Post Cataract surgery IOL decisions

[concernd5]

24 days ago I had surgery on my left non-dom eye and was targeted for -1.2  Blended vision.  I ended up at -2.5 with Tecnis 9002.  Dominance testing;  my right eye could see the object clearly which disappeared completely when my right eye was covered up. I did not choose near/intermediate blended vision. He won’t do a lens exchange stating it is much too risky, he offered no solution to reach target.

Prior to surgery, he did ultrasound measurements in both eyes, but was only able to get an IOLMaster reading in my soon to be done right eye. He said if the ultrasound comes in similar for both eyes he will factor in the IOLMaster in the other eye to help him pick a lens, as I had 20/20 vision in both eyes for all my life with no problems. He used the HofferQ formula. I can’t say if he used any other formulas.  Because the target was greatly missed in the surgery eye (left), a new target for my right eye went to a -1.0.  He did state that I could still end up, again, around -2.0   He told me the same thing prior to my first surgery! The posts I have read here state that good surgeons end up within .25 of target.

Visited a 2nd opinion surgeon today. An AAO listed as a Cataract/ refractive specialist. He was voted as one of  the six top Ophthalmologists   2008 (out of more than 85 in the Milwaukee area) in Milwaukee Magazine’s  survey of 2500 doctors and 2500 nurses, who pick from each specialty 3 doctors of their choice.  The survey is taken every 4 years and screens out anyone who has had a complaint filed against them with the Wisconsin dept. of licensing. He was awarded four times previously for Ophthalmology. There were no complaints filed against him in the last 17 or more years.   His recommendation is  1.   IOL exchange   2.   piggyback lens   3.   Lasik.   He said, he has no qualms about IOL exchange,   he does about 10 per year. never had a complication (have to qualify here that we had talked about infection, at some point, and he may be referring to this point, I will  verify complications.   Lens exchange should be done within 2 months.  He felt HofferQ is not used  frequently and hinted, in a non verbal way, it is not the best formula to use.  He uses 2 formulas, Holliday/? and the latest IOL Master, which he states can be read through the densest cataract.  I understood him to say, about hitting the target, he will get me where I want to be, but recommends I  should speak with my  surgeon to find out what he needs to do to get it right and, if I don’t get satisfaction, tell him I will find another surgeon. He will not act as a consulting physician but, would be my surgeon if I would choose him. Wouldn’t get in depth with my concerns stating things in a way that I need to make a decision first as to who I want to be the surgeon.

Question
1.    Since I do not have faith in my current surgeon do you concur I should move on?
2.  What is the maximum Diopter difference you would target for my right eye, which I believe is strongly dominant?
3.  Is there a newer IOL Master that can read through the densest cataract?
4. Is doing 10 lens exchanges a year a low average or good as to proving a surgeons skill at it?
5.  I highly value my good sight. I have seen occasional fluttering when my surgical eye has been dilated. Would not want to have Dysphotopsia constantly. What are my chances of Dysphotopsia after lens exchange?       Thank You.    Mitch

[JodieJ]

I'm glad to share my personal experience with you, but keep in mind that everyone's different.  I've read that 90% of the people who try monovision are able to adapt to it.  (I'm not sure that degree of eye dominance is a factor in adaptation.)  Monovision gave me the sense of having continuously good vision at all distances.  I never had a problem seeing small print or using the computer.  My distance vision was better than 20/30--good enough for almost all of my daily tasks. (I wasn't a marksman in the military.)  I sometimes wore glasses over my contacts for driving at night, which corrected my distance vision to 20/20+.  I was never aware of a problem with my depth perception (but I wasn't a tennis pro.)

Dr. Pernoud's post raises an important point--no correction is going to be perfect.  My friend who ended up at plano and about -1.2 (your initial target) has very good distance and computer vision.  But he cannot read the times a movie is playing in the newspaper without glasses.

You should not have to have to find a solution to your vision problems on your own--surely you can find a good cataract/refractive surgeon who'll take the time to explain things and address your questions and concerns.  I don't know much about laser vision correction, but I believe that the minor touch-up you might (or might not) need in your left eye would carry very little risk.  And many people have both LASIK and Yag--with good results.  Best wishes.  

[concernd5]

Thank you so much JodyJ for your comment! Your posts here and before are so treasured to me!

