Slanting of vision and pain in the left eye

[abhi_1122]

I will explain complete history, so please bear with me till end. Thanks in advance for the patience. So, basically 3 months ago I was diagnosed with -0.5 cylinder refractive error in my right eye and doc informed me that vigorous rubbing of eye can induce astigmatism. My mind became disturbed after this as i used to rub my right eye a lot due to itching in morning and my dad used to advice me not to rub it. One month ago, in the heat of the moment as i was angry due to guilt, I intentionally tried to change the shape of cornea in my left eye also out of curiosity to see whether it develops a cylinder power or not. I never had used knuckle in past for rubbing and probably this idea striked due to reading articles of Keratakonus where they mention " knuckling". That night , rather than using my finger for rubbing , I tried to use knuckle. And it was not even an effective rub but rather i rolled my fist very hard over the eye by keeping knuckle at a fixed position on the eyeball and even kind of pressed on my eyeball ( compression force to push it inside). I created jerky circling motion over the eyeball and ended up doing something completely weird .  From next day onwards, my eye started hurting and on 4th day left side of sclera started picking up redness/congestion. I also developed blur in that left eye for many days like a vapour obstructing vision .I actually waited for 15 days but since pain was not resolving , i visited hospital where junior resident of opthalmology said that everything looks fine after undilated slit lamp exam ( JR's not very experienced though ) . Just after 4 days of this exam, I developed slanted vision in both eyes. I see straight line, be it vertical or horizontal as slanted/bent towards one side on computer screen, mobile . Similarly rectangle looks more of trapezoid. Even whole paragraphs slant sometimes upwards or downwards. Piano keys also look odd shaped and slanted but i dont notice it when i look at people's faces or trees or parks. Now after complete 30 days, I had dilated eye exam and full workup including corneal topography as well as MACULAR OCT and everything came out normal. The clarity in painful eye has restored 80 percent but not 100 percent, pain has also reduced finally after a month by 85 percent. Now, following are the questions in a sequential manner I request you to address:-

1. I am worried as to the fact that i visited hospital pretty late, and if there could be untreated inflammation during initial 15 days post knuckling act. If current eye exam is normal, does it mean that there is no damage at all? can opthalmologists document even minor injuries/changes if patient presents late? ( i am panicky after reading iritis/uveitis)..

2.  Where do you think my pain come from? was it muscle strain/trauma. An year ago, i tried pressing on both the eyes with fingers for the first time to see what happens but that time pain lasted only for few days and was mild. First time ever, pain was so evident for a complete month . The pain was as if something is tearing within the eye and was also felt just below eye near the cheek when touched.

3. The eye which was in pain is reporting pressure on higher side. In morning on air puff test ,left eye had 28 and right eye had 16. So we did applanated tonometry on left eye in the afternoon and it was 20. NEXT day i again repeated puff test in a local clinic where it was 22/20 ( 22 in left eye and 20 in right). You decide how to be cautious about it and what to do next , or if its concerning.

4. Even trying glasses to correct refraction of -0.5 R eye and -0.25 L eye is not resolving problem of slanting at all. There are also posts on medhelp with users reporting same slant issue which dates back to 2015 but was closed and no one reported final resolution or treatment plan. The link is https://www.medhelp.org/posts/Eye-Care/Slanted-Vision-/show/1828542.

5. They did perform slit lamp but did not do gonioscopy. Can doctors grossly check if drainage canals are working properly on slit lamp exam ? without special gonioscope test.

Final comments:- The most difficult thing for me as of now is to reassure myself that i did not cause any permanent injury to my eye . As per above case description and normal eye exams, can we safely assume here that my eye is not changed in any way from trauma. i dont even know if slanting is related to my act as its not only in the affected eye but in both eyes. The symptoms are not going away. I was able to traumatize the eye because i was probably angry in that moment otherwise our reflexes usually stop us . I did by closing the eyelid which made it possible.

[Dikshachopra]

Hiii... Do you find solution for this .. as i m having same issue of slanted vision after wearing my glasses for very first time nd now even without glasses i had same issue... I have keratoconus though...!! Nd had cxl done

[John C Hagan III, MD, FACS, FAAO]

What is the mystery here? K-conus is a common cause of irregular astigmatism that cannnot be corrected with glasses:      from above:  Slanting vision is ususally:   1: corneal disease (irregular astigmatism)   2. regular refractive error   myopia/astigmatism/hyperopia  3. inaccurate or poorly fit gasses  4. Lens of eye disease (cataract)  5. Macular disease (edema/membrane)   6. Eye muscle problem such as inferior or superior oblique palsy.     You and your physicians will need to work through the causes.

[John C Hagan III, MD, FACS, FAAO]

0.50 diopter of cylinder (astigmatism) is next to nothing.   A single rub will not cause astigmatiasm  even in an adult.   K-conus might be changed with repeated rubbing in a young person. There you are talking about  3 to 6 diopters of astigmatism.  You may have abraded the cornea which can cause pain, redness, sensitivity to light.  Gonioscopy is not a test that need be done for your complaints.  Slit lamp exam should exclude any iritis/uveitis.   Corneal topography should exclude K conus and macular OCT macular edema. Your IOP is high and should be watched with Visual fields, Nerve fiber layer OCT and at some time you should have a gonioscopy.   Learn your lesson and don't rub or knuckle you eyes. Remotely that is all I can say. Continue to see ophthalmologist Eye MD on regular basis and schedule a visual field, NFL OCT and gonioscopy.

