IOL choice for combined ERM & cataract surgery

[Rainier28]

I am scheduled for combined surgery to address epiretinal membrane and cataract in my left eye in a couple of weeks.  This involves a vitrectomy, membrane peel and IOL implant.  My surgeon cautions that achieving precise results for the IOL power is not possible in the combined procedure due to the variations in how the retina "settles" after the procedure.  I'm nearsighted, have worn glasses all my life.  I value my ability to see fine detail up close without my glasses.  Thus, surgeon proposes to use an IOL that will target -2.0.  My other eye is -3.0.  My understanding is that the end result is that I will see well up close without glasses and will of course need glasses to see at distance, just as I do now.  I have some astigmatism, not enough to warrant a toric IOL per the surgeon.  So that would still need correction with glasses, just as now.  My first question is whether I will be able to achieve the desired results - good close up vision without glasses, and clear sharp vision with glasses following this procedure. What if I don't "settle" at -2.0, but somewhere else?  My second question is whether I should consider having a "plano" IOL so that I would achieve good distance vision without glasses, and then need glasses for all close up vision.  I understand if I went that route I would need cataract surgery on the right eye pretty quickly as it is -3.00; currently the right eye has only a minor cataract -- it's not enough to do anything about on its own, it would need to be done only if I went for distance vision in the left eye.  My impression is that nearsighted people who choose 20/20 distance without glasses and then need reading glasses after cataract surgery tend to wind up unhappy because the situation is so different from what they have lived with prior to cataract surgery.  Hoping to hear from people who may have had similar procedure under similar circumstances.  I'd like to wake up in the morning and see without glasses, but I would be upset I think if I could not get the same level of good close up vision in reliance on reading glasses -- I would not want to be in a situation where I just plain couldn't see well up close.  My work is very dependent on reading and computers.

[Rainier28]

UPDATE: I had the combined surgery 4 days ago (vitrectomy/ERM peel/cataract).  The IOL choice was a -1.75 lens.  Pre-surgery I was -4.25 in the operated eye; post-surgery goal was a -2.  There were no complications in the surgery.  (As a side note, I was a nervous wreck on the day of surgery, and hence had general anesthesia; I had no problems from it.)  The next day, my vision was blurry but I could see generally at close range.  At this point, 4 days later, I can see well at close range, and am able to use the computer and read without glasses.  I am on 4 different eye drops, 3 are 4X day, one is 2X day.  One of the drops keeps my eye dilated; I was told this helps to prevent muscle spasms that can cause headaches.  My biggest issue is that for distance my glasses are hard to wear because the left lens is just way too strong (by about -2.25).  I am hoping at my next appointment at the one week mark my doctor can give me a prescription for a temporary lens that will enable me to wear my glasses more successfully until the 3 month mark, when I'm told I can get new glasses.  Other annoyances in the recovery process (other than all the eye drops) are having to tape an eye shield to my face when I sleep, a beautiful black eye, and the activity restrictions -- no bending, no lifting, no strenuous exercise.  Hoping these restrictions will be eased at my one week appointment; I'm used to being active, and am getting pretty bored.  Visually, I notice that where before the ERM peel there were missing pieces in about every third letter when reading, now those areas are visible, though smudged.  It seems to get a little better each day.  Straight lines like the side of a wall or bookcase still appear bowed, but it's very early in the recovery process so I expect that will improve with time.  Since the eye drops I have are designed to keep my eye dilated until my one week appointment, I have quite a bit of sensitivity to light; I'm wearing sunglasses a lot of the time.  My expectation is that once I'm off the dilating drops I should have additional improvement in VA.

Overall, I feel I am recovering quickly, and I am optimistic about the future for my vision.  I will update again after I have my next follow up appointment.

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

consider having the optician remove your lens from the operated eye (-4.25) and just not having a lens on one side till the eye has healed enough for new lens. Best of luck.

[GrandKK]

Thanks for the update. Glad you're doing well.

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

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[Rainier28]

Today has been a bit of setback -- trouble with increased light sensitivity & glare, more visual blurring than yesterday, with dry scratchy feeling in my eye.  Was advised to add artificial tears drops to the regimen; this is helping some.  

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

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[MrPresley]

I used artificial tears as part of my eye drop regimen for a month after cataract surgery. Still use them occasionally as needed, but that may be more a result from wearing contacts than anything else.

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

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[Rainier28]

Turns out I was having a reaction to one of my eye drops. Stopping that and treating the dry eye improved things.  Had my one week check up today and was told I am progressing well for the one week mark.  No more dilating drops, but one more week with the darned nighttime eye shield.

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

Glad you identified a problem and corrected

[Rainier28]

My latest OCT shows a cyst. I think I had a small one pre-surgery, but this is more defined.  It looks like a drop of fluid. What exactly is the cyst and will it resolve? I’m on prednisone and diclofenic drops for next 3-4 weeks. Will those treat the cyst?

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

Hard to tell.  Often the cysts are CME  (cystoid macular edema) inflammatory fluid and that would be why you are on a steroid and a NSAID drops.

[MrPresley]

My own CME persisted after my eye drop regimen was finished, and continues in a diminishing fashion to this day. To be honest, I wouldn’t know I even have it if my retinal specialist hadn’t mentioned it.

