How soon after cataract surgery can YAG be performed?

[chilkat]

I had monofocal lenses implanted Dec. 3 2015 and Dec 10, 2015.  Right eye turned out great (set for distance), left eye also set for distance but did not turn out as well (is now slightly near sighted).  The left eye vision fluctuates daily (clear, blurry, sensation of a haze over the eye, etc.).  4 days ago my optometrist said I already have PCO on both lenses and would benefit from the laser treatment.

He consulted the surgeon who apparently said my insurance will not cover it for 3 months (presumably after the surgery) .  When I asked the price of doing it I was quoted $3000 per eye.  I have yet to be billed for my surgery but know the charges will be close to $2000 for my copay (total).  I can not afford the procedure outside of insurance.

Can anyone explain why 3 months is required to wait when my vision is already compromised?  Is there a medical reason to wait?  Is it risky to do the laser treatment at 6 weeks?

I am disturbed that an insurance company can dictate to a surgeon when a procedure (which they cover) can be done.  Is the optometrist wrong to suggest I would benefit from having it now? I don't know whether I should fight the insurance company decision or just wait.  

When I try to get answers from the surgeon I only get to speak with assistants.  It feels like she is avoiding talking directly to me.  One assistant said she would do it if I really wanted it.  When I said I could not afford it she said "oh it will just be written off".  That sounds nice but I don't believe that for a second.  Another assistant then said "she doesn't really want to do it yet", but gave no reason why.  With so much conflicting information I am confused and do not know who I can trust for straight answers.

When I read other posts about the laser procedure (YAG) I have concerns about whether it will even work that well.

Thanks for any opinions or suggestions.

[JohnHaganMD]

Okay, best of luck. JCH MD

[JohnHaganMD]

Okay thanks.  Most docs use a 1-4 plus grading (some use 5 so ask him) but if you have 2 out of 4 plus posterior capsular opacification especially if central and 20/25 distance and 20/40 at near and you understand the costs and risks of Yag capsulotomy it would be justified to proceed.

Just FYI.  If you were quoted a price over $3000 for a yag laser capsulotomy you might want to consider a formal complaint to the HMO or insurance company or state insurance commissioner or the state medical society. That is egregious and totally indefensible.

[chilkat]

Dr. Hagan, I so appreciate your remarks and willingness to spend time sharing your expertise.  I do intend to have the left eye treated in a month.  I will have to think about whether I want to risk treating the right eye as it has not been quite as problematic.

As for the outrageous charges it's interesting you bring up filing a complaint. I had a lengthy discussion with a customer service rep at Anthem.  Since I am a retired federal employee she suggested I should complain to the Office of Personnel Management since they are supposedly the ones negotiating the contracts with the insurance companies.  I never thought about the state insurance commissioner but that does make sense too.

[JohnHaganMD]

The health care profession is made up mostly of men and women that are hard working, honest, over-worked, over-stressed and who are leaving Medicine in droves. They are retiring early or taking jobs that involve research or no patient care and regular hours. This increases the stress on those of us left in the system and its a self perpetuating downward spiral.  It will be a sad day when there are not enough intelligent women and men to fill the physician spots and medicine is 'dumbed down" and farmed out physician wanna-bees.

That being said every community including where I practice in Kansas City has a very few both incompetent and/or dishonest physician that make me ashamed and embarrassed. I've always been fine, and quick to suggest, 2nd opinions especially in difficult cases or where there are several options.

One reason your new surgeon may want to wait on the yag Cap is that it might allow time for the vitreous to settle. There is no procedure that surgeons do that does not involve risks and you should understand the risks of yag capsulotomy. The primary risk is increased risk of retinal detachment. In the general group of people who have had uncomplicated cataract surgery and who do not have risk factors for RD (high myopia, history of trauma, family members with RD, etc) the post surgery risk of RD may be about one in 3000-4000. After a Yag cap the risk may ncrease by 1%.  Higher in patients with risk factors, maybe not increase at all in people with no risk factors, the studies have some conflict.  Increased intraocular pressure is possible but rare with new drops used at surgery, the IOL could slip out of place, rare except in eyes with trauma or pseudoexfoliation or operative complications. It also makes IOL exchange much more difficult. Be sure you understand the risks.

I'm happy to sign off if you have all the information you need but one piece of vital information you have not posted and that is your visual acuity distance and near each eye with and without glasses and your refractive error (glasses RX) That would be very useful information.

[chilkat]

I agree with your assessment of the state of medicine today.  My sports med doc of 25 years is likely retiring this spring as a result of what you describe.  It is sad and frustrating.  The same clinic where I had the cataract surgery drove him to change affiliations last year, and now the new one is so bad he is leaving early.  I get it.

The new surgeon is good, he did take a fair amount of time to discuss the risks and I understand them.  I have had no other eye diseases or issues other than floaters (a pesky issue for shooting but otherwise not a problem).  I know he is being cautious about the YAG and I appreciate his caution.  I wish the first surgeon had taken the interest and time.

