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Cataract surgery questions after consult
Hello to all, at consultation yesterday for cataract in RE only, surgeon advised standard monofocal set to intermediate, target post op refractive error of -1.50 to balance dominant LE astigmatism of -2.75. Astigmatism correction WITH GLASSES. Dr. said "Leave LE alone, why do it if it doesn't need it", etc. Indeed, I see 20/20 in LE, corrected.
I am dissatisfied but now fairly close to being resigned to this solution, for reasons I will get to shortly. Dissatisfied because it has been a very long-held dream of mine to be glasses-free or as close to that as possible. I have many reasons for this, but they all reduce to my feeling that I am a much, MUCH better person when I take them off. (Except for not being able to see too well of course).
I had hopes of cataract surgery being a great boon instead of a life-stopping problem, the cataract resulting from a RE vitrectomy (macula-off RD) done October of 2022. After finding this site and educating myself about my new challenge, it dawned on me that this 'problem' was actually an opportunity to be free of glasses! I finally figured that I could get toric lenses in both eyes, set them for mini-monovision (distance and near combination I think it is), and then just have to wear readers perhaps for extended reading. End of problem! Dr. Hagan endorsed! I still harbor that hope.
The following (I admit are) cogent reasons for my being close to resigned to my surgeon's solution:
1. Dr. Hagan's stricture of "PROTECT THE EYE WITHOUT THE RD". Risk of RD in (my) other eye "extreme". (I looked for this post, to get its DATE, but could not find it again).
2. My surgeon's seemingly sound advice to not do anything with my left, good eye.
3. Being unconvinced by the advice of a "VERY knowledgeable" tech (who also participated in my consult) (this accolade from the surgeon himself), who advised "With modern techniques there is not as much concern about having an RD in one's other eye as there used to be".
4. Being also unconvinced of this same tech advising that my blepharitis (NOT a diagnosis, just a term I selected to describe a recurring "gunk in eyes" problem I have) was not something to worry about should I desire to go with toric lenses. (I was worried my constant, multiple-times-every-day digging into my eyes to clear them might cause my lenses to go out of alignment).
5. A simple procedure, low complication risk.
I would like to hear this most intelligent and helpful forum's thoughts: Should I take my resignation and dissatisfied thoughts and live with them, laying aside my life-long dream of being (mostly) glasses-free, settling for limited potential? Do you think the surgeon's solution is best? Is he and Dr. Hagan right or is this outdated advice? Would it be a bad idea to implement my solution and try to be "the best that I can be?" I understand my last question can possibly be answered with an "Only you can decide that"- type answer. What I would like to hear about is my best MEDICAL course of action. Including other options.
I have surgery scheduled for 9/21. All replies appreciated, thank you very much in advance.
I am dissatisfied but now fairly close to being resigned to this solution, for reasons I will get to shortly. Dissatisfied because it has been a very long-held dream of mine to be glasses-free or as close to that as possible. I have many reasons for this, but they all reduce to my feeling that I am a much, MUCH better person when I take them off. (Except for not being able to see too well of course).
I had hopes of cataract surgery being a great boon instead of a life-stopping problem, the cataract resulting from a RE vitrectomy (macula-off RD) done October of 2022. After finding this site and educating myself about my new challenge, it dawned on me that this 'problem' was actually an opportunity to be free of glasses! I finally figured that I could get toric lenses in both eyes, set them for mini-monovision (distance and near combination I think it is), and then just have to wear readers perhaps for extended reading. End of problem! Dr. Hagan endorsed! I still harbor that hope.
The following (I admit are) cogent reasons for my being close to resigned to my surgeon's solution:
1. Dr. Hagan's stricture of "PROTECT THE EYE WITHOUT THE RD". Risk of RD in (my) other eye "extreme". (I looked for this post, to get its DATE, but could not find it again).
2. My surgeon's seemingly sound advice to not do anything with my left, good eye.
3. Being unconvinced by the advice of a "VERY knowledgeable" tech (who also participated in my consult) (this accolade from the surgeon himself), who advised "With modern techniques there is not as much concern about having an RD in one's other eye as there used to be".
4. Being also unconvinced of this same tech advising that my blepharitis (NOT a diagnosis, just a term I selected to describe a recurring "gunk in eyes" problem I have) was not something to worry about should I desire to go with toric lenses. (I was worried my constant, multiple-times-every-day digging into my eyes to clear them might cause my lenses to go out of alignment).
5. A simple procedure, low complication risk.
I would like to hear this most intelligent and helpful forum's thoughts: Should I take my resignation and dissatisfied thoughts and live with them, laying aside my life-long dream of being (mostly) glasses-free, settling for limited potential? Do you think the surgeon's solution is best? Is he and Dr. Hagan right or is this outdated advice? Would it be a bad idea to implement my solution and try to be "the best that I can be?" I understand my last question can possibly be answered with an "Only you can decide that"- type answer. What I would like to hear about is my best MEDICAL course of action. Including other options.
I have surgery scheduled for 9/21. All replies appreciated, thank you very much in advance.
The most important information missing is your current age, and from that how long you potentially could go with an IOL in one eye and not the other. I would not do a IOL in a perfectly good eye either unless I had to. You also do not mention your sphere refraction in the good eye. This said there are ways to work around a mismatch between the eyes. I would not compromise the eye that needs cataract surgery just to match it with the other eye with poor vision. If there is a big mismatch then it probably is not a great solution to do one, not the other, and correct with eyeglasses. It is much better to correct the other eye with contact lenses. They sit much closer to the lens and do not have the issues with a large correction in one eye, and not the other.
Just my initial thoughts. What is your age and sphere refraction in the good eye?
Just my initial thoughts. What is your age and sphere refraction in the good eye?
15 Comments
Thx for replying, and also suggesting an alternate solution. I am 68. See below reply to Dr. H for my current Rx. LE sphere is +0.25, slightly farsighted.
Not operating on my good eye seemed sound advice to me as well.
