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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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233488 tn?1310693103
MEDICAL PROFESSIONAL
THIS STRING IS TOO LONG PLEASE MAKE NEW POSTS ON NEW QUESTION
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Avatar universal
I haven't been here or to this thread for several years.  (Well, "thread", they've changed the format so much, odd.)  Anyway, the membrane in my right eye has continued to grow. I still have technical 20/20 vision, I have a lot of distortion and floaters in that eye but my brain seems to adjust the stereo picture from both eyes so my vision overall is fine.  My retina doc can't believe I can see through scar tissue that thick. However, he is finally recommending a peel in my right eye - he says if I couldn't get along with that eye only, it's probably time, and it's thick enough that if I ever want to do it, I should soon.  I will probably do it, but wondering if  anyone else has faced the decision of whether to peel or not when overall vision is still ok.
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Avatar universal
The ERM is slowly getting worse. I'm still 20/20 corrected in that eye, but I notice the symptoms - bent line distortion, lines that break up into hashes, and it's slightly darker/more opaque.  Combined with the huge floaters in that eye it's pretty annoying.  My retinal doc says wait and see, he'd be hardpressed to do a peel when I have technical 20/20, despite the problems.  I'm torn.  I've been through it in the other eye (albeit with a much worse membrane), and it was not pleasant but th eventual recovery was good.  Anyone else have to make this decision?
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3 Comments
No matter what you feel with 20/20 I doubt your surgeon will proceed with the surgery. Generally you want vision of 20/60 or worse
Thanks.  It's odd, 20/20 is not really reflective of the vision quality. It's hard to describe.
You can have 20/20 but have distortion, (metamorphopsia), larger than normal (macropsia), smaller (micropsia), crowding of letters together, reduced color and glare  so 20/20 does not imply normal vision
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.
Helpful - 1
Avatar universal
Maybe I'm still not done with this nonsense.  Yesterday's 3 month retina checkup showed a small epireteinal membrane in my right eye.  So far no symptoms I can isolate - there's some haze around outdoor lights at night and inside under flourescents, but I also have a huge cloudy floater and some posterior capsule opacity, so I can't tell what's from what.  And I'm still 20/20 with glasses.  But once an ERM started in my other eye, it got very bad very fast.  Sigh.
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177275 tn?1511755244
Probably saved you a fortune over the years.
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177275 tn?1511755244
VSP is pretty specific in terms of what they will and will not pay for. Most VSP patients don't want to spend much or any money more that VSP allowable.  I also don't know how or if any optical would 'negotiate' a price. That might work in Europe or the Middle East but  bargain and barter are not a part of American retail.
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1 Comments
In a high and opaque pricing situation with unknown profit margins, I never hesitate to ask if I'm being given the best price and/or for a discount. E.g., not for groceries, but for appliances.
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
Thank you for the information. I have published a paper on the absolute high end of glasses which is called wavefront technology. Its very expensive and for most people is not worth the extra money.  This is a link to the paper:  http://www.omagdigital.com/article/Grinding_It_Out%3A_Wavefront_Spectacle_Lens_In_Clinical_Practice/805950/78197/article.html

JHagan MD
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1 Comments
Thanks for the paper.  The anterior practice I go to sounds much like yours (integrated ophtmamologists/optometerists/opticians, with routine care pushed down to the lowest cost provider.  I understand the economics, but what it means for th e patient is if something is considered routine (i.e., you probably can't charge much for it) the patient really has to take responsibility for their own care.

So many of the buzzwords surrounding progressives seem to have little meaning other than as a marketing matter.  Everyone touts their lenses as "digital" and "free form" - but is anyone today really being fitted in anything else?  The cheap Zenni glasses are digital and free form.  And as I mentioned it is very hard as a consumer to tell what you're being given and how it differs from anything else on the market.  Opticians tout the service they provide as the differentiator, but that's very hard to quantify and clearly is not worth the price differential from the internet ultra-discounters, or even the  trendy moderate discounters like Warby Parker.
Avatar universal
There have been no further tears.  Though I've had occasional black speck floaters in BOTH eyes, the last dilated exam showed no issues with either retina.  I have mild PCO in the right eye (the one with more recent cataract surgery and tear), but the retina doc doesn't want me to do anything about it until I pass the three month mark from the tear.  So another retina exam in several  months before I can go back to my anterior practice and try to get a YAG treatment scheduled, which I"m quite sure will take at least a couple of visits there.  I'm not expecting huge improvements because the majority of my vision issues there are a result of the big greasy floater caused by PVD.

