. As Tony would say, “They’re great!” OM