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

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

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

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[MrPresley]

9-10 months was the approximate time it took for my vision to return essentially to it’s pre-surgical state. I’m speculating that since my macular vision was affected it took longer than you might think it should, but I was fine with it. Note that my vision was not bad during that 10 months, rather it was not what it had been.  I also was diagnosed with cystoid macular edema afterward, which continues to improve to this day, three years after the surgery, but it never caused any significant visual issues in and of itself.

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

First read this link carefully:  
http://www.medhelp.org/user_journals/show/1648102/Consider-ALL-the-Options-Before-Your-Cataract-Surgery-Working-Through-Whats-Best-For-You
  
Your biggest concern should be the success of the membrane peel not the IOL power.   ERM peel is a much larger operation with many more potential complications than a standard cataract/IOL surgery. Moreover even if the ERM is removed you may not have 20/20 vision and you may experience some distortion (Metamorphopsia) or things could look bigger (macropsia) or smaller (Micropsia) than normal.   Setting ideal target of -2.00 would be a good choice.   Myopes that have read without glasses all their life that chose to set both eyes at 0.00 are uniformly unhappy in my experience.

[Rainier28]

I've read your article, and found it very helpful.  My situation with the ERM is that my corrected vision has declined from 20/25 in May when it was first diagnosed to 20/40 now in the affected eye.  The level of distortion and blurring I'm experiencing now is affecting driving (can't see smaller road signs & depth perception off), and causing eyestrain and other difficulties with my work, which is mostly reading papers and computer work.  After a couple of hours, I find myself taking my glasses off, putting them back on, and can't really see that well either way.  Recent studies I've read indicate that there is better visual result if the ERM procedure is performed sooner rather than later, and that the combined procedure with cataract removal has better results and fewer risks than a post-vitrectomy cataract procedure.  I'm aware the ERM procedure is not risk free.  I don't see 20/20 in the left eye now even with my glasses, and with the increase in distortion I've had in just a few months, it seems like having the procedure is the better choice to preserve (and hopefully improve a bit) on the vision I have.  Neither choice - doing nothing and living with vision difficulty in driving and working, with potential continued decline in vision--or having a scary eye surgery--is desirable.  It seems like my best option to prevent further vision damage is to have the procedure, though.

[pinhole]

I had a combined ERM peel and IOL implant surgery, performed by a vitreoretinal surgeon and a general ophthalmologist. As a mild to moderate myope, I am very happy to be able to read without glasses just as I had always done before the surgery. (My situation differs from yours in that I had previously had a detached retina repaired with a vitrectomy and scleral buckle in that eye, so the ERM peel was my second vitrectomy on that eye.) Best wishes to you.

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

Yes, good luck

[GrandKK]

Best of luck. Please let us know how you do. Considering this surgery myself.

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

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[Rainier28]

MrPresley and Pinhole, I’d be very interested to hear about your experiences in healing after the Vitrectomy and ERM peel.  I’m told I should not have to have a gas bubble (so no face down) and that I can expect one to two weeks healing time, with blurry vision for some period, and with gradual visual improvement until 3 months post op when I can get new glasses. It’s all pretty vague.  I know every patient and procedure is different. But it’s hard to plan without better information.  My job is the kind of job that has to get done no matter what.  I also live alone, so there won’t be a nursemaid unless prearranged.

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

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[CBCT]

I didn’t have an ERM, but I have had bilateral IOL exchanges with vitrectomies.  I understand your frustration about vague timeframes, but the reality is that you will progress according to your unique healing process, and it will likely take a couple weeks before you are back to full time work.  Don’t rush it.  You may be using a lot of eye drops.  My regimen took a half hour every four hours.  Plan accordingly, rest is essential to healing.  If you have no gas bubble, you shouldn’t need helpers beyond the first day or so.  Best wishes.

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

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[MrPresley]

@Rainier28 it took about 9-10 months for my final visual acuity to settle out following a vitrectomy/ERM peel. I did have a gas bubble, no face-down recovery period required though. My vision was pretty good after the gas bubble dissipated in about three weeks, maybe 20/40 or so.

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

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[Rainier28]

10 months is a long time.  Why does it take so long, do you think?

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

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[pinhole]

Rainier28, you asked what my experience was after the combined ERM peel and IOL implant surgery. First, my vision in the surgical eye had dropped to 20/150 some months after a retinal detachment repair. I had developed a visually significant cataract and a fine membrane was covering the central macula. The morning after the combined ERM/IOLsurgery, which took just under one hour, the eye patch was removed and my vision in that eye was 20/30, a dramatic improvement! My recollection is that my vision was very, very clear in that eye right away, even with a gas bubble. Before the macula-off retinal detachment in that eye I had never used eye drops for any reason, never had any eye problems. Getting the hang of administering eye drops took some practice! I found it useful to create a chart for administering the various drops and taping it to the wall.

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

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[MrPresley]

That’s what I have, an IOL in my LE that is in approximate parity with my non-operative RE. My close up vision is excellent, as is distance vision with contacts or glasses. Granted my cataract surgery following my vitrectomy/ERM peel by about 18 months.