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Choosing an IOL after vitrectomy with Aniseikonia and diabetes T2
Something I omitted in my decryption of issues in earlier posts is that I was diagnosed with Type 2 diabetes in December 2013. I have worked hard since then to get blood sugar under control and so far no complications. I talked to my primary care doctor in mid-February 2016 about getting tested for the double vision in the center of my field of vision that I have had since May of 2014 after my first vitrectomy. My health insurance is with an HMO which has its own staff optometrists. Specialist appointments are with the University teaching hospital. I have high hopes that my primary care doctor will arrange for some testing for the field dependent aniseikonia and accompanying double vision that I have had for 21 months. Consequently, I need to figure out what questions to ask before my next appointment (whenever that may be.). Currently the cataract in my left eye is in an early enough stage that my vision can be corrected except for a defect from the macular hole. . I am also developing a nuclear sclerosis in my right eye which is progressing much more slowly.
December 2013 Diagnosed with diabetes Type 2
4-28-14 Optometry appointment which had been postponed because of diabetes. Diagnosed with Epiretinal Membrane in both eyes and macular hole left eye.
May 2014 Vitrectomy with gas bubble in left eye. I first noticed image sixe difference after a couple of weeks after the gas bubble got smaller.
July 2014. Vitrectomy without bubble in right eye.
January 2015 Appointment with optometrist. Glasses with mild myopia and astigmatism correction. Vision except for defect from macular hole is close to what it has been for 20 years. About two months after this I noticed increasing myopia in my left eye as the nuclear sclerosis cataract has progressed. This has continued to progress.
Am I considered to have retinal disease? Surgery was very successful and optometrist said he couldn’t tell by looking that I had had an epiretinal membrane. For me the Amsler grid is far from perfect. With left eye, there are some broken lines but grid is close to being rectangular. Right eye lines are intact but more wavy. Will the fact that vitreous gel was replaced by saline affect cataract surgery or IOL choice?
With increasing glasses power , I have aniseimetropia on top of the aniseikonia – Right eye image larger than left. I saw in an article online that the aniseimetropia can be a reason for recommending cataract surgery. In fact the retina surgeon said he would recommend a cataract surgeon if I wanted a referral. At this point I have too many questions and am not ready to give up the near vision and focusing that I have in my left eye.
Dr. Hagan recommends monofocal IOLs. What are the difference between monofocal and premium IOLs that are responsible for fewer probl em?. What are the issues in my history that would limit my choices and why? The Symfony lens sounds very good. Are there reasons why it would be a poor choice for me with my history once it is available in the US? I have seen in articles that cataracts can also cause aniseimetropia. Is this common? Does lens choice have any bearing?
Michael J Kutryb, MD made a Medhelp Journal post in 2008 on monovision. In his post he recommended that patients considering monovision do a trial first with contact lenses. Is this a reasonable request for HMO doctors? Is there normally a test for mini-monovision.
Thanks for all of your help.
December 2013 Diagnosed with diabetes Type 2
4-28-14 Optometry appointment which had been postponed because of diabetes. Diagnosed with Epiretinal Membrane in both eyes and macular hole left eye.
May 2014 Vitrectomy with gas bubble in left eye. I first noticed image sixe difference after a couple of weeks after the gas bubble got smaller.
July 2014. Vitrectomy without bubble in right eye.
January 2015 Appointment with optometrist. Glasses with mild myopia and astigmatism correction. Vision except for defect from macular hole is close to what it has been for 20 years. About two months after this I noticed increasing myopia in my left eye as the nuclear sclerosis cataract has progressed. This has continued to progress.
Am I considered to have retinal disease? Surgery was very successful and optometrist said he couldn’t tell by looking that I had had an epiretinal membrane. For me the Amsler grid is far from perfect. With left eye, there are some broken lines but grid is close to being rectangular. Right eye lines are intact but more wavy. Will the fact that vitreous gel was replaced by saline affect cataract surgery or IOL choice?
With increasing glasses power , I have aniseimetropia on top of the aniseikonia – Right eye image larger than left. I saw in an article online that the aniseimetropia can be a reason for recommending cataract surgery. In fact the retina surgeon said he would recommend a cataract surgeon if I wanted a referral. At this point I have too many questions and am not ready to give up the near vision and focusing that I have in my left eye.
