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IOL options with impaired acuity after ERM peel

My eyes were both very myopic, around -9 each.  I’ve been happily wearing multifocal contact lenses for years.

Last April, I had a retinal detachment and an emergency vitrectomy – I got a scleral buckle and had a gas bubble. I almost immediately got a cataract.  I wanted to go with a multifocal IOL to correct the cataract, but then I developed a significant epiretinal membrane, which made hat inadvisable.  

A couple of weeks ago I had a combined second vitrectomy/membrane peel and monofocal IOL implantation.  They were aiming for -1 to -1.5 so that either I could decide to either use the eye for mini-monovision (get the other eye done plano later) or just have a consistent near/intermediate focus. Recovery from the membrane peel seems to be going ok – the surgeon says I’ve gone from 20/400 best corrected to about 20/80, though so far it’s not clear to me whether this eye will ever have sufficient acuity for easy reading.  The other problem is that we had a big refractive error – if I remember the numbers right, I’ve ended up about -4.5, but (at least with the stitch still in) wit about +2.25 of astigmatism.  The surgeon said that effectively leaves me around -3.5, an unhappy result.

She’s ruled out explantation of the IOL as too invasive because of the multiple surgeries, says that when things settle down I could do either a piggyback lens or have Lasik.

So here are the questions.

Has anyone had either a piggyback lens implant or Lasik to correct an IOL refractive error?  How did you choose the approach?

Any input on abandoning the mini-monovision plan and having both eyes done about the same, whether plano or about -1.5?  As a non-expert I would think that if I continue to have significant acuity problems with one eye, having both of them at about the refraction is probably going to give me better results.

As an alternative, has anyone ever heard of a strategy using one eye for everything and the lesser quality eye just for periphery/stereopsis?  I.e., not worry too much about where the “bad” eye ends up, and get a multifocal IOL (or just wear a multifocal contact) on the other.

Thanks for any thoughts.
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177275 tn?1511755244
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Avatar universal
I'm there with you, had a vitrectomy/ERM peel in my left eye a little over a year ago and my ophthalmologist has diagnosed a macular pucker in my right eye now as well.  No symptoms yet other than a minor floater, and my vision in that eye with glasses remains a solid 20/20.  Meanwhile we'll keep monitoring it every six months or so, barring any sudden change in my vision.
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177275 tn?1511755244
Probably saved you a fortune over the years.
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177275 tn?1511755244
We don't push routine care down to the optometrists. Any patients that wants to see and eye MD ophthalmologist for routine care can. Some insurance plans mandate the exam be with an Eye MD as example diabetic. Some visual care plans for routine exam only cover optoms.  If there is a medical diagnosis then patients can opt for an Eye MD using their health insurance.

An informed consumer can ask about the costs and advantages of different brands and types of progressive multifocal glasses. Few do.  Our practice "stands behind" glasses RX filled at our dispensary or any commercial dispensary. Without charge we will check the glasses, if necessary repeat the glasses test and work with the optician to try and make the patient happy. HOWEVER we do not do that for internet glasses. We will not even adjust them. Some people are happy and have saved a lot of money, some people, especially when dealing with multifocal glasses (bi-, tri, no-line) are very unhappy.  One of the biggest wastes of money is "anti-reflective" (AR) coating. All opticians (including ours) push them. AR is expensive, hard to keep clean and not at all durable. After a couple of years its mostly worn off and makes the surface of the lens look strange.
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1 Comments
Perhaps I should not have generalized so much from the practice I go to.  :-)

I found getting information on the glasses I was being fitted in to be like pulling teeth, and had to do my own research on alternatives as no detail was forthcoming.  The only advice they really had was "try to get used to them," which I did.  All's well that ends will as they did what was necessary, though I had to really push.

I wonder if I'd have been treated any differently if I'd just negotiated a price from their lab without going through VSP?  
177275 tn?1511755244
Yes
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177275 tn?1511755244
Since your LE is very slightly hyperopic it is "under-corrected" that means the IOL power should have been slightly stronger.  It's under-corrected for distance and way under-corrected for reading.

Best of luck to you

JCH MD
Helpful - 1
Avatar universal
At a little over 2 months since PRK, I'm around 20/25 in the "bad" left eye.  They can refract me to close to 20/20.  I'm currently wearing daily wear contacts in my right eye, which is at -9.  My retinal and anterior doctors have both cleared me for cataract surgery and iol implantation, which is scheduled for late May. I'm going to keep it simple, with a monofocal iol set for distance, and plan on wearing light progressive with readers as a backup. I'm wondering if anyone has any thoughts as to whether traditional or femtosecond surgery is preferable to minimize the risk of retinal detachment.  The literature I've read doesn't seem to say much.  The ability to check the iol power right away sounds great, given that I had such a large refractive error in my left eye. But the use of the pressure ring sounds like a bad idea.
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Avatar universal
Something odd is going on, and the opthamologist doesn't know what.

The first time he had his assistant do the refraction in my "bad" eye they couldn't get me closer than 20/200, which was odd since my previous doctors thought I was correctable to 20/30ish.  So he had me go to their practice's best optometrist, who was the one who refracted me to 20/20 as per my last post.

So I go in today to "confirm" the refraction and the opthamologist's assistant (a different one) again couldn't get me better than 20/200, though he says he was using the measurments the optometrist gave him.  They're sending me back to the optometrist to double-check and I've politely suggested it might eventually be a good idea to have both doctors in the office at the same time.

