IOL options with impaired acuity after ERM peel

[chazas]

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.

[JohnHaganMD]

Yes

[chazas]

Thanks.  The hyperopic eye is the one where I had a detachment, two vitrectomies, scleral buckle, ERM peel and IOL implantation.  I originally had about a -3.5 refractive error, then PRK to correct that. Not an ideal result, but I'm assuming that the low error is not worth the pain and risk of a touch up procedure.  Would you agree?

[JohnHaganMD]

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

[chazas]

Last week I noticed 4-5 new dark floaters in my right eye, the one that just had cataract surgery.  My retina specialist says my retina is still fully attached, but that my vitreous in that eye has separated substantially since the surgery.  It's not all the way there, so we're in wait and see mode, but hopefully it will all end up well without another retinal detachment.

One month after that cataract surgery in my right eye, my final prespection is:

OD: Sphere -0.50, Cyl -0.75, Axis 175, Add 2.25
OS: Sphere +0.50, Cyl -0.75, Axis 100, Add 2.25

So my left eye, the one on which I had PRK to correct the IOL refractive error, actually ended up being slightly OVER-corrected.  That explains the disparity I've noticed between my eyes.  Not ideal, but I can still get around without glasses - it's far better than it was before this all started.  

I've ordered a pair of fancy progressive glasses with high-end Zeiss lenses through my eye practice and plan to wear them all the time.  (I actually bought stylish frames on vacation to make me feel better about that.)  As my insurance kicks in for new pairs I'll buy them.  In the meantime I'm going go splurge on some cheap internet pairs just so I have something else to wear.

Unless the glasses don't work or the retina in my right eye doesn't hold up, this is my last update.  Fingers crossed!

[teller4]

Glad to hear of your progress /results!

[JohnHaganMD]

Thanks for the informative posts. And cograts for getting to the light at the end of the tunnel

[chazas]

I'm getting close to the end here, I think.

I had cataract surgery on my right eye earlier this week.  I ended up opting for laser-assisted surgery - as posted in another thread, the extra cost wasn't a deal-breaker for me, my surgeon didn't pressure me either way but felt slightly more comfortable with the laser procedure, and on balance I preferred any advantage I felt like I could get, no matter how slight, given the history of problems with my other eye.


A little pain a couple of hours after surgery, which was relieved by the first dose of the extensive eyedrop regimen.  Otherwise, very little discomforte.  I could see extremely well out of the right eye within about 6 hours after surgery, watched TV that night without problems.

At the first follow-up, the pressure in the operated eye was at 33, so they "burped" it (gross) and it immediately went down to 22.  They added eye pressure drops to my regimen.  Hopefully that will settle down.

I opted, as planned, for a monofocal lens set for distance, as I already have in the other eye.  I had expressed a great deal of concern about the refractive error I had in the other eye - likely a result of the scleral buckle and the membrane I had at the time.  The surgeon wanted to aim a little under in the new eye, because in his experience most refractive errors in high myopes are a result of overcorrection.  

I'm expecting that is where I'll end up, a little undercorrected in my right eye - they tested me quickly at 20/20 in my first followup appointment, but I was probably squinting and didn't get all the letters.  So I've got a touch of monovision, the "bad old" eye is crystal clear af the furthest distances but blurry within about six feet, the new eye currently becomes clear at around three feet but is a little blurred at the farthest distances. Because the new eye hasn't had a vitrecomy, I also have minor jelly-like floaters, nothing that bad but it does bring the acuity down a touch.

The old eye, while crystal clear, does have some distortion remaining from the ERM peel - mostly visible when looking at a circular object with only that eye, but my brain appears to compensate and eliminate it when using both eyes.  I also still have a weird visual artifact in the center of my vision, a shimmering or vibrating dark patch that appears only when I first wake up or after exercise.  May be pressure-related, maybe a blood vessel, who knows.  It's minor and I don't notice it much.  The PRK touchup was painful but well worth it, almost all of the buckle-related astigmatism is gone and the refractive error totally eliminated.

Binocularly, my distance vision is great - having just a little more trouble adjusting to the intermediate vision.  For lack of a better description, it feels like I'm under water.  We'll see how it goes.  Hopefully, I'll adjust - while I'd prefer both eyes at plano, I was planning on wearing progressive glasses most of the time anyway, so I'll give it time for the vision to settle and then experiment with those.  My inclination is that even if Lasik/PRK touchups are heavily discounted by my surgeon (which I think they are), I should probably leave well enough alone at this point.  The benefit is that I can see myself in a bathroom mirror and can read reasonable sized text at arms-length, without glasses.

All in all, given how crappy my vision has been (in different ways) over the last year, I'm very pleased.  It takes a long time to recover from a retinal detachment and all of its complications, but I would not have guessed I'd end up with such good vision, without contacts.  Another follow-up today to check the pressure, then an appointment with the surgeon mid-week next week.