Dr. Hagan recommends monofocal IOLs. What are the difference between monofocal and premium IOLs that are responsible for fewer probl em?. What are the issues in my history that would limit my choices and why? The Symfony lens sounds very good. Are there reasons why it would be a poor choice for me with my history once it is available in the US? I have seen in articles that cataracts can also cause aniseimetropia. Is this common? Does lens choice have any bearing?
Michael J Kutryb, MD made a Medhelp Journal post in 2008 on monovision. In his post he recommended that patients considering monovision do a trial first with contact lenses. Is this a reasonable request for HMO doctors? Is there normally a test for mini-monovision.
Thanks for all of your help.
Your eye issues like macular holes and epiretinal membrane aren't things I've had reason to look into. However I'll note re: "What are the difference between monofocal and premium IOLs that are responsible for fewer problems?"
I do generally see articles on multifocals suggesting that problems like you mention may be a problem with multifocals due to concerns like lower contrast sensitivity and that distortion from other eye issues could interfere with the multifocals functioning. The Symfony reportedly has contrast sensitivity comparable to a good monofocal, so I do recall comments that surgeons suspect it is a potential option even for patients with certain other eye issues who can't use a multifocal. I don't know though if your particular issues raise any concerns for it, and unfortunately I do recall some mentioning the issue that there simply hadn't been studies done on the issue of using the Symfony with other eye conditions and that since it was new they were still trying to figure what could cause problems for it. Its likely something you'll need to ask a surgeon who has experience with it and has looked at the details of your situation (including examining scans). I'd suspect the Crystalens is a potential option since it is essentially a single focus lens, the risk being that it won't accommodate and a small risk of other issues (like z-syndrome, which may not be much of an issue in the newest model Crystalens).
I've also seen articles talking about IOLs specifically designed for dealing with macular issues, though they usually refer to AMD, they do sometimes mention other macular issues. I don't know if any of these might be relevant to your case. The first is a London clinic's website that mentions macular holes as being one indicator for these special IOLs, the others are trade publication articles on these IOLs
http://www.londonoc.co.uk/age-related-macular-degeneration-iol-vip.php
http://crstodayeurope.com/2015/03/iol-selection-for-patients-with-age-related-macular-degeneration
http://crstodayeurope.com/2015/02/sutureless-telescopic-iol-for-patients-with-dry-amd/europe/2015/07/europe/2015/09/a-us-perspective
http://crstodayeurope.com/2016/02/seeking-to-fulfill-an-unmet-need-iolamd/
I do generally see articles on multifocals suggesting that problems like you mention may be a problem with multifocals due to concerns like lower contrast sensitivity and that distortion from other eye issues could interfere with the multifocals functioning. The Symfony reportedly has contrast sensitivity comparable to a good monofocal, so I do recall comments that surgeons suspect it is a potential option even for patients with certain other eye issues who can't use a multifocal. I don't know though if your particular issues raise any concerns for it, and unfortunately I do recall some mentioning the issue that there simply hadn't been studies done on the issue of using the Symfony with other eye conditions and that since it was new they were still trying to figure what could cause problems for it. Its likely something you'll need to ask a surgeon who has experience with it and has looked at the details of your situation (including examining scans). I'd suspect the Crystalens is a potential option since it is essentially a single focus lens, the risk being that it won't accommodate and a small risk of other issues (like z-syndrome, which may not be much of an issue in the newest model Crystalens).
I've also seen articles talking about IOLs specifically designed for dealing with macular issues, though they usually refer to AMD, they do sometimes mention other macular issues. I don't know if any of these might be relevant to your case. The first is a London clinic's website that mentions macular holes as being one indicator for these special IOLs, the others are trade publication articles on these IOLs
http://www.londonoc.co.uk/age-related-macular-degeneration-iol-vip.php
http://crstodayeurope.com/2015/03/iol-selection-for-patients-with-age-related-macular-degeneration
http://crstodayeurope.com/2015/02/sutureless-telescopic-iol-for-patients-with-dry-amd/europe/2015/07/europe/2015/09/a-us-perspective
http://crstodayeurope.com/2016/02/seeking-to-fulfill-an-unmet-need-iolamd/
2 Comments
Thanks SoftwareDeveloper for your detailed reply. I took a look at the links and while I have no macular degeneration, both of my parents did. Have you heard any rumors of when the US will be getting. Symfony?
