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1.75 diopters astigmatism after routine cataract surgery???
A week ago I had a cataract removed from my left eye by phacoemulsification and an Acrysof SA60AT IOL inserted. I am 50 years old an in good health, other than the cataract. Both of my eyes were around 5 diopters nearsighted, and the Dr. was aiming for 2.5 Diopters after surgery so that the difference in image size between the two eyes wouldn't be too great to allow me to wear glasses. That isn't how it turned out though - it was "clear" from the moment the bandage came off that there is now a lot of astigmatism in that eye, with the first focal plane (lines close to horizontal in focus) at 33cm and the second coming into focus at around 66 cm (for lines close to vertical), and for long extended lines, staying in focus out to at least a hundred meters. This has not changed a bit in the last week. I asked the Dr. to give me a lens prescription for that eye, and it now has a sphere of 0.5 Diopters (nearsighted) with 1.75 Diopters astigmatism. There had been a little bit of astigmatism in that eye before surgery, but on a very different axis (130 degree rotation of the axis).
The Dr. says there were no complications during surgery, and the IOL is centered and correctly placed. No stitches, no postoperative infection, very little pain the first day and none thereafter. There is no obvious swelling and the eye's pressure is normal.
My question is, what the heck is going on here? Here's hoping the Dr. is right and this is just some temporary swelling and the prescription will go to "what it should be" in a month or two.. However, since in the last week there has been no improvement, or change, at all , I have my doubts. This much astigmatism seems to be very unusual for this type of cataract operation, Anybody else here experienced this? What sort of complication could be causing this?
The simplest explanation that I can come up with is that the wrong IOL was inserted - a toric with the wrong power, but that would mean somebody screwed up very badly, either at the factory or in the operating theater, and the fix for that sort of error is surgery that might well induce as much astigmatism as I have now, even with the right IOL in place.
The Dr. says there were no complications during surgery, and the IOL is centered and correctly placed. No stitches, no postoperative infection, very little pain the first day and none thereafter. There is no obvious swelling and the eye's pressure is normal.
My question is, what the heck is going on here? Here's hoping the Dr. is right and this is just some temporary swelling and the prescription will go to "what it should be" in a month or two.. However, since in the last week there has been no improvement, or change, at all , I have my doubts. This much astigmatism seems to be very unusual for this type of cataract operation, Anybody else here experienced this? What sort of complication could be causing this?
The simplest explanation that I can come up with is that the wrong IOL was inserted - a toric with the wrong power, but that would mean somebody screwed up very badly, either at the factory or in the operating theater, and the fix for that sort of error is surgery that might well induce as much astigmatism as I have now, even with the right IOL in place.
I had cataract surgery on my left eye 2.5 months ago. I had a very minor bit of astigmatism in that eye before the surgery but now it's worse. Last week I saw the surgeon for a pre-op visit before surgery on my right eye, and told her that my optometrist said when I get my new glasses there will be a correction for astigmatism added, which will improve my vision in that eye. I mentioned this to the surgeon last week and she said astigmatism is common after cataract surgery. She said she made the incision above my pupil to help minimize this. No one told me this prior to the surgery. I would like to know if this is common, and why it happens. I am having the cataract on my right eye removed in 2 days. Now I'm nervous that I'll have astigmatism in my right eye too. Was this carelessness on the surgeon's part, or something that can't be avoided?
1 Comments
If anyone sees the above thread: An incision into the cornea creates astigmatism. The smaller the incision the less the astigmatism. So the new small incision (5 mm or <) are much less astigmatism causing then the older large incision, multiple stitch incisions of the 1980's. The incision flattens the cornea in the direction its placed. So if placed along the axis of pre-existing astigmatism there will be LESS after surgery and if placed 90 degree away from the steep axis there will be MORE astigmatism post operative. It is not always possible to place the incision on the steep axis of the cornea. The amount the astigmatism increases or decreases is relatively small usually about plus/minus 0.50 diopters. So more astigmatism post op does not mean the surgeon was careless or made an error.
and what happened at the end?
now I have astigmatism 1 week after the operation, I had non before. is this normal? can't trust my doctor who says it will disappear completely, it hasn't improve in the last few days.
advice please
now I have astigmatism 1 week after the operation, I had non before. is this normal? can't trust my doctor who says it will disappear completely, it hasn't improve in the last few days.
advice please
2 Comments
It eventually settled down to a regular astigmatism of 0.75D on a 145 degree axis. That eye corrects pretty well with a lens.