My surgeon is advocating for IOL in just one eye. I asked him if he could give me an estimate of when my good LE (with 'noticeable' cataracts my retina surgeon said, but nothing that needs to be addressed now) cataracts would need to be addressed but he could not tell me other than to say it could be 1 year or 10 years.
You wrote "If there is a big mismatch then it probably is not a great solution to do one, not the other, and correct with eyeglasses." This is the solution he is prescribing. As I understand it, he will target -1.50 cylinder in RE to balance with present LE cylinder of -2.75. For him this solution is viable until the LE becomes a problem. For me, not considering the fact that overall I regard this as a subpar solution (see original post), this is OK too. I should add that my surgeon is considered by my retina dr. as probably the #1 dr. in the ENTIRE U.S. for number of cat surgeries performed. He is EXTREMELY experienced.
You mentioned contacts. I do not get along well with them. I tried them MANY yrs ago and decided NO. Perhaps now I could adapt to them better. I will not rule them out completely: never say never I guess.
It is indeed curious that my surgeon did not suggest to me your solution. He IS 'compromising my bad eye to make it balance my good eye'. So your solution would be to correct RE to plano with toric lens and wear a toric contact in LE to correct to say, -1.50??
As I said your spherical equivalent in both eyes is currently about -1.3 D. If you correct your cataract eye to plano you have very close to mini-monovision with potentially no need for eyeglasses. You may find vision quite acceptable with no need for a contact in the non operated eye. At 68, the years to needing cataract surgery in the other eye are likely numbered. If it were me, I would get a toric in the cataract eye to bring the cylinder as close as possible to zero, and on a spherical equivalent basis target -0.25 D. This should give you 20/20 or better. Your other eye should be good enough to let you read. And, you should be able to test that now by attempting to read with that eye only and without glasses.
Oh, and the differential between the eyes is not large. If necessary you could get prescription glass lenses for both eyes and use glasses until it is time for cataract surgery in the second eye. Then target -1.5 D in that eye with a toric to give you the reading vision.
You wrote, "Your other eye should be good enough to let you read. And, you should be able to test that now by attempting to read with that eye only and without glasses."
I tested it (LE): First, at laptop distance (20"), VERY difficult, and Second, at book-reading distance (10"), fuzzy but doable. And actually slightly better if I uncover my bad eye. You do understand I have significant astigmatism, correct? I like your idea and mini-monovision in general and I might run it by my cat surgeon, but ...my results with your test do not seem promising.
And could you show me how SE is calculated. Using my RX, would it be +0.25 + (-3.00/2) = -1.25D ?
I tested it (LE): First, at laptop distance (20"), VERY difficult, and Second, at book-reading distance (10"), fuzzy but doable. And actually slightly better if I uncover my bad eye. You do understand I have significant astigmatism, correct? I like your idea and mini-monovision in general and I might run it by my cat surgeon, but ...my results with your test do not seem promising.
And could you show me how SE is calculated. Using my RX, would it be +0.25 + (-3.00/2) = -1.25D ?
Yes, spherical equivalent is the sphere plus 50% of the cylinder respecting the signs. In your example -1.25 SE would be correct. The issue is that astigmatism is not the ideal way to get reading ability. It kind of works, but is no where near as good as getting -1.25 purely with sphere. It is kind of a poor man's EDOF, but with issues. For example my current refraction in my near eye for mini-monovision is -1.25 sphere, and -0.75 D cylinder. SE is about -1.60 D. I can read very well (J1 in good light), but I am sure it would be better if I had -1.50 D with pure sphere.
So I think with your less than good reading it would be necessary to use a contact to correct the cylinder and sphere to bring you as close as possible to a true -1.50 D. You should be able to simulate that now with a contact in your better eye.
So I think with your less than good reading it would be necessary to use a contact to correct the cylinder and sphere to bring you as close as possible to a true -1.50 D. You should be able to simulate that now with a contact in your better eye.
Thanks for that.
You also wrote, in an earlier post, "Oh, and the differential between the eyes is not large. If necessary you could get prescription glass lenses for both eyes and use glasses until it is time for cataract surgery in the second eye. Then target -1.5 D in that eye with a toric to give you the reading vision."
As I mentioned, contacts are my least favored alternative, even less than wearing glasses. With your statement here you are referencing RE "to bring the cylinder as close as possible to zero", then as I understand it, comparing this with your calc of both eyes SE of -1.30 (your 'differential'). THEN you say I could get 'prescription glass lenses' etc. THAT would be much preferred, I could see doing that if my ultimate outcome should I need cat surgery for the LE (which is not guaranteed but will probably happen I would say) would be mini-monovision with possibly only a slight need for glasses. Am I reading you right? Please also keep in mind that all this discussion should be with the understanding that I am highly likely to have some distorted vision in the end anyway after any and all "solutions" due to my RD and the consequences therefrom, perhaps to a degree that would affect offered advice.
Appreciate your time.
You also wrote, in an earlier post, "Oh, and the differential between the eyes is not large. If necessary you could get prescription glass lenses for both eyes and use glasses until it is time for cataract surgery in the second eye. Then target -1.5 D in that eye with a toric to give you the reading vision."
As I mentioned, contacts are my least favored alternative, even less than wearing glasses. With your statement here you are referencing RE "to bring the cylinder as close as possible to zero", then as I understand it, comparing this with your calc of both eyes SE of -1.30 (your 'differential'). THEN you say I could get 'prescription glass lenses' etc. THAT would be much preferred, I could see doing that if my ultimate outcome should I need cat surgery for the LE (which is not guaranteed but will probably happen I would say) would be mini-monovision with possibly only a slight need for glasses. Am I reading you right? Please also keep in mind that all this discussion should be with the understanding that I am highly likely to have some distorted vision in the end anyway after any and all "solutions" due to my RD and the consequences therefrom, perhaps to a degree that would affect offered advice.
Appreciate your time.
The suggestions I have given you are not considering any other vision impairment from your RD. You would have to overlay that issue with the strategy for each eye.