One month ago my RX was RE +.25, -.50, 144, LE -.25, -.75, 101.  My reading add on +2.50 both eyes.  Yesterday I learned one of the cylinders was .25 different (not sure which though).  As measured yesterday - No glasses RE 20/30 and 20/400 near,  LE 20/40 and 20/200.   With glasses RE 20/30, 20/20 near, LE 20/25, 20/40 near.  

[chilkat]

As an update to my posting I have changed eye surgeons due to what I perceived to be a lack of interest from the original surgeon and the discovery that the charges for a YAG would be $3106 per eye.  Another local and well respected clinic that only does eyes quoted me $478 per eye, with or without insurance, plus office visit costs.  I am now sorry I did not shop around before having the cataract surgery.  

I visited the surgeon yesterday.  He confirmed I have PCO on both eyes (LE rated a 2, RE rated a 1).  The left has been the most problematic.  We had a lengthy discussion about the lie I was told by the first clinic (that my insurance required a 90 day waiting period which turned out to be incorrect).  I believe he was truthful that the 90 day waiting period has become a standard because Medicare requires it and some surgeons have adopted it to avoid legal issues down the road if anything goes wrong with the YAG performed before 90 days have passed.  Despite telling me he thought it would be okay to do it now (60 days post op) he suggested waiting another 30 days anyway.  I am again mystified by this but I am weary of trying to understand the double talk and double standards in the health care industry.  Maybe he is covering for another professional or maybe he has been sued before.  Just speculation.

In 4 weeks I go back to have the LE treated.  He thought I would benefit from having the right eye treated also but is leaving that up to me.  While I am satisfied that I will get the PCO removed eventually, I am frustrated and disappointed overall with my experience - it has shown me that many in the health care industry do not advocate for their patients but rather act (or not act) to protect themselves.  Until now I have never viewed health care as something for which I had to shop around.  News flash - always get at least two opinions and price quotes.

[Mimidav]

I had cateract surgery on both eyes in December. 5th and 12th.  I have had nothing but problems ever since. The  left eye wrinkled immediately and the right eye a month later. I have had to go back to my regular eye Dr several times because the pain in the left eye is so bad. The surgeon that did it says the Yag surgery will fix the problem but I have to wait 3 months for medicare to pay. I've already paid almost  $6500 that I had to save up to get the cateract surgery. 1st,will the Yag fix the wrinkles. 2nd, does medicare really require 3 months wait? I feel like the left eye is getting an infection or something.

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

You can, and probably should, get a second independent opinion from a different surgeon. You must have opted for a 'premium' lens because with medicare even without a tie in insurance your bill shouldn't have been anywhere near that high.

[JohnHaganMD]

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[JohnHaganMD]

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[chazas]

A few thoughts.

I agree that $3000 is outrageous. I'm getting PRK on one of my eyes from a high end practice in a very expensive market and its only $2000/eye.  I had YAG and it only takes a minute.

Listen to your own instincts about how much YAG will help you.  My doc cautioned me that it was unlikely to help much, but I perceived an immediate difference.  

In the greater scheme of things, 3 months is nothing.  Eye issues take time and thought to get to the end point.

[chilkat]

Thanks for the insight.  

[chilkat]

Thanks again.  I will wait until I get the glasses this week.  I will schedule with the surgeon if necessary.  

[JohnHaganMD]

Since you've already paid for the surgery and the post op care I would insist on seeing the surgeon for her/his opinion.  As i said originally if you see well out of the RE it doesn't need YAG,  if not happy with vision and glasses in LE and you are told BY THE SURGEON the problem is cloudy capsule you might ask for a YAG to be included in the amount you've already paid.

[JohnHaganMD]

You would not expect a yag capsulotomy to be recommended for the RE since you have good vision are are happy.  Makes you wonder about your optometrist understanding of when a yag is needed.  Your LE may or  may not need a yag. If the eye corrects to good vision with glasses then likely you need glasses not yag.  As for the insurance most insurance fees include the pre-op visit, the surgery and a specified amount of post surgery care called the 'global period'.  Often 90 days.  Any treatment including a complication surgery is to be included in the original fee if its the same surgeon.  Most people do not need a yag capsulotomy in the 90 days post op. With modern cataract surgery only about 20% will ever need it.  Some surgeons would do the yag capsulomy at no charge if was obvious at surgery or shortly after that the capsule was cloudy.  This is especially true with private insurance (as opposed to Medicare or Medicaid).  You might ask for a meeting with the surgeon's office manager and plead your case. NOTE  $3000 for a yag capsulotomy is an outlandish price.  I think our cash price is about $500 we receive much less than that from medicare.  The Federal government and insurance companies run the show; not physicians and patients.   You also have the right to demand to see the surgeon (not an assistant and not your optometrist) to discuss your situation.  JCH MD

[chilkat]

Dr. Hagen, thanks for your input. I thought the price was ridiculous but this is a high profile, well known clinic in northern Ohio.   Some great drs. but an overgrown ego. IMHO.  I have glasses ordered.  I believe the surgeon is competent and caring but protected by the management system.  Once this is all over I am changing optometrists for several reasons.  Is the laser procedure worth the risks?  Would I be better off getting another opinion before trying it?