Later I had the right eye done (by the "go to" guy), again with a scleral incision, and it came out with 1D astigmatism on a 178 degree axis, and it didn't change a bit from right after surgery until today (5 years later). Unfortunately 1D doesn't really describe the optics in that eye, the astigmatism is mostly irregular, and the best correcting prescription is actually worse than nothing at all.
Later I had the right eye done (by the "go to" guy), again with a scleral incision, and it came out with 1D astigmatism on a 178 degree axis, and it didn't change a bit from right after surgery until today (5 years later). Unfortunately 1D doesn't really describe the optics in that eye, the astigmatism is mostly irregular, and the best correcting prescription is actually worse than nothing at all.
If the astigmatism you have is irregular corneal astigmatism and glasses do not correct it satisfactorily you can try contacts (soft, soft toric or gas permeable) or see if the irregular astigmatism can be corrected to regular astigmatism or a regular spherical shape with the femtosecond laser.
and what happened at the end?
now I have astigmatism 1 week after the operation, I had non before. is this normal? can't trust my doctor who says it will disappear completely, it hasn't improve in the last few days.
advice please
now I have astigmatism 1 week after the operation, I had non before. is this normal? can't trust my doctor who says it will disappear completely, it hasn't improve in the last few days.
advice please
Status update 8 weeks post surgery:
State of the eye. Once the steroid drops were stopped the eye began to heal a little. (That timing may have been coincidental.) Initially the astigmatism made distant point sources show up as a sort of narrow vertical "X", but now it is more of a "\" which pokes out of a round smear. This is actually good, since if everything had gone perfectly the eye would be 2.5D myopic, and the round smear was the expected result. Oddly, on blinking a few times the "\" can evolve one or more bright points of focus, each of which results in an image if I look at something. Some of these images can be sharp enough to read text at 20/20 on a chart. (Not really 20/20 though, because of all the other images.) Also, even without the funky focus tricks I can now read a medium sized font on a computer, or about 12 point font on paper, at the circle of least confusion, which is at around 55 cm. Before this change reading such text was impossible.
Two 2nd opinions have been obtained:
The first was with a well known LA area surgeon. I paid him for the visit, and he has no financial contacts with my health care group at all, so no conflict of interest. He said to wait until the eye stopped changing, which could be a while, and then to correct the residual astigmatism with either Lasik or PRK, to be determined by what the eye looked like at that point. He didn't think further surgery on the eye was a good idea. His best guess was that even though the external scleral incision was only 3 mm, my surgeon had ripped the inside of the sclera to a much larger size. This would be consistent with enough bleeding to make the original surgeon think it should be cauterized. He teaches and so is very cutting edge (excuse the pun) on surgical technique. In his opinion the style of surgical method used on me was state of the art - 20 years ago.
The second 2nd opinion was from the go to guy for the company that contracts out eye care between my primary care and the local (a couple of adjacent cities worth) eye doctors. He agreed that it was necessary for the eye to stop changing before doing anything. He thought at that time a limbal relaxing incision would probably be enough to get the eye down to 0.3 D astigmatism. His take on my surgery was that the first surgeon should never have cauterized the scleral incision because that can change the shape of the eye. As he put it, cauterization is unnecessary because "nobody ever bled to death from the eye". Since this fellow is much closer to my home than the first 2nd opinion, and the visits will be paid for by my health insurance instead of out of pocket, I will monitor the eye at his office. At that point I have to decide who is right about the next step. Or I might just get lucky and it heals all the way back to normal, but my luck has not been great so far.