On the use of glasses to correct vision after cataract surgery and before the second eye is done, I would expect there to be no significant issue based on my experience. I went 18 months with my cataract eye corrected to -0.25 D SE, and the other eye more like -3.0 D SE. While a contact in the non operated eye felt better from a vision point of view, glasses with the correct prescription for both eyes also worked. You will have a lower differential than I had.
I emailed a description of what you had done with your eyes to my cat surgeon. He does not think this is a good idea with my mac-off RD. I have canceled my upcoming 9/21 surgery and got scheduled for another consult on 9/27 to discuss my situation further. But did you have an RD?
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AbqDon: First of all you gave "spherical power" not astigmatism. To answer you question need you full glasses RX in each eye plus or minus sphere, plus or minus cylinder power and axis. Then best corrected visual acuity. Did your RE recover 20/20 after the macula off RD repaired? It is not possible to give you the best answer without this information.
The information about RD risk in the fellow eye is BOGUS. Once surgeons switched from intra-capsular (take entire lens out) to planned extracapsular ECCE (early 1980's tje risk of RD went down dramatically. However with change from ECCE to small incision Phaco it did not change much at all. RD are more common in eyes have complications at the time of surgery mainly vitreous loss, and that has slowly declined. But the risk of RD post cataract surgry has been the same for the past 30-40 years and the risk of RD in fellow eye remains very high compaired to the general population.
So post that information I requested.
One other thing, this forum is FULL of people that wished they had not rushed into surgery without understanding all the options, all the risks. You might want to reconsider surgery in 9 days and consider getting a independent 2nd opnion (not from another member of the surgeon's group). I have posted here that the state of the art for IOLs right now is the light adjusted lens. As a matter of information, you should inquire of your surgeon it he/she does LAL. There is a consistent tendency of surgeons to push IOLs they use and discount other that they have not or don't know how to use. I would make sure your second opinon does light adjusted lens. If I were having cataract surgery now (which I'm not) I would chose LAL without any hesitation.
The information about RD risk in the fellow eye is BOGUS. Once surgeons switched from intra-capsular (take entire lens out) to planned extracapsular ECCE (early 1980's tje risk of RD went down dramatically. However with change from ECCE to small incision Phaco it did not change much at all. RD are more common in eyes have complications at the time of surgery mainly vitreous loss, and that has slowly declined. But the risk of RD post cataract surgry has been the same for the past 30-40 years and the risk of RD in fellow eye remains very high compaired to the general population.
So post that information I requested.
One other thing, this forum is FULL of people that wished they had not rushed into surgery without understanding all the options, all the risks. You might want to reconsider surgery in 9 days and consider getting a independent 2nd opnion (not from another member of the surgeon's group). I have posted here that the state of the art for IOLs right now is the light adjusted lens. As a matter of information, you should inquire of your surgeon it he/she does LAL. There is a consistent tendency of surgeons to push IOLs they use and discount other that they have not or don't know how to use. I would make sure your second opinon does light adjusted lens. If I were having cataract surgery now (which I'm not) I would chose LAL without any hesitation.
37 Comments
Dr. Hagan: Thank you for your reply
4/1/2022 optometrist Rx (PRE RD)
OD Sphere +0.25 Cylinder -2.75 Axis 085 Add +2.25 (Wear as needed)
OS " +0.25 " -2.75 " 095 " +2.25 " " "
At the consult my surgeon said I was now -3.00 in RE (I would think that would be 'cylinder'). That is the latest Rx info I have as I was not told of my vision numbers when I next saw my retina surgeon (February 2023) after the gas bubble disappeared (January 2023), I just had the cataract! Do I need to find out my present "numbers" in my RE? As I mentioned I am 20/20, corrected, in my LE. Is 'visual acuity' a composite of both eyes or a separate number for each eye?
Regarding RD risk: If I understand you correctly you are saying RD risk in my left, un-operated eye is significant and should not be minimized, is that right?
I DID ask the practice and the surgeon I chose if they did LALs: I was most disappointed to hear that they do not. I think there is only one dr. who does them in my area.
4/1/2022 optometrist Rx (PRE RD)
OD Sphere +0.25 Cylinder -2.75 Axis 085 Add +2.25 (Wear as needed)
OS " +0.25 " -2.75 " 095 " +2.25 " " "
At the consult my surgeon said I was now -3.00 in RE (I would think that would be 'cylinder'). That is the latest Rx info I have as I was not told of my vision numbers when I next saw my retina surgeon (February 2023) after the gas bubble disappeared (January 2023), I just had the cataract! Do I need to find out my present "numbers" in my RE? As I mentioned I am 20/20, corrected, in my LE. Is 'visual acuity' a composite of both eyes or a separate number for each eye?
Regarding RD risk: If I understand you correctly you are saying RD risk in my left, un-operated eye is significant and should not be minimized, is that right?
I DID ask the practice and the surgeon I chose if they did LALs: I was most disappointed to hear that they do not. I think there is only one dr. who does them in my area.
In the scheme of things that is not a very strong eyeglass prescription. On a spherical equivalent basis (sphere + 50% of cylinder) you are at about -1.3 D in both eyes. If you correct your right eye to distance with a toric lens to correct most of the astigmatism you will be left with one plano eye and the other eye at -1.3 SE. That is pretty close to what would be ideal for mini-monovision. The only issue is that most of that myopia in the near eye will be coming from cylinder which is not ideal. You could correct the cylinder with a toric contact and adjust the sphere to -1.5 D for a better simulation.
Also with a differential between the eyes that low, you could also get eyeglasses that would correct both eyes. The small differential should not be a problem at all. And if your long term objective is to be eyeglasses free, it would be a mistake to pass on the opportunity to bring this eye with the cataract back to plano.
Also with a differential between the eyes that low, you could also get eyeglasses that would correct both eyes. The small differential should not be a problem at all. And if your long term objective is to be eyeglasses free, it would be a mistake to pass on the opportunity to bring this eye with the cataract back to plano.
You are missing some very crucial information. You give the glasses RX and LE vision of 20/20 but you do not give the best corrected vision post RD repair. There is a very ligh likely hood that even if the macula was re-attached that it did not or will not achieve 20/20 vision. SO WHAT IS THE BEST POST RD VISION IN RE?
