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]

1. Your situation is not rare. Lasik is the less invasive, less expensive and less risky procedure.
2. Read this article and the discussions it covers your situation: http://www.medhelp.org/user_journals/show/841991/Consider-ALL-the-Options-Before-Your-Cataract-Surgery-Working-Through-Whats-Best-For-You
3. You would do well to steer clear of multifocal IOLs as the vision is not as good as monofocal IOLS and with your impaired vision you wanted to see out of both eyes as good as possible

JCH MD

[chazas]

Thanks.  Lasik has always sounded awful to me, but a professional opinion that it's less invasive helps.  I do have some very mild dry eye which every time I have surgery is exacerbated, but which seems to abate once I can start up Restasis again.

I guess I'm just still struggling with the idea that if I can't make mini-monovision work due to the impaired acuity in my left eye, I'm not going to be (mostly) spectacle-free any more.  I hate readers (when I've worn them with regular contacts) because I never have them when I need them, and they read "old."  I hate wearing glasses only, because (1) they're so thick, heavy and ugly given my current prescription, and (2) how narrow and distorted the viewing areas are for progressive lenses.  

Maybe the best way to solve all of this for me would be to focus both eyes at a near/intermediate range then have new progressives made. I could theoretically read an iPad or do computer work without glasses, but I'd mostly be wearing a vastly thinner, lighter and more attractive pair than I have to now, so no nose indentation or "tiny distorted eye" look.  And I'd always be wearing them so no dreaded search for missing readers and no "old guy" look.

[JohnHaganMD]

You need to look at the positive aspects. A RD can lead to blindness; even if RD and ERM  "fixed" the vision often is not real good and sometimes quite distorted.  Remember also anyone that has RD in one eye had 3-10% chance of RD in other eye. So be grateful if you can work out a solution that involves glasses.  

JCH MD

[chazas]

I'm still not sure how I will eventually deal with the touch-up of the eye with the detachment/ERM peel/IOL or corresponding correction on the fellow eye.  I'm in wait and see mode, but speaking of positive aspects, at about 5 weeks from the latest surgery, I can read a couple of letters on the 20/30 line of the close-up vision card.  I wouldn't call the vision great quality in absolute terms, but it's so much better.

[JohnHaganMD]

best of luck and glad you're seeing some improvement

[chazas]

Since my last post I've moved cities due to work, developed PCO behind the IOL, found a new retina specialist (who confirms that the surgeons in the old city did a good job), and found a new anterior segment specialist who so far has done a YAG capsulotomy.  It made a huge difference.  I had a careful refraction yesterday and they were able to refract the "bad" eye to 20/20.  It's a technical 20/20 (there's still distortion and quality just doesn't seem as good, despite a nascent cataract in my "good" eye that keeps me from getting to 20/20 there), but I'll take it.  I go back in a month to see if I have a stable refraction, then we're going to tackle the refractive error.  The doctor has ruled out a piggyback lens, he thinks invasive surgery is a mistake and is worried about a membrane forming between the lenses (and my eyes do apparently like to form membranes).  Now the question is between Lasik or PRK.  The doctor thinks I'm a candidate for either.  I have significant astigmatism now, probably caused by the buckle, but it doesn't seem like either procedure is preferable for that. I've had a little dry eye following all the surgeries, it sounds like PRK might be a little preferable for that reason.  I'm not scared off by the increased recovery time from PRK - can't be near as bad as what I've been through already.  Does anyone have any other thoughts on which procedure to use in this situation, or at least other issues to consider?

[JohnHaganMD]

If you have confidence in your refractive surgeon would suggest going with what she/he recommends. JCH MD

[chazas]

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?

[JohnHaganMD]

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

[chazas]

Thanks.  I wasn't peeking.  :-)

I've asked my retina specialist for another referral to get a second opinion as well.

[JohnHaganMD]

best of luck

[CBCT]

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.

[JohnHaganMD]

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[chazas]

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.

[CBCT]

Happy to hear that you can see!  Best wishes and Happy New Year.  

[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.

[JohnHaganMD]

Thanks

[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.

[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.

[JohnHaganMD]

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

[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]

=

[chazas]

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.  

[JohnHaganMD]

Best of luck