The cornea scans at both offices show that the figure 8 shaped 42D curvature region on my cornea is now much more asymmetric, with one lobe (that most distant from the incision) nearly back to the same curvature as the rest of the eye. The 45D region outside the figure 8 has relaxed back a bit towards the eye's original nearly uniform curvature of 43D. These changes in the scan explain pretty well the recent changes in my vision, especially the transition from an "X" to a "\ + smear" for a distant point source.
Stay tuned...
State of the eye. Once the steroid drops were stopped the eye began to heal a little. (That timing may have been coincidental.) Initially the astigmatism made distant point sources show up as a sort of narrow vertical "X", but now it is more of a "\" which pokes out of a round smear. This is actually good, since if everything had gone perfectly the eye would be 2.5D myopic, and the round smear was the expected result. Oddly, on blinking a few times the "\" can evolve one or more bright points of focus, each of which results in an image if I look at something. Some of these images can be sharp enough to read text at 20/20 on a chart. (Not really 20/20 though, because of all the other images.) Also, even without the funky focus tricks I can now read a medium sized font on a computer, or about 12 point font on paper, at the circle of least confusion, which is at around 55 cm. Before this change reading such text was impossible.
Two 2nd opinions have been obtained:
The first was with a well known LA area surgeon. I paid him for the visit, and he has no financial contacts with my health care group at all, so no conflict of interest. He said to wait until the eye stopped changing, which could be a while, and then to correct the residual astigmatism with either Lasik or PRK, to be determined by what the eye looked like at that point. He didn't think further surgery on the eye was a good idea. His best guess was that even though the external scleral incision was only 3 mm, my surgeon had ripped the inside of the sclera to a much larger size. This would be consistent with enough bleeding to make the original surgeon think it should be cauterized. He teaches and so is very cutting edge (excuse the pun) on surgical technique. In his opinion the style of surgical method used on me was state of the art - 20 years ago.
The second 2nd opinion was from the go to guy for the company that contracts out eye care between my primary care and the local (a couple of adjacent cities worth) eye doctors. He agreed that it was necessary for the eye to stop changing before doing anything. He thought at that time a limbal relaxing incision would probably be enough to get the eye down to 0.3 D astigmatism. His take on my surgery was that the first surgeon should never have cauterized the scleral incision because that can change the shape of the eye. As he put it, cauterization is unnecessary because "nobody ever bled to death from the eye". Since this fellow is much closer to my home than the first 2nd opinion, and the visits will be paid for by my health insurance instead of out of pocket, I will monitor the eye at his office. At that point I have to decide who is right about the next step. Or I might just get lucky and it heals all the way back to normal, but my luck has not been great so far.
The cornea scans at both offices show that the figure 8 shaped 42D curvature region on my cornea is now much more asymmetric, with one lobe (that most distant from the incision) nearly back to the same curvature as the rest of the eye. The 45D region outside the figure 8 has relaxed back a bit towards the eye's original nearly uniform curvature of 43D. These changes in the scan explain pretty well the recent changes in my vision, especially the transition from an "X" to a "\ + smear" for a distant point source.
Stay tuned...
Six weeks out and no change in the optics of the eye from day 1 post surgery.. It turns out the incision was not corneal as I had thought, but scleral. and pretty much straight up towards the top of my head from the center of the eye. (Obvious once I picked up my eyelid and looked.) No stitches, but the wound was cauterized. There is some irritation there, with a radial segment centered on the incision, and maybe 3 times as wide as it, radiating out from the iris with the blood vessels a bit enlarged, relative to the rest of the eye. The incision doesn't look at all odd itself, with no raised scar or a pucker there, or anything obvious that I can see. A corneal map two weeks ago showed a centered figure 8 shaped patch of 42D curvature, although not quite as symmetric as that sounds, and at the correct angle to account for the more distant focus of the astigmatism. It wasn't there before surgery. The rest of the cornea was 45D curvature, accounting for the nearer focus. (Also what the eye was before surgery.) Today I'm trying to work on my computer using a pair of glasses:
OD 4.25
OS +0.50 -1.75x170
but I can only fuse the two images in regions very close to the optical axis, and it takes a couple of seconds to do so each time after my eyes move around on the screen. Turning my head more than a few degrees is nauseating, as the images appear to rotate at two different rates, That is, as if one eye was rotating more quickly than the other. I don't see glasses like these as being a long term solution.