I've heard they submitted the application for approval, but the FDA is unpredictable, it could next year. I'll note that although Dr. Hagan referred to the IOLs specifically for those with macular issues as being for those with more advanced conditions, I passed the articles on because some of them refer to them being of use to those even with early stage issues. I don't have reason to explore the issue in detail to see if they are overkill for those with early issues and they are over-selling them, or perhaps getting one early is a useful precaution for later or if its magnification will be inconvenient, etc.
I'll note that most doctors in the US aren't going to have reason be as aware of the details of technologies not approved here yet since they are focused on the treatments they can use here and what they hear from their colleagues in the US (since most have networks that are US based doctors they went to school with, practiced with, or meet at conferences).
Obviously among regular IOLs the lowest risk path in terms of whether the optics cause issues for those with macular problems is a monofocal, and not far behind is the Crystalens (since it is a single focus, any risks involve other aspects of it, however I"m not sure the optics are as good as some monofocals like the Tecnis). I'll note that someone I know here about my age seems to have more problems with low light vision with the Crystalens than I do with the Symfony despite the fact that the Symfony isn't a single focus lens. So the question is whether an extended depth of focus is safe. There are actually a few different extended depth of focus lenses now out in Europe which use different mechanisms, but unfortunately they haven't yet been studied as much as the Symfony so I don't know if any of them may be options (and unfortunately I haven't heard of any even starting the approval process in the US, the IC-8 might but that I suspect has more risk of lowering contrast sensitivity, it uses the pinhole effect like the Kamra inlay).
I'll note that most doctors in the US aren't going to have reason be as aware of the details of technologies not approved here yet since they are focused on the treatments they can use here and what they hear from their colleagues in the US (since most have networks that are US based doctors they went to school with, practiced with, or meet at conferences).
Obviously among regular IOLs the lowest risk path in terms of whether the optics cause issues for those with macular problems is a monofocal, and not far behind is the Crystalens (since it is a single focus, any risks involve other aspects of it, however I"m not sure the optics are as good as some monofocals like the Tecnis). I'll note that someone I know here about my age seems to have more problems with low light vision with the Crystalens than I do with the Symfony despite the fact that the Symfony isn't a single focus lens. So the question is whether an extended depth of focus is safe. There are actually a few different extended depth of focus lenses now out in Europe which use different mechanisms, but unfortunately they haven't yet been studied as much as the Symfony so I don't know if any of them may be options (and unfortunately I haven't heard of any even starting the approval process in the US, the IC-8 might but that I suspect has more risk of lowering contrast sensitivity, it uses the pinhole effect like the Kamra inlay).
I take issue with this statement by software developer which I believe is false:
POSTED BY SOFTWARE DEVELOPER: I'll note that most doctors in the US aren't going to have reason be as aware of the details of technologies not approved here yet since they are focused on the treatments they can use here and what they hear from their colleagues in the US (since most have networks that are US based doctors they went to school with, practiced with, or meet at conferences).
ANSWERS JC HAGAN MD
Every USA resident should be aware that the inept FDA and the overly litigious US society and the trial lawyer industry have conspired to create a serious drug, device and procedure lag in the USA that is costing lives and vision. It is a subject I have written on here many times and in the medical journal I Edit. Examples in ophthalmology abound. IOLS that are in use in Europe cannot be used here; the standard treatment for keratoconus corneal collagen crosslinking using riboflavin has been the standard of care in the world for 10 years but in US can only be done under experimental protocols. Recent studies have shown that an injection of an antibiotic into the eye at the end of cataract/IOL surgery can reduce the incidence of ultra serious infection called endophthalmitis. US cannot do this because FDA will not allow compounding or use of the medicine in the eye as a branded or standard treatment.
US Physicians however are aware of these things and developments. US medical journals such as JAMA, NEJM, Ophthalmology, American J of Ophthalmology and the Journal of the Cataract & Refractive Surgery Society are still the most prestigious in the world. The difference is now is that we read about treatment done in Europe and Asia that the FDA will not allow us to use. It drives US physicians to tears. When the LASIK came out it took so long for the FDA to approve we sat up a clinic in Mexico and our patients and surgeons flew down and back on a chartered plane to do the surgery there. When our surgeons run out of permits to do corneal cross linking we have to send them out of state or to Canada to do what is really a very very simple procedure. The American public deserves better, a campaign issue in the general elections should be to stream line the FDA and bring it into line with Europe and Asia in speed of approval and change the power of trial lawyers and make it harder to file junk lawsuits.