The risk of RD in you LE is substantial and increases significantly post cataract surgery, true of both eyes. Higher risk is likely the LE that has not had RD surgery.
As to the number of cataract surgeries done, quantity is not quality. As of September 2023 any cataract surgery that does not do, or offer to refer a patient to a surgeon that does LAL is not state of the art and science of surgery. That doesn't mean everyone needs a LAL, but for people that wish to be as glasses independent as possible is the method most likely to achieve the very high expectations you have.
That is about all I have to say.
The risk of RD in you LE is substantial and increases significantly post cataract surgery, true of both eyes. Higher risk is likely the LE that has not had RD surgery.
As to the number of cataract surgeries done, quantity is not quality. As of September 2023 any cataract surgery that does not do, or offer to refer a patient to a surgeon that does LAL is not state of the art and science of surgery. That doesn't mean everyone needs a LAL, but for people that wish to be as glasses independent as possible is the method most likely to achieve the very high expectations you have.
That is about all I have to say.
Thank you very much for responding sir.
So I guess I need to hie myself over to my optom stat to get that current RE vision. Why was I not told this??
I will provide what you request as soon as I can. But I am wondering how any measure of my RE vision WITH A CATARACT IN IT is relevant, I mean it is going to be ridiculously bad, right? Although I CAN see with my RE if I turn my head, almost to the point of equivalence with my LE. My retina surgeon said I was looking beyond the cataract.
I HAVE been made aware that there is a high likelihood of less than previous vision due to macula off. That much my various dr's have told me.
So I guess I need to hie myself over to my optom stat to get that current RE vision. Why was I not told this??
I will provide what you request as soon as I can. But I am wondering how any measure of my RE vision WITH A CATARACT IN IT is relevant, I mean it is going to be ridiculously bad, right? Although I CAN see with my RE if I turn my head, almost to the point of equivalence with my LE. My retina surgeon said I was looking beyond the cataract.
I HAVE been made aware that there is a high likelihood of less than previous vision due to macula off. That much my various dr's have told me.
The vision in the RE immediately prior to the mac off RD surgery would be important and a refraction done maybe 2-3 months post surgery, before the cataract developed and started to grow would give the most information about potential vision. Many people have cataracts and can see 20/20, millions in fact. Think of it like a dirty windown, can be a film that barely causes any problem to one so dirty can't see anything through it.
The RX I gave above from 4/2022 would be the closest to "immediately prior to the mac off RD surgery" (done 10/2022). My retina surgeon informed me in Feb of 2023 (4 mos. post RD surgery) my RE visual acuity was 20/70. This was confirmed at my recent consult with my prospective cataract surgeon when I asked for my 'best corrected vision in RE'.
ADDENDUM: I accessed the following info on my Retinal Surgeon 'pt. portal':
FEB 2023 exam:
OD 20/70 -1
PH: 20/60 -2
OD lens: central vacuoles, 2+ nuclear sclerosis, and posterior subcapsular present
OS 20/30 -1
OS lens: 2+ nuclear sclerosis
AUG 2023 exam:
OD 20/100 -1
PH: 20/60 -2
OD lens: central vacuoles, 3+ nuclear sclerosis, and posterior subcapsular present
OS 20/20 -1
OS lens: 2+ nuclear sclerosis + trace posterior subcapsular
FEB 2023 exam:
OD 20/70 -1
PH: 20/60 -2
OD lens: central vacuoles, 2+ nuclear sclerosis, and posterior subcapsular present
OS 20/30 -1
OS lens: 2+ nuclear sclerosis
AUG 2023 exam:
OD 20/100 -1
PH: 20/60 -2
OD lens: central vacuoles, 3+ nuclear sclerosis, and posterior subcapsular present
OS 20/20 -1
OS lens: 2+ nuclear sclerosis + trace posterior subcapsular
Well those are heavy duty cataracts especially the PSC. Not much useful information there. Also the mac off RD often cannot predict post op vision with the macular OCT because the damage is done at the cellular/neuronal level. Given your history, the level of vision post cataract/IOL surgery is uncertain.
Does this mean I should act conservatively? For instance doing as my cataract surgeon advises (standard monofocal RE IOL set to intermediate, continue nearsighted, leave LE alone, correct astig with glasses)? What is your opinion of Ron_AKA's mini-monovision suggestion, is that feasible? Would an LAL consult still be a consideration?
After canceling my 9/21 surgery, getting a 3rd consult, and additional back and forth, my cat surgeon and I have decided a good solution to my problem would be to implant a RE monofocal, set to 'near" (approximately -2.00), to balance with the -2.75 in my LE. This will approximate how I am now, nearsighted, wearing glasses to correct astigmatism. He likes this solution for me, thinking I should be able to read w/o glasses and to have some near vision additionally. Then wearing specs for distance (and intermediate), I do that now, so I am ok with it too. (I must tell, however, that this was MY idea, not his; initially he wanted to do a 'distance' IOL, which subsequently I had changed to an 'intermediate 'one, and only lastly [another brainstorm I had] to a 'near' one).
Each of the 3 times I saw him when I proposed alternate solutions (in search of as much glasses independence as I could get) he said the same things: "You won't be happy", "Your vision will have a poor chance of being balanced", and finally at the last consult telling me he "would not be comfortable" doing what I was thinking of doing, which was implementing Ron_AKA's idea of targeting plano in RE and wearing glasses to correct the remaining 1.3D SE of my LE.
In retrospect now I view him and his advice as more than a bit hidebound. However, I have had enough of this problem and I want to get back to LIVING. His solution promises this soon, as contrasted with another 2-month cycle of getting another opinion and another surgery scheduled with the ONLY Dr. in my area who does LAL's, and about whom I have heard not-too-good things from a friend who had his surgery with him. In addition, and not only because time is of great importance to me, I have decided to accept wearing glasses because in the past they have served to save my eyes from injury, which I seem to be susceptible to. No, this is not an ideal solution, as I have written earlier, but I have had enough of this challenge, I have lost a full year and counting of my life, of which perhaps not a tremendous amount remains, and I have decided to take a route that is perhaps not optimal from an vision standpoint but potentially satisfies other goals I have. I am at the 'tradeoff' point. I think I am making a good decision. Hopefully things will work out well.