I'm semi-convinced that the two assistants are making some fundamental mistake - but it would be very odd to have it happen twice. The opthamologist doesn't see any sign of a new membrane or anything like that.  

Has anyone ever had this happen?
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177275 tn?1511755244
Not very often especially if both are competent refractionists. Having both in one room is good idea.  Be sure you're not peaking and reading the line with your good eye.

JCH MD
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Avatar universal
Thanks.  I wasn't peeking.  :-)

I've asked my retina specialist for another referral to get a second opinion as well.
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177275 tn?1511755244
best of luck
Helpful - 0
Avatar universal
Hi Chazas,
Like you, I have retinal issues (cryo and laser for two tear experiences -- but no buckle, macular pucker and retinally induced   aniskonia).  I am very happy with my surgeons (cataract and retina), but my experience with their techs doing refractions has not been so good.  I have also had varied experience with optometrists.  If you can't solve the mystery with the resources at hand, consider contacting Ohio State University School of Optometry -- perhaps they can field questions, or refer you to a local graduate of their program.  I contacted Dr. Toole, an OHU professor, who was very helpful.  
Best wishes.

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177275 tn?1511755244
=
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Avatar universal
Thanks, CBCT.

I just got back from a second appointment with the optometrist who confirmed the refraction. She has me temporarily in a toric contact in my "bad" eye and a single vision contact in my "good" eye.  All I can say is - I can see! I can see!

She scrutinized my chart and the opthamologist's techs had the axis completely wrong.  She also thinks they may have been confusing plus and minus cylinders.  So I was right, they were making at least one fundamental error.  And they shouldn't have been so dismissive of me.

I'm going back in a couple of weeks to see both docs on the same day - to check the contacts and revisit the PRK option.  So I'm finally making progress.
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Avatar universal
Happy to hear that you can see!  Best wishes and Happy New Year.  
Helpful - 0
Avatar universal
I'm updating because I find reading others' stories helpful, hopefully someone will find my journey useful too.

The contacts (particularly the toric contact in my bad eye) are basically good, my vision is stable and I appreciate being able to see much better.  At my request the optometrist also gave me trial pair for monofocal (bad eye at -2, good eye at plano).  She was insistent on the -2 rather than -1.5.  In any event, after only a couple of days trying them out I pretty much know it won't work for me.  The monovision approach does give me functional reading and distance vision, but when my eyes are working together rather than individually I'm getting much better visual acuity.  It's like my brain is picking the best of both images.  

The toric contacts for the "bad" eye aren't perfect, though - they get dry, they rotate, etc.  I'm guessing I have good vision about 60% of the time they're in.  So I'm decided to proceed with the PRK touch-up.  If I'm not doing monovision, the opthamologist really wants both eyes to end up focused at distance, rather than close up/intermediate, he says he has literally never had anyone be happy with that choice.  Still pondering whether I'm ok with that, I had wanted the opposite so I could work (I spend all day at the computer) without glasses.  The downside is that I will always have to use glasses to read/use the computer.  The upside is that if I forget or damage my glasses, I should be able to get by with drugstore readers.  I'll probably reconcile myself to what he wants, but need to think about it.

The last piece will be dealing with my "good" eye, which also has a cataract that is just starting to impair my vision.  Most likely, I will just do a "match" with a monofocal lens to wherever the "bad" eye ends up. Though I may experiment with multifocal contacts in that eye after I get the PRK, and am also pondering waiting for the Symfony lens to be approved in the US, on the theory that the extended depth of field couldn't hurt and I'm not in any rush to do it.

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177275 tn?1511755244
Thanks
Helpful - 0
Avatar universal
Hi chazas,
Contrary to your opthamologist's observation, I am happy with my choice of monofocal vision set for close and intermediate.  My glasses script is
OD  -1.50  x  -1.25 @ 170
OS  -1.50  x  -0.75 @ 180
I can navigate the house in the early mornings and the middle of the night without my glasses, and I can see my phone at night which serves as my clock, alarm, and source of audiobooks.  I use lightweight multifocal glasses which provide excellent vision at all distances.  Granted, it can be a chore to adapt to multifocal lenses, but I think it will be easier for you with a milder script than you had previously.  Also, don't hesitate to ask for a remake if you are not happy with glasses lenses.  

When I asked for the bias toward close and intermediate, my opthamologist was skeptical; however, he understood when he learned that I am a librarian.  His responses was, "Ah yes, librarians and accountants like that."

Best wishes.
Helpful - 0
Avatar universal
Both of my contacts are set up to see at a distance, and I use OTC readers for close-up viewing.  It's worked out best that way for me, I tried mono vision and never adapted to or liked it.
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177275 tn?1511755244
As they say, "Different strokes for different folks."
Helpful - 0
Avatar universal
Thanks, CBCT.  I'm pondering.

The stupid toric lenses are awful. The first trial one blinked out. The second trial one tore during a routine cleaning. Since I have to have it out for 2 weeks before the PRK evaluation appointment (they've already done some of the measurements, but not all) I'm probably not going to buy any, just move straight to the procedure if I can schedule it.
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177275 tn?1511755244
=
Helpful - 0
Avatar universal
I had PRK on the bad eye yesterday.  Man, that hurts!  I'm at work today, but with the lights off in my office and the computer monitor brightness all the way down...

The good news is that before it got so painful last night I had to sit alone in a dark room with my pain meds, I was watching TV and reading closed captions from 10 feet away. At this morning's follow up appointment, I read a little better than 20/40 and they said my epithelial cells were already about 40% healed.  
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177275 tn?1511755244
Best of luck
Helpful - 0
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