So yeah we do know what eye surgeons are doing in Europe and Asia and it drives us nuts especially since many are by US companies and US researchers developing their products in countries that approve drugs, devices and procedures in a timely manner.
POSTED BY SOFTWARE DEVELOPER: I'll note that most doctors in the US aren't going to have reason be as aware of the details of technologies not approved here yet since they are focused on the treatments they can use here and what they hear from their colleagues in the US (since most have networks that are US based doctors they went to school with, practiced with, or meet at conferences).
ANSWERS JC HAGAN MD
Every USA resident should be aware that the inept FDA and the overly litigious US society and the trial lawyer industry have conspired to create a serious drug, device and procedure lag in the USA that is costing lives and vision. It is a subject I have written on here many times and in the medical journal I Edit. Examples in ophthalmology abound. IOLS that are in use in Europe cannot be used here; the standard treatment for keratoconus corneal collagen crosslinking using riboflavin has been the standard of care in the world for 10 years but in US can only be done under experimental protocols. Recent studies have shown that an injection of an antibiotic into the eye at the end of cataract/IOL surgery can reduce the incidence of ultra serious infection called endophthalmitis. US cannot do this because FDA will not allow compounding or use of the medicine in the eye as a branded or standard treatment.
US Physicians however are aware of these things and developments. US medical journals such as JAMA, NEJM, Ophthalmology, American J of Ophthalmology and the Journal of the Cataract & Refractive Surgery Society are still the most prestigious in the world. The difference is now is that we read about treatment done in Europe and Asia that the FDA will not allow us to use. It drives US physicians to tears. When the LASIK came out it took so long for the FDA to approve we sat up a clinic in Mexico and our patients and surgeons flew down and back on a chartered plane to do the surgery there. When our surgeons run out of permits to do corneal cross linking we have to send them out of state or to Canada to do what is really a very very simple procedure. The American public deserves better, a campaign issue in the general elections should be to stream line the FDA and bring it into line with Europe and Asia in speed of approval and change the power of trial lawyers and make it harder to file junk lawsuits.
So yeah we do know what eye surgeons are doing in Europe and Asia and it drives us nuts especially since many are by US companies and US researchers developing their products in countries that approve drugs, devices and procedures in a timely manner.
1 Comments
I'm sorry if I phrased that poorly. I have no doubt you are aware that we are kept behind the times. I said "aren't going to be as aware", but I didn't complete the comparison to note it meant compared to doctors overseas who already have access to these technologies and therefore have seen the results firsthand, or who have colleagues who do, and are more likely to be discussing these things since they are actively using them. You may keep up with technologies overseas in detail perhaps, but that doesn't mean all surgeons do, and I would bet that you are more familiar with the minute details of US products than you are products overseas merely because you don't use them.
A few surgeons I talked with here admitted having no real knowledge about the IOL options available overseas for instance, like the surgeon who first diagnosed my cataract (though I consulted a high profile surgeon who is in touch with all the latest for a postop). They are busy focused on treating their patients with technology they currently have access to, and while they may be curious about technologies overseas, those with limited time aren't going to explore the minute details of products they aren't able to put into practice. It would be a waste of time to learn minute details of products they can't use, since they may never get the products here. I know in the realm of computer technology many people are too busy with the products they currently use to be fully aware or products they aren't using.
I'll note that a few of your comments indicate you are lumping the Symfony for instance in with multifocals. I'm sure you know they aren't the same, even if they may have some similarities, but I've noted doctors who have access to the lens are more careful to stress the difference more. There are crucial differences between extended depth of focus lenses and multifocals (though the extent of those differences and what drawbacks they may have I think is still being discovered), and between different types of extended depth of focus lenses as well that use different optical mechanisms, there still needs to be more data.
A few surgeons I talked with here admitted having no real knowledge about the IOL options available overseas for instance, like the surgeon who first diagnosed my cataract (though I consulted a high profile surgeon who is in touch with all the latest for a postop). They are busy focused on treating their patients with technology they currently have access to, and while they may be curious about technologies overseas, those with limited time aren't going to explore the minute details of products they aren't able to put into practice. It would be a waste of time to learn minute details of products they can't use, since they may never get the products here. I know in the realm of computer technology many people are too busy with the products they currently use to be fully aware or products they aren't using.