Thanks again to all who have responded. My surgery is scheduled for Nov. 2. Should I need additional advice I will not hesitate to post to this excellent resource.
Each of the 3 times I saw him when I proposed alternate solutions (in search of as much glasses independence as I could get) he said the same things: "You won't be happy", "Your vision will have a poor chance of being balanced", and finally at the last consult telling me he "would not be comfortable" doing what I was thinking of doing, which was implementing Ron_AKA's idea of targeting plano in RE and wearing glasses to correct the remaining 1.3D SE of my LE.
In retrospect now I view him and his advice as more than a bit hidebound. However, I have had enough of this problem and I want to get back to LIVING. His solution promises this soon, as contrasted with another 2-month cycle of getting another opinion and another surgery scheduled with the ONLY Dr. in my area who does LAL's, and about whom I have heard not-too-good things from a friend who had his surgery with him. In addition, and not only because time is of great importance to me, I have decided to accept wearing glasses because in the past they have served to save my eyes from injury, which I seem to be susceptible to. No, this is not an ideal solution, as I have written earlier, but I have had enough of this challenge, I have lost a full year and counting of my life, of which perhaps not a tremendous amount remains, and I have decided to take a route that is perhaps not optimal from an vision standpoint but potentially satisfies other goals I have. I am at the 'tradeoff' point. I think I am making a good decision. Hopefully things will work out well.
Thanks again to all who have responded. My surgery is scheduled for Nov. 2. Should I need additional advice I will not hesitate to post to this excellent resource.
Best of luck.
Best of luck in your upcoming cataract surgery, as Dr. Hagan posted. You’re having done almost exactly as I did, and I’ve never second-guessed my decision or that of my cataract surgeon after what is now been 6 1/2 years.
At the end of the day you have to go with what your are comfortable with. With all the IOL variations available and targeting strategies the combinations are almost limitless. Good luck with your outcomes.
I am posting again because I have another question.
I am now 19 days post-cataract surgery. Surgeon comes to me immediately afterwards and says I'm probably going to need a YAG. Tech at 1-day post-op said things look very good and that maybe I would NOT need one. I said NOTHING HAS CHANGED, it's like I had no IOL inserted at all, vision still impaired. He says we are going to monitor you for the next while, saying "sometimes the body will heal the scarring you have on its own". I return in 7 days; tech says "OMG, your IOP is 39! We've got to get you to our pressure specialist!" Pressure specialist prescribes Dorzolamide and Brimonidine drops, after advising increased IOP possibly a negative prednisolone reaction. Return a week later, IOP down to 19. Breathe BIG sigh of relief. Pressure guy examines me and says continue on drops AND prednisolone taper for next 3 weeks to see if IOP stabilizes. Says I have a 2 PSC. This is where I'm at now. Body apparently not healing it.
My question concerns the YAG, which I have tentatively scheduled for 12.11.23. My tech/clinician told me "the final arbiter of your vision is going to be the condition/shape/ability of your retina" (having had a detachment). When I saw him at my 1-week post-op appt. I first was examined by an intake person who ran me through some basic vision tests. This was extremely frustrating as everything was changing faster than I could focus on it, I could hardly make anything out. I found out from the clinician later this was due (he said) to the removal of the DENSE lens cataract allowing the functioning of the retina to be seen to its full (and not very good!) resolving ability.
So the question is do I even need a YAG. What good will it do me to get more light to the retina when this person seems to be telling me (not in so many words) that it is already messed up beyond repair? And WHY would they be recommending I have this procedure? What do I not understand? Certainly I hope I'm missing something as maybe then there would be some kind of hope for me, but I cannot see what that is. Perhaps a communication problem. I mean I hope I might be able to benefit from a YAG, and I'll probably go ahead and have it done, I just do not understand how it could make any difference.
Are things as bad as I think they are? How is a YAG going to fix my retina? Advice going forward?
I am now 19 days post-cataract surgery. Surgeon comes to me immediately afterwards and says I'm probably going to need a YAG. Tech at 1-day post-op said things look very good and that maybe I would NOT need one. I said NOTHING HAS CHANGED, it's like I had no IOL inserted at all, vision still impaired. He says we are going to monitor you for the next while, saying "sometimes the body will heal the scarring you have on its own". I return in 7 days; tech says "OMG, your IOP is 39! We've got to get you to our pressure specialist!" Pressure specialist prescribes Dorzolamide and Brimonidine drops, after advising increased IOP possibly a negative prednisolone reaction. Return a week later, IOP down to 19. Breathe BIG sigh of relief. Pressure guy examines me and says continue on drops AND prednisolone taper for next 3 weeks to see if IOP stabilizes. Says I have a 2 PSC. This is where I'm at now. Body apparently not healing it.
My question concerns the YAG, which I have tentatively scheduled for 12.11.23. My tech/clinician told me "the final arbiter of your vision is going to be the condition/shape/ability of your retina" (having had a detachment). When I saw him at my 1-week post-op appt. I first was examined by an intake person who ran me through some basic vision tests. This was extremely frustrating as everything was changing faster than I could focus on it, I could hardly make anything out. I found out from the clinician later this was due (he said) to the removal of the DENSE lens cataract allowing the functioning of the retina to be seen to its full (and not very good!) resolving ability.
So the question is do I even need a YAG. What good will it do me to get more light to the retina when this person seems to be telling me (not in so many words) that it is already messed up beyond repair? And WHY would they be recommending I have this procedure? What do I not understand? Certainly I hope I'm missing something as maybe then there would be some kind of hope for me, but I cannot see what that is. Perhaps a communication problem. I mean I hope I might be able to benefit from a YAG, and I'll probably go ahead and have it done, I just do not understand how it could make any difference.
Are things as bad as I think they are? How is a YAG going to fix my retina? Advice going forward?
