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.

[chazas]

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.

[JohnHaganMD]

As they say, "Different strokes for different folks."

[MrPresley]

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.

[CBCT]

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.

[JohnHaganMD]

Thanks

[chazas]

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.