I'll note that a few of your comments indicate you are lumping the Symfony for instance in with multifocals. I'm sure you know they aren't the same, even if they may have some similarities, but I've noted doctors who have access to the lens are more careful to stress the difference more. There are crucial differences between extended depth of focus lenses and multifocals (though the extent of those differences and what drawbacks they may have I think is still being discovered), and between different types of extended depth of focus lenses as well that use different optical mechanisms, there still needs to be more data.
Hi Becky,
I agree with Dr. Hagen. Given our previous history with retina surgeries, a multifocal is not likely a good choice.
I know that you have been dealing with these problems for a while. In regards to your future appointments, you mention your optometrist and primary cares docs, but nothing about your retina surgeon.
The major medical player here is your retina surgeon.
Have you consulted with her/him? A referral from your retina surgeon will certainly advance your case at a university opthamology school. During that consultation, you should discuss your suspicion of retinally induced aniseikotonia and refer to Dr. deWit's work at optical diagnostics.com
Best wishes,
Cheryl
I agree with Dr. Hagen. Given our previous history with retina surgeries, a multifocal is not likely a good choice.
I know that you have been dealing with these problems for a while. In regards to your future appointments, you mention your optometrist and primary cares docs, but nothing about your retina surgeon.
The major medical player here is your retina surgeon.
Have you consulted with her/him? A referral from your retina surgeon will certainly advance your case at a university opthamology school. During that consultation, you should discuss your suspicion of retinally induced aniseikotonia and refer to Dr. deWit's work at optical diagnostics.com
Best wishes,
Cheryl
1 Comments
Thanks Cheryl
Retina surgeon has insisted that he is a retina surgeon and any refererals for aniseikonia should come frome HMO optometrists. I am hoping my primary care doctor will work with HMO optometry. The one optometrist that I have seen said that he would not look into binocular vision issues until after cataract surgery and I am not in a hurry for more surgery especially since I have unresolved issues and my vision is still functional..
Sorry everyone for all of the posts. I have been frustrated from no help so far from any of the doctors plus I am a slow learner who has to understand it all. . I have a handle on the IOL issues and have been wary of making a decision that will affect me for the rest of my life.
Retina surgeon has insisted that he is a retina surgeon and any refererals for aniseikonia should come frome HMO optometrists. I am hoping my primary care doctor will work with HMO optometry. The one optometrist that I have seen said that he would not look into binocular vision issues until after cataract surgery and I am not in a hurry for more surgery especially since I have unresolved issues and my vision is still functional..
Sorry everyone for all of the posts. I have been frustrated from no help so far from any of the doctors plus I am a slow learner who has to understand it all. . I have a handle on the IOL issues and have been wary of making a decision that will affect me for the rest of my life.
Yes you have retinal-macular disease and always will. Once you have a macular hole/ epiretinal/macular membrane even if the ERM is removed and the hole closed you have macular-retinal disease. Think of it like someone that has an impending heart attack and has angioplasty and stents put in, that person will always have heart disease.
Patients with macular disease are not good candidates for multifocal IOLs because for better for worse even for the Symfony the optics are not as good as a monofocal aspheric IOL. The best candidates for multifocal IOLs are people like Software Developer that have healthy eyes, an aversion to wearing glasses and willing to accept higher risks of dysphotopsia or needing glasses for some things. An intelligent and diligent enough to learn the risk/benefit profile of multifocal IOLs.
The telescope IOL is for patients with severe macular pathology and visual potential even after cataract removal of 20/200 or less. Our clinic in KC has done some of the FDA investigation of this type of IOL.
This is like the 22nd post on your eye problems and I really don't have any more to say.
Patients with macular disease are not good candidates for multifocal IOLs because for better for worse even for the Symfony the optics are not as good as a monofocal aspheric IOL. The best candidates for multifocal IOLs are people like Software Developer that have healthy eyes, an aversion to wearing glasses and willing to accept higher risks of dysphotopsia or needing glasses for some things. An intelligent and diligent enough to learn the risk/benefit profile of multifocal IOLs.
The telescope IOL is for patients with severe macular pathology and visual potential even after cataract removal of 20/200 or less. Our clinic in KC has done some of the FDA investigation of this type of IOL.
This is like the 22nd post on your eye problems and I really don't have any more to say.
1 Comments
Thanks for your replies
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