With your damaged retina it is important to treat all the other parts of the eye and visual process that can be treated. Of all patients with normal eyes having cataract/IOL surgery about 10% will need YAG due to the posterior capsule of the natural lens turning cloudy. That capsule is left it place as it holds the IOL in place. The younger the patient the more likely YAG is necessary. Children have cataract surgery (it happens) turn cloudy so fast at the time of surgery them make a hold in the posteriod capsule (like the YAG Does) In some cases, expecially wity a posterior subcapsular cataract (PSC) the capsule is cloudy alreay when the cataract is removed and the IOL put in. In this instance YAG is done usually 3-8 weeks post op when the eye is quieted down. Know that Yag can raise the IOP so additional meds may be necessary. It sounds like you are a 'steroid responder" and your IOP us because of the steroid drops used post op. Some steroid drops are less likely to raise the IOP lotemzx and durezol. If your posterior capsule is still quite cloudy there is a good expectation that post YAG you will notice considerable improvement. Good luck
I think some cataract surgeons over-medicate with eye drops. The surgeon I had uses a minimal drops name brand, not generic drops, regime. There were no drops prescribed before the surgery, and after Vigamox 4 times a day for 7 days, and Durezol once a day for 21 days. Drops are not taken until they are all gone. You stop at the prescribed time and throw out what is remaining. With this minimal regime I had no issues with infection or high pressure.
Thank you Dr. Hagan for your response, the nature of it especially, I was afraid I was going to hear some very bad news.
I will go ahead with the yag. The tech told me not to expect a "WOW"- type result; I have interpreted that to mean I should not expect to get all my vision back. This I have understood from the start, so that was not the shock I at first thought it was. My expectation throughout this experience has been that I might get most of it back, which would be a BIG improvement from where I am now, and satisfactory enough.
I will go ahead with the yag. The tech told me not to expect a "WOW"- type result; I have interpreted that to mean I should not expect to get all my vision back. This I have understood from the start, so that was not the shock I at first thought it was. My expectation throughout this experience has been that I might get most of it back, which would be a BIG improvement from where I am now, and satisfactory enough.
Good luck, Happy Thanksgiving and do come back and post post Yag
Hello to the forum again. I had YAG surgery Dec. 11th. Results not as good as I had hoped, impaired right eye vision is only a little better. Additionally, my "pressure" guy (another MD, not one of the two surgeons) is concerned I may have or am getting glaucoma. I have been on glaucoma drops since I was found with elevated IOP on Nov. 10th. One week later IOP was judged to be 'improved and controlled'. At Dec. 8th appt. IOP in both eyes was 17; advised to stop the Brimonidine (but not the Dorzolamide in RE). On Dec. 11th surgery day IOP was 22 (not sure if measured pre or post-surgery) so I was put back on it. I saw him again on Jan 4th: IOP was 18/19. The "Impression" at this appointment was "Open angle with borderline findings, high risk, bilateral H40.023". I was advised to get a glaucoma workup, him telling me "he would be uneasy telling you to stop the drops until more recent testing has been done". I decided to have him do this testing and made an appt. for March 8th. I also have a 6-mo follow-up appt with my retina surgeon on Feb. 22, during which I will ask if an ERM peel (or anything else) would help my impaired vision, something the pressure dr. suggested.
I have two questions today:
1. Is this Dr's focus on possible glaucoma first a correct course for my situation? I am frustrated, because
A. I am impatient to address my impaired vision problem
B. I am very desirous of getting off the eyedrops
C. this seems to be DELAYING getting a new glasses Rx (which could help with "A")
2. Would a second YAG procedure be an option for me?
TIA for all comments.
I have two questions today:
1. Is this Dr's focus on possible glaucoma first a correct course for my situation? I am frustrated, because
A. I am impatient to address my impaired vision problem
B. I am very desirous of getting off the eyedrops
C. this seems to be DELAYING getting a new glasses Rx (which could help with "A")
2. Would a second YAG procedure be an option for me?
TIA for all comments.
Glaucoma is a potential blinding disease and should be your highest priority. A glaucoma evalation is indicated first. This would involve visual field exam, measurement of corneal thinkness, gonioscopy, NFL OCT and assessment of risk factors such as a positive family history. If you do have glaucoma most physicians recommend laster treatment (selective laser trabeculoplasty or SLT) as initial therapy. Often that is enough and drops don't have to be used. A second Yag would only be indicated if there is still cloudy posterior capsule in the visual axis and that is rare and unlikely.
My March 8th glaucoma eval went well, my remaining impairment not due to a glaucoma-caused blind spot. I was taken off Brimonidine (what a relief) but kept on Dorzolamide until next appt in 2 months when it may be possible to get off drops completely. Dr. advised semi-annual optom visits and annual glaucoma screenings to monitor my IOP, measured at 20 in both eyes at visit.
I was also given a new glasses Rx at this visit:
SPH CYL Axis Add PD
OD -2.25 +1.50 175 +2.50 32
OS -3.00 +3.00 005 +2.50 32
Corrected DVA OD: 20/25 Corrected NVA OD: J1+
Corrected DVA OS: 20/25 Corrected NVA OS: J1+
These numbers are radically different from any previous Rx's I have ever had from optometrists (some previous Rx's were given above). When questioned the Dr. said "optometrists often use different equipment to measure the glasses and the notation is different".
He is optimistic the glasses will help, saying, "We were able to get you to see 20/25 in the right and 20/25 in the left eye". I am not so sure. I find it very hard to believe the blurriness I currently have in my RE can be remedied by glasses. Is it possible he is correct? He also added, "If it doesn't help, then at least we tried". Now there's a helpful reassuring bright-future professional opinion for you!
My Feb. 22nd appt with the retina specialist's office (but not with the Dr. who performed the vitrectomy) produced two suggested options after I got the glaucoma testing done:
1. A "polishing" of the lens, and/or
2. A "peel" of the retina, which the Dr. said showed an approximate 1 mm 'buildup' (in height or depth, I guess) from last August's visit, about which she "somewhat agreed" was responsible for perhaps 20% of my impairment.