[abhi_1122]

Thanks Dr. John. However, I have to tell you this point  that I again went to a local clinic of optometry only for pressure check and today it was 17/16 ( 17 in left eye and 16 in right eye), which means at some times during day it's not high and keeps fluctuating. And original doctors treating my case don't seem concerned about doing additional OCT of optic nerve or tests like visual field as applanated tonometer showed pressure of 20 on the first day which is again in normal range as per them. So the iop point is not clear to me. They usually do dilated exam to see health of nerve etc and said to me it's healthy. Remaining tests were done for slanting problem and not high iop.

[John C Hagan III, MD, FACS, FAAO]

Slanting vision is ususally:   1: corneal disease (irregular astigmatism)   2. regular refractive error   myopia/astigmatism/hyperopia  3. inaccurate or poorly fit gasses  4. Lens of eye disease (cataract)  5. Macular disease (edema/membrane)   6. Eye muscle problem such as inferior or superior oblique palsy.     You and your physicians will need to work through the causes.

[abhi_1122]

But sir , my main anxiety is now linked to iop. As if I checked it at 12;45 pm then it was 22/20 and if I repeated puff test at 1:15pm with a gap of 30 minutes it was 17/16. And you know iop is not conclusive and only test for glaucoma so it's very confusing and frightening that iop values are sometimes in higher range and sometimes in normal range. What average decision should we draw from this.Is my act of trauma causing any pressure change?. I should worry about it or ignore it.

[John C Hagan III, MD, FACS, FAAO]

Ignore it but have your eyes checked with an additional glaucoma test (visual field or nerve fiber layer OCT) at least yearly.  Many things in our body change from minute to minute (pulse, blood pressure, blood sugar) and IOP is one of them. Many tests have been done to show that in all of us IOP varies throughout every 24 hours period.  If tested hourly and plotted on a graph it is called "a diurnal curve'  think of it like the tide table.  Everyone is different  some people have their highest IOP (high tide) at night and thus it will not show up in the eye doctor's office, others occur during the day.  for most people the variation between high and low is about 6-8 points and does not rise above 20-21 in non-glaucoma patients.  However in glaucoma or glaucoma suspects the variation can be as high as 10-15 points. That is why diagnosing glaucoma does not use IOP along to make the DX as was the case 75 years ago.  Also the measurement of IOP (like blood pressure) is subjective and varies from tester to testor and sometimes between the same person testing the IOP rapidly.  The variation whether done by Goldman applanation or pull tonometer or tonopen will depend on experience and how relaxed and easy to test the person is. Squeezing will artificially raise the IOP.  So don't worry about the IOP varying, that is normal.

[abhi_1122]

Dr john, following after weeks with you. First of all thanks for previous answers. Actually my Oct macula,dilated eye exam,corneal topography, eye track/trace tests are normal. Eye cover /uncover and patching one eye was done to rule out muscle problem as well. But slanting vision problem not solved. Even wearing glasses does not solve it. I am referred to a neurologist. Meantime I am very curious to know that you said I may have abraded the cornea which caused me pain. But abrasion heals in a day or two. I had evident pain in my eye with redness in the corner for one full month till I went to the doctor.  I want to mainly ask from you that if I had any inflammation during this time...any uveitis/iritis. Then does eye has ability to heal from inflammation automatically after trauma? We have heard that inflammation is natural healing response of body.  I know that chronic uveitis if caused by autoimmune response and arthritic disorders can trigger tissue damage..but what if it's from Injury ?. I feel there must be "cell and flare" effect visible during that month when I didn't see a doctor. My friend though who is a nurse asked me to put ketorolac eye drops. I didn't take those as nsaids cause me severe gastritis in stomach, so I was afraid. Can I be sure that there is no damage from inflammation and pain. And could putting drops have had helped me significantly or eye heals automatically also.

[John C Hagan III, MD, FACS, FAAO]

That are a lot of errors in your thinking.   First the cornea does not heal quickly and frequently heals improperly.  [search and read about recurrent corneal erosion syndrome].  Best case scenario it takes the cornea 6-8 weeks minimum to be fully healed as before. (this is due to the time it takes hemidesmasomes to form that hold the epithelisum onto the cornea stroma and Bowman's membrane. Eye pain and slanted vision are likely two different things unless you have a small scar in visual axis.   Cell/flare/inflammation is not difficult to see and should have easily been visible to the ophthalmologist that treated you.  Ketorolac to the eye is not at all like talking NSAIDS  internally.   See the neurologist.

[abhi_1122]

I am afraid, there was little misunderstanding. I am pretty convinced that on slit lamp exam, inflammation cannot go unnoticed by the opthalmologist. But my concern is that I did not even see the doctor for one complete month and kept bearing the pain. I want to know in regards to that please. That what if there was inflammation during that time, does eye has ability to heal itself from inflammation or nsaid topical eye drop is really necessary. You advice people to seek docs care immediately after any eye trauma. I did not seek the immediate care.

[John C Hagan III, MD, FACS, FAAO]

Everything in the body had the ability to heal, sometimes completely, sometimes incompletely. Think a cut on your arm.  I've taken this as far as I can and have nothing else to offer.  You will need to work through this with your local physicians.

[abhi_1122]

hello after a long time, as far as you were referring to the abraded cornea and told me that it can take 6 weeks to heal completely. Does this kind of abraded cornea presents itself with normal slit lamp findings? as no doctor told me that i have corneal abrasion causing pain like symptoms. but they did give me lubricating drops. Is it that recurrent corneal erosion presents with normal eye exams? and treatment is based on symptoms being experienced by patient.

[John C Hagan III, MD, FACS, FAAO]

Recurrent cornea erosions can be very easy or very difficult to see on slit lamp exam. Especially if the eye doctor is looking at the cornea after drops have been put in. Treatment is often based on  history. If patient tells me they go to sleep and wake up in the night or in the morning with pain in the eye then I treat for RCE even if I don't see evidence on slit lamp