The more interesting stuff recently has been getting fitted for glasses.  The super expensive (even after insurance) progressive glasses fit by the opticians in my anterior segment practice never worked right  - I was much happier with the 1/10 the cost "spare" pair I had ordered online from Zenni.  The optician spent some time adjusting the frames and I gave it another couple of weeks, but near and intermediate vision were paltry, making reading and computer work difficult.  

He had fit me in what he claimed where the "latest technology," Zeiss Choice.  I dug into research and determined that these were NOT the latest and greatest, and they were known for narrow intermediate/near corridors.  I suggested a different Seiko lens, which is when I learned that my vision insurance dictated  lens brands and Seiko wasn't on the list.  So they then put me in what is actually a newer product from Zeiss, Individual 2.  These are great - I now like them better than the cheap internet glasses, though not anywhere close to 10x better.   I checked the relative costs of the two lenses and with the insurance price I paid I got not much of a discount at all with the Choice lenses, and much more substantial discount with the Individual 2 (they didnt' charge any more).

Lessons learned on buying progressive glasses:  Price does not equal quality.  Progressives bought off the internet (without a segment height measurement) at a huge discount can be prefectly fine, though if something does go wrong you're probably out of luck.  When being fitted for glasses prior to all the surgeries, I'd just assumed I was being given something relatively standard - but that' snot true.  Opticians push you toward what they want to see you in, maybe for good reasons, maybe for bad, but it's not transparent.  THey don't want to give you the information necessary to make your own informed choice as to the brand/model they're fitting you in.  Nor do lens manufacturers - it's very hard for a consumer to access any meaningful information at all on the differences between various types of progressive lenses.
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Avatar universal
My follow-up today revealed a horseshoe tear, was lasered.  Ouch.  The doc ise going to monitor very closely over the next few weeks as he thinks getting a tear after the Weiss ring separation is indicative of potential trouble.  Oh, and while the blood has mostly disappeared from my vitreous, and I'm not noticing the Weiss ring so much, I have a very large and cloudy floater that does makes the vision in that eye quite difficult.
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2 Comments
Hope everything has gone well and no more issues.  
Maybe your retina Eye MD can tell you if this big floater is blood.  The life of a red blood cell is 120 days so it can take  3-4 months for blood to clear from the vitreous.
Avatar universal
Spoke a little too soon.  The PVD continues in my right eye.  As I was playing a board game yesterday, I watched a long stringy black floater develop in real time - very disconcerting.  The doc called me back quickly and saw me first thing today.  The stringy floater has resolved itself into a ring (likely a Weiss ring) and my eye is blurry overall (he says it's blood, which hopefully should resolve).  The good news is no new retinal tears. I go in again in a week.

It's all so frustrating.  I know there's nothing to be done, but I really just want everything to stop.  Since I've had every complication known to man so far from every issue, I'm keeping my fingers crossed I don't get a tear or an ERM in what was (?) my good eye.
Helpful - 0
1 Comments
Yes its hard to be philosophical when a string of bad luck comes along. I have a Weiss Ring in my RE. Took quite a while to get use to it.
177275 tn?1511755244
Yes
Helpful - 1
Avatar universal
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?
Helpful - 0
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
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!
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Avatar universal
Glad to hear of your progress /results!
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1 Comments
Thanks for the informative posts. And cograts for getting to the light at the end of the tunnel
Avatar universal
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.  
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177275 tn?1511755244
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Avatar universal
Thank you.  
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Avatar universal
I think it's individual.  In my case both were seriously affecting my vision and the membrane was growing so fast it needed to come out quickly. The downside was that because of all the interference, the iol measurements did not come out well, resulting in the need for later PRK. It took a few months for the retina to settle down enough from the peel to really tell what was going on. If I recall correctly, the Google can find some recent studies on doing the combined surgery.  
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177275 tn?1511755244
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177275 tn?1511755244
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1 Comments
I was reviewing some posts from 2009 on here - Dr Oyakawa recommended 'cataract surgery first' - I too have cataract plus membrane and between the doctors I have, I'm sure they will be able to figure out what the best and safest options would be for my case.  It seems that both the membrane and the cataract could both be impacting visual acuity. I wonder if the procedure and collaboration you describe might be something of a possibility.  Because every case is individual with different conditions, I won't know if they would recommend a dual same operation procedure.
Thanks for the info.  
Avatar universal
It was a collaboration between a retinal surgeon and an anterior segment surgeon - I was living in another city, both were at the university teaching hospital's eye clinic and were on faculty at the medical school.
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177275 tn?1511755244
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