This Dr. was of the opinion that a new glasses Rx would help my vision only "some". And also that a second YAG was inadvisable. (No laser can "polish").
So I have two fairly different views. Both using the slit-lamp, the first one said my lens looked clear. The second one recommends "polishing" it, apparently seeing some cloudiness.
Even though I am very doubtful glasses will fix my vision (mostly fix it, that is) I am going to fill the new Rx, see how I can see, then go from there.
I would like to get some comment(s) on my recent visits and these two Dr's ideas. Have I reached the point where ophthalmology becomes more an art than a science?
I was also given a new glasses Rx at this visit:
SPH CYL Axis Add PD
OD -2.25 +1.50 175 +2.50 32
OS -3.00 +3.00 005 +2.50 32
Corrected DVA OD: 20/25 Corrected NVA OD: J1+
Corrected DVA OS: 20/25 Corrected NVA OS: J1+
These numbers are radically different from any previous Rx's I have ever had from optometrists (some previous Rx's were given above). When questioned the Dr. said "optometrists often use different equipment to measure the glasses and the notation is different".
He is optimistic the glasses will help, saying, "We were able to get you to see 20/25 in the right and 20/25 in the left eye". I am not so sure. I find it very hard to believe the blurriness I currently have in my RE can be remedied by glasses. Is it possible he is correct? He also added, "If it doesn't help, then at least we tried". Now there's a helpful reassuring bright-future professional opinion for you!
My Feb. 22nd appt with the retina specialist's office (but not with the Dr. who performed the vitrectomy) produced two suggested options after I got the glaucoma testing done:
1. A "polishing" of the lens, and/or
2. A "peel" of the retina, which the Dr. said showed an approximate 1 mm 'buildup' (in height or depth, I guess) from last August's visit, about which she "somewhat agreed" was responsible for perhaps 20% of my impairment.
This Dr. was of the opinion that a new glasses Rx would help my vision only "some". And also that a second YAG was inadvisable. (No laser can "polish").
So I have two fairly different views. Both using the slit-lamp, the first one said my lens looked clear. The second one recommends "polishing" it, apparently seeing some cloudiness.
Even though I am very doubtful glasses will fix my vision (mostly fix it, that is) I am going to fill the new Rx, see how I can see, then go from there.
I would like to get some comment(s) on my recent visits and these two Dr's ideas. Have I reached the point where ophthalmology becomes more an art than a science?
You were told right about the glasses prescription. Think of it like your weight, looks a whole lot different if it is lbs. vs kgs. Optoms use minus cylinder ophthalmologist use plus cylincer. You can read how to convert the two, if you convert to minus cylincer will look more like what you are using. Yes go ahead and get the glasses before you decide about any other treatment. Peeling a membrane off the retina is a big deal with significant risks; only consider if you are wildly unhappy with your vision WITH glasses. I don't know what "polishing' of a lens is. you would have to ask him to explain. Perhaps he means a yag laser capsulotomy but the IOL itself is not polished. Ophthalmology will always be more science than art.
These numbers are in positive cylinder and can be converted to the more common negative cylinder used by optometrists and the optical industry with the calculator at this site. There is nothing better or worse about it. They are just a different way of expressing the same refraction. Converting to negative cylinder will let you compare current to older negative cylinder prescriptions.
https://www.aclens.com/positive-cyl-converter
A quick test that can be helpful in determining whether your loss of vision is a refraction problem is called the pinhole occluder. If it helps your vision then the issue is likely refraction. And if not, then you should be looking elsewhere for the problem.
https://www.reviewofoptometry.com/article/a-peek-at-the-pinhole
https://www.aclens.com/positive-cyl-converter
A quick test that can be helpful in determining whether your loss of vision is a refraction problem is called the pinhole occluder. If it helps your vision then the issue is likely refraction. And if not, then you should be looking elsewhere for the problem.
https://www.reviewofoptometry.com/article/a-peek-at-the-pinhole
Thank you for these replys.
On converting recent plus cylinder Rx to minus I get
Sphere Cylinder Axis
OD -0.75 -1.50 85
OS 0 -3.00 95
Comparing this to my pre-RD, pre-vitrectomy, pre-IOL, pre-YAG minus cylinder Rx (April 2022) of
Sphere Cylinder Axis
OD +0.25 -2.75 85
OS +0.25 -2.75 95
it appears I have become slightly more nearsighted in both eyes and considerably less astigmatic in the operated RE. Roughly speaking, is this consistent with having an IOL set for "near" as mine was? Why are the LE measurements different? Are they within the realm of measurement error, or simply due to passage of time?
Thank you Ron_AKA for the info and link about the occluder. The Dr. who thought I would not benefit much from a new glasses Rx did not perform this test, the other did. I think I understand now what the latter meant when he said I was seeing "4 lines better on the chart", although this device HAD been used on me before, several times. So I remain skeptical, both of his confidence and his competence. But hopeful for the best.
On converting recent plus cylinder Rx to minus I get
Sphere Cylinder Axis
OD -0.75 -1.50 85
OS 0 -3.00 95
Comparing this to my pre-RD, pre-vitrectomy, pre-IOL, pre-YAG minus cylinder Rx (April 2022) of
Sphere Cylinder Axis
OD +0.25 -2.75 85
OS +0.25 -2.75 95
it appears I have become slightly more nearsighted in both eyes and considerably less astigmatic in the operated RE. Roughly speaking, is this consistent with having an IOL set for "near" as mine was? Why are the LE measurements different? Are they within the realm of measurement error, or simply due to passage of time?
Thank you Ron_AKA for the info and link about the occluder. The Dr. who thought I would not benefit much from a new glasses Rx did not perform this test, the other did. I think I understand now what the latter meant when he said I was seeing "4 lines better on the chart", although this device HAD been used on me before, several times. So I remain skeptical, both of his confidence and his competence. But hopeful for the best.