Second opinion next week.
In the mean time, hypothetically, since we seem to know where the problem area on the cornea is, I wonder if anybody makes custom weighted contact lens with blacked out patches, to cover specific areas of the cornea? If a set of these could mask off the 42D region of my cornea it would block all the rays causing the astigmatism, at the cost of losing maybe 30% of the incoming light. I suspect it would be a lot better visually than things are now. Obviously the first choice would be to set the cornea back to its original shape somehow, but if that isn't possible for some reason...
OD 4.25
OS +0.50 -1.75x170
but I can only fuse the two images in regions very close to the optical axis, and it takes a couple of seconds to do so each time after my eyes move around on the screen. Turning my head more than a few degrees is nauseating, as the images appear to rotate at two different rates, That is, as if one eye was rotating more quickly than the other. I don't see glasses like these as being a long term solution.
Second opinion next week.
In the mean time, hypothetically, since we seem to know where the problem area on the cornea is, I wonder if anybody makes custom weighted contact lens with blacked out patches, to cover specific areas of the cornea? If a set of these could mask off the 42D region of my cornea it would block all the rays causing the astigmatism, at the cost of losing maybe 30% of the incoming light. I suspect it would be a lot better visually than things are now. Obviously the first choice would be to set the cornea back to its original shape somehow, but if that isn't possible for some reason...
A bit over two weeks post surgery now and optically nothing has changed at all. Not only does it look the same through that eye, but the the two astigmatic focal planes are at exactly the same distances and the axis is unchanged. For the Dr.'s, how common is this sort of complication, and what time constraints should I be aware of in addressing it???
Thanks.
Thanks.
The incision was on the side of the cornea nearest the ear, but I cannot tell you what orientation the cut was, nor where it fell on the ray from the edge of the cornea to the center of the eye. It didn't need stitches, so it must have been small. There was only ever very slight irritation, and I could never see the wound in the mirror.
They have not yet remeasured the shape of my cornea.
I know the SA60AT isn't a toric and the prescription is far from the target value. That's why I am trying to find out how unusual it is to be this far off, since lens mix ups do happen, and implantation of the wrong lens could immediately account for both discrepancies.
What is a reasonable expectation for the time course of this to resolve, or at least to show some changes, if the aberrations are surgically induced?
They have not yet remeasured the shape of my cornea.
I know the SA60AT isn't a toric and the prescription is far from the target value. That's why I am trying to find out how unusual it is to be this far off, since lens mix ups do happen, and implantation of the wrong lens could immediately account for both discrepancies.
What is a reasonable expectation for the time course of this to resolve, or at least to show some changes, if the aberrations are surgically induced?
MEDICAL PROFESSIONAL
This is early. It will probably change. I need more details on the incision location and pre and post operative keratometry. This will allow me to determine if this was very unusual.
Also, SA60AT is not a Toric IOL. Alcon Toric IOLs are SN60T(3,4, or5) and SN6AT(3,4, or 5).
If the rx is -.50 -1.75 then the spherical equivalent is -1.36, NOT 2.5
Dr. O.
Dr. O.
Also, SA60AT is not a Toric IOL. Alcon Toric IOLs are SN60T(3,4, or5) and SN6AT(3,4, or 5).
If the rx is -.50 -1.75 then the spherical equivalent is -1.36, NOT 2.5
Dr. O.
Dr. O.
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