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Management of aphakic retinal detachment patients

I know there have already been many posts about this so I'll try hard not to cover old ground.

I'm aphakic from congenital cataract surgery, and last October (at age 41) I had a superior-temporal retinal detachment in my right eye. It was macula-on, spotted early, fairly slowly progressing and repaired successfully with vitrectomy, laser, cryo and short-acting (SF6) gas. It has been stable since October, with no change in vision at all, which is a very pleasing outcome indeed!

However, I'm only too aware of the possibility of future detachment in that or in the other eye. I may possibly have had a PVD already in my good eye (symptoms about six years ago suggest this), which would put me at less risk of that one detaching, but my surgeon is quite rightly not wanting to assume anything about the completeness of this and is keeping close watch on this eye as it probably does about 95% of my seeing. I have amblyopia in the right eye from very late surgeries for the congenital cataract and later clouding of the posterior capsule all causing lack of early visual stimulation.

I suppose like most RD patients I have many worries about the future. Some are common to all RD patients while others are specific to me. I'm particularly concerned about silicone oil being placed in my eyes, something that may inevitably have to happen at some point in the event of any future detachments. With nystagmus as well as aphakia it could emulsify quickly, but the main thing that would worry me would be the thought of an attack of angle closure glaucoma. This sounds horrific to me, and if the pain from this is as bad and sudden as everyone seems to say it is, I'd be worried about being so incapacitated as not to even be able to get to a phone to dial emergency services! (I live alone).

Corneal damage or open-angle damage from emulsification sound horrible too, but at least give a little more time for decisions to be made. Having to worry about the possibility of a sudden angle-closure attack happening at any time if I ever had a permanent oil-fill sounds worse than worrying about the retina detaching - and I gather that even the latter can still happen anyway, with attendant pressure-related issues from forward prolapse of the oil. (This, incidentally, happened to me when my retina detached in October and may have been connected with forward movement of vitreous - the doctors didn't have time to explain it to me so I'm guessing a little - but my pressure shot up to 56. I had no pain with this, which presents the opposite worry to that above - if I can get to 56 and feel nothing untoward, I might not know when vision-threatening complications are occurring until it's too late).

I know I'm getting way ahead of myself in many ways, and none of this may ever happen, but I'm sure many other patients must ask these kinds of questions. How are patients like me typically managed (other than being told to stop worrying about things that may never happen!)? In other words, patients who are aphakic and who may, at some future stage, require oil.

With an oil-fill, would lots of extra face-down positioning (even if not instructed) help to mitigate glaucoma / cornea-related worries? I know about the iridectomy for drainage, but I also know even if it's made it can still close up. The odds must surely still be at least somewhat in favour of long-term success for the whole eye (and not just for the retina) after use of silicone oil in aphakic patients, even if there are never any guarantees. If all we were doing was staving off problems for a few years, I'm assuming all these eyes would surely just be "put out of their misery" (enucleated) early so as to enable the patient to move on with the least amount of time in severe pain, and adapt to a somewhat stable "new normal", albeit one that involving no sight (possibly in both eyes)!

Any general thoughts on this would be very much appreciated. (I know everyone's individual case is different).

One other question I had if I may (and I may ask my surgeon about this as she has actually been inside my eye and knows what the possibilities are - but I'm not seeing her now until December). Could implant of an IOL, even at this stage in my life, mitigate oil-related risks were I ever to need oil? To be absolutely clear on this, given my history, I'd never even dream of suggesting this at any time other than when surgery was going to be necessary anyway for other reasons. I suspect my capsules, if anything remains of them at all, wouldn't support a posterior lens, so I'm not sure quite what, if anything, would help in this situation.

Once again, any thoughts would be greatly appreciated. All I'm really doing here is to try and seek out general knowledge ahead of time. I have an excellent relationship with both my retinal consultant and my glaucoma consultant (who gives me yearly checkups), but a limited amount of time with both so it sometimes helps to be able to formulate the right sorts of questions to ask ahead of time.
1 Responses
177275 tn?1511755244
You are way, way, way ahead of your self. I am not even going to attempt to answer you questions which is ultra-hypothetical.  It's like getting in an car and dwelling on how you will live your life if you are in an accident and left quadraplegic.  Moreover technology changes rapidly in ophthalmology and future techniques will be different and better. I doubt any surgeon will have much enthusiasm about putting an IOL in your better eye with a history of RD in the fellow eye.
Thanks Dr. Hagan, for taking the time to respond, and for all that you do for this website.