You did not have a toric IOL or other astigmatism reducing surgery. The cornea is flattened in the axis of the incision. Your incision was likely a 'temporal incision" that would flatten or reduce plus cylinder at 180 or minus cylincer at 90 which appears to be the case. Because astigmatism does not bring light to focus as a point but as a line the vision is not as sharp as a spheriical prescription with no cylincer. In other words a post op Rx of -1.50 will be clearer than a post op spheral equivalent of -1.50 of a prescription with cylinder. Anyone having a vitrectomy and having a macular epi-retinal membrane with vision of 20/25 should be happy as that is better than normal
The other factor in a cataract surgery, even with a non toric IOL, is that the astigmatism in the natural lens is gone post surgery. That may be the reason astigmatism went down. Your right near eye SE is about -1.50 D now which is about right for a near eye. But a residual astigmatism of -1.50 D is a lot. It is probably going to give you an increased depth of focus, but at the cost of reduced visual acuity. If eyeglass free vision was the objective, it would have been better to use a toric lens. When it comes time for the other eye, you may want to consider a toric lens. Ask what the astigmatism will be if a toric lens is not used. If over 0.75 D then a toric will have some benefit. Your can't estimate what it will be from the eyeglass prescription though. You need the measurements from the IOLMaster and Pentacam to get an accurate estimate.
Your astigmatism was probably reduced by the IOL implant. The astigmatism in the cataract lens was eliminated even though it was not a toric lens. Only the astigmatism in the cornea is left and in many cases that is lower than the combined astigmatism in the lens plus cornea.
When it comes time to do your second eye it would be worthwhile to ask what the predicted astigmatism will be after surgery with a non toric lens. If it is 0.75 D or more, and eyeglass free vision is a priority it would be worth considering a toric lens to correct most of the astigmatism. It is unlikely to go to zero, but should be significantly reduced.
When it comes time to do your second eye it would be worthwhile to ask what the predicted astigmatism will be after surgery with a non toric lens. If it is 0.75 D or more, and eyeglass free vision is a priority it would be worth considering a toric lens to correct most of the astigmatism. It is unlikely to go to zero, but should be significantly reduced.
Sorry for the double post...
Thank you both for those explanations. To Dr. Hagan: Yes hopefully the "20/25 guy" is right and with new glasses that will indeed turn out to be my vision. As mentioned, I have my doubts. I expect I will be posting here again after I get them, informing all if I'm ...happy. Or not.
To Ron_AKA: Your point of "Your astigmatism was probably reduced by the IOL implant. The astigmatism in the cataract lens was eliminated even though it was not a toric lens. Only the astigmatism in the cornea is left and in many cases that is lower than the combined astigmatism in the lens plus cornea" I have come across in other posts on this forum, and it makes much sense. Not to say it WAS the entire reason but of course it was a factor.
Regarding your suggestion for my other eye, laying aside for the moment that at this point I think I'm hoping that day never comes, you mentioned possibly getting a toric in the LE if "eyeglass free vision" is desired. You must be aware I have chosen to wear glasses now; are you saying that could still be an option for me in the future? But how would that be eyeglasses free, little lens astigmatism in LE, -1.50 (minus cylinder) in my RE? Wouldn't that be an Rx for NON-"eyeglass free vision"?
To Ron_AKA: Your point of "Your astigmatism was probably reduced by the IOL implant. The astigmatism in the cataract lens was eliminated even though it was not a toric lens. Only the astigmatism in the cornea is left and in many cases that is lower than the combined astigmatism in the lens plus cornea" I have come across in other posts on this forum, and it makes much sense. Not to say it WAS the entire reason but of course it was a factor.
Regarding your suggestion for my other eye, laying aside for the moment that at this point I think I'm hoping that day never comes, you mentioned possibly getting a toric in the LE if "eyeglass free vision" is desired. You must be aware I have chosen to wear glasses now; are you saying that could still be an option for me in the future? But how would that be eyeglasses free, little lens astigmatism in LE, -1.50 (minus cylinder) in my RE? Wouldn't that be an Rx for NON-"eyeglass free vision"?
Your right eye as I understand it is at -0.75 sphere and -1.50 cylinder. On a spherical equivalent basis of sphere plus 50% of the cylinder that works out to be -1.50 D SE. That could be suitable as the near eye in a mini-monovision configuration. -1.50 D SE is the normal target for the near eye, but ideally that should be with more sphere and less cylinder. However, you should be able to evaluate this as a possible option now. Is your left eye good enough to read without glasses? If so, you could get a toric lens if necessary in your right eye and target it for full distance, and combined you may be eyeglasses free for most vision needs.
"Is your left eye good enough to read without glasses?" Yes, barely. Depending on how my new Rx works out I may be happy going forward. Plus there's the idea of not replacing an iol with another iol that deters a pursuit along the line you suggest. We will see. Thx for the post.
I did exactly as your surgeon proposes primarily by my own choosing, and my cataract surgeon concurred I had a ERM peel/vitrectomy in my LE and experienced the expected cataract 18 months afterward. Had a monofocal IOL set for approximate parity with my non-operative RE and returned to using contacts or glasses for distance correction. I have a so-far asymptomatic ERM in my RE and a relatively minor cataract, neither of which are in need of treatment. For me personally, I do not want to advocate for any surgical procedure that is not medically required or recommended.
4 Comments
TY for replying Mr. P. My Dr's solution is not for approximate parity but close enough to enable eye cooperation. I have read many of your posts and your solution was attractive to me, as were your results.
MY solution is certainly not required nor does my surgeon recommend it. It is the result of my desire to be as free from specs as I can possibly get. BUT, despite all my fervent optical desires, I am leaning towards taking a kind of simple conservative path that you took.
The monofocal IOL in my LE was -4.5 compared to my non-operative RE which was -6.0 (in 2017). Close-up vision is of course excellent without correction. It may seem unusual or unwise to some to have cataract surgery in only one eye and still need distance correction, but I’ve worn contacts for so long with good results I decided to continue. In the back of my mind too I wondered if the ERM issue in my LE that was treated in 2015 might not occur in my RE as well to the point of needing similar treatment. If so, and using my own non-medical opinion, I didn’t want an IOL to already be in place.
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