I think I probably needed to hear something along the lines of what you've just said! I am conscious of getting into hypotheticals a fair bit, and also of the increased risks I face with my eyes from now on. My hope, of course, is that if/when anything does go wrong again, surgical techniques may have moved on by that time, as you say - and if not, we deal with things as they come.

The IOL was more just a "naive" thought as a sort of prophylactic barrier and my question I suppose was more along the lines of "why don't all aphakic patients automatically get IOLs as soon as they are injected with oil - or indeed long-acting gas - as opposed to iridectomies being done etc.?". It's a naive question and I know that things are never actually done that way to prevent problems, but I've never been able to find out the reason why. I realise that any isolated surgery for an IOL would carry a massive RD risk for the likes of me, and am guessing from what you're saying that combined RD / IOL surgery would make the RD part of the surgery more likely to fail?

Thanks again for your help.
Putting in an IOL in an aphakic eye and putting in oil while doing vitrectomy, endolaser, scleral buckle is  too much surgery. Many aphakic eyes are not candidates for secondary IOLs.
Thanks for this. Sounds as if the eye can only take so much in one go and an IOL might not work for my particular eyes anyway.

Hoping as you say that there may be future developments at some point that may ease things (hydrogel tamponades? pharmocological cures for PVR?) but from what I can glean they look some way off, although you're likely to know much more than I do!

There is an awful lot of information "out there" - much more than there used to be - and you can see that people like me (and I know from being in various RD support groups that I'm far from being the only one) do probably more researching and thinking about "hypotheticals" than is perhaps good for us. I do it partly because I'm genuinely interested in how the eye works - always have been - but also, unfortunately, to try and anticipate future problems. It's impossible of course to anticipate everything that could happen. But RD certainly can put one into a frame of mind that makes all this much easier to fall into. Even with completely successful surgery and no vision lost at all (like mine), it's a life-changing event. So I'm very grateful to you for giving your time to help people through all this.
Yes thanks but any psychologist or psychiatrist will tell you dwelling on the worst possible outcomes creates an unhappy life filled with stress and anxiety and actually increases the risk of disease such as heart problems.
Thanks - I am receiving ongoing help and support with this side of things, as are many of the fellow RD patients I have met recently - counselling for RD patients seems to be fairly commonly needed from what I can gather having spoken to many.

I do try to be at least somewhat sensible if ever looking at worst-case scenarios, and to try to estimate the true likelihood (quite difficult, but can be done to a certain extent by dividing % likelihood of x occurring with % likelihood of y sequelae - something that often leads to a reasonably comforting small figure - so some of the eventual events I mentioned could end up from my current position with a likelihood of something like 1 or 2%, despite the precipitating events being much higher likelihood than that). Spending lots of time thinking about the 1-2% stuff is unwarranted.

More problematically, I sometimes also try to think about how I'd likely cope with these events in an attempt to "make peace" with risks. This has problems in that one can't ever make peace with every possible thing that may happen - one has to live through it to be able to know, and furthermore, although eye stuff is the current focus, other things will come along as well!

Thank you for all your help. It's an ongoing struggle but I think I'm gradually making progress! Some people find all this much easier to deal with than others.
Best of luck, best of sight, peace of mind.
Thank you!
Actually I did have one other very quick question if I may, which I can't seem to find the answer to. My plus prescriptions for glasses always have a tendency to increase over the years. Does this likely mean my axial length is increasing or decreasing? I know that eg. for phakic myopes, going from eg. -5 to -9 means the eye is probably getting longer, but how does this work with aphakic prescriptions, and would you say that with +15.5 in the left and +14.5 in the right, focused at 2m for distance, I'm likely to be axially myopic? (Of course I haven't given astigmatism correction here).
In most adults the axial length does not change much. An exception is progressive pathologic myopia. In individuals with their natural lens the change in reading glasses is due to lens of the eye getting stiff and not flexing to focus. In an aphakic changes would likely be due to corneal changes and the need to see at different near distances. If the eye gets longer it needs LESS power on reading glasses.
Thanks for that info - that's very helpful.
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177275 tn?1511755244
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