Can I ask if you know how strongly dominant you are in your eye? If I recall your were highly myopic before and I am assuming that, because of this, you might not be as strongly dominant in one eye over the other. If I remember all that I had read, this may explain why some people, as yourself, can handle and enjoy a 2.0 diopter difference whereas people with strong dominance can not handle such a wide difference. If this is true, do you know what the level of diopter difference is handled by people with strong dominance?

I also have read that after some neuroadaptation that there is an amazing ability for some to have a visual acuity through the whole range of the difference for up to a 1.5 diopter difference. Would you comment here on how well you have adapted to your visual acuity on say the distance in between the two focal distances? For example your dominant eye(0) is focused at 20 feet and beyond and your nondominant eye(2.0) is focused, I think, around 24"(not sure), so a 1.0 distance is around 5 feet(again I think), if my assumptions are true, how clear do things appear for you in the 4 to 8 foot range? Also very important did you notice any  depth perception affects right after the surgery? I don't know at what level of difference it is affected but I thought I had read that at your level there is some affect involved. Do you think you have become accustomed to the change since?

It is my wish to study Lasik now, as I believe, through Drs. Hagen's and Kutryb's posts both favor Lasik over lens exchange where possible. One option, I will have at my disposal, is by following your suggestion and testing the use of multiple glasses with different corrections and determine what difference works best for me, I can  then use this number to target Lasik on the non dominant eye. I just don't know the danger of Lasik at this time.

Lastly, Is there a problem or risk factors with YAG lasering after one has had Lasik done on the eye?

Again thanks for all your help!!! Mitch

[JodieJ]

Dr. Pernoud has provided an excellent response to your post.

I had a 2-diopter difference between my eyes when I used to do monovision with contact lenses.  (My dominant eye was at plano and non-dominant was -2.0.)

Your second opinion surgeon sounds like a winner to me.  I'd follow Dr. Pernoud's suggestion and let him do my second eye.  (In your place, I might go with a target of -.25 for my second eye, and probably a little LASIK to reduce the myopia in my nondominant eye.

[concernd5]

Joan M Pernoud MD
In my haste I tend to not write clearly. Here is a second attempt to write it better.
  I understand from previous posts here, and from your opinion, that explanting has many risks associated with it including some possibly devestating results. Explanting here does not give me much comfort either, so I would prefer to use Lasik as an option to bring me to an acceptable outcome.  My goal is to get me to an outcome that gives me clear vision through the range between the two eyes that includes as much distance focus as possible. Knowing once I do choose the other target for the cataract eye I can't change it.

If I choose to do the cataract eye first the problem is, what do I target for the cataract eye, especially with what I believe to be strong dominance in it? I have been light headed after the surgery and after my eyes were dilated, lasting for a few days after. It then clears up and I'm fine. Neuroadaptation ability dealing with eye dominance issues worries me as to how much to limit the difference between the two eyes in the end.

I have read that the brain can blend the two eye's images to a good focus up to a 1.5 Diopter difference. Some people don't have problems even at a 2 Diopter difference. I don't know what level I can handle again with the eye dominance issue. But
I have thought that might help decide this and can you please comment. I have been light-headed after my surgery and after my eyes were dilated lasting a few days. I have light iris color and was told that those who have them are much more easily affected by the drops. After a few days, the light-headedness clears up, along with the distance focus a little. My feeling is to use this non dilated Diopter difference level between the two eyes to pick my maximum Diopter difference. What do you think?

If this is a good idea then could you advise one of the two.  Should I target accordingly, see how it works with glasses and if I don't like distance glasses then Lasik both eyes or to plan in Lasik and add this to the Diopter difference shoot for the target, see how it works, then adjust one eye accordingly?

God bless you dearly, Mitch

[concernd5]

Dr. Pernoud thank you so much for your reply!

   I understand from previous posts here and from your opinion that explanting has many risks associated with it and with it some possibly devestating results. Explanting here does not give me much comfort but I have thought of Lasik for my surgical eye to get me into closer range of intermediate first and then go for a Diopter difference target between them for targeting the other cataract. Knowing once I do choose the other target I can't change it. My wish would be to get as close to distance vision as best as I can.

I have thought strongly of  your suggestion of do the cataract first and then see if I can live with it. The problem is, what do I target for the cataract eye, especially with what I believe to be strong dominance in it. I have been light headed after the surgery and after my eyes were dilated for a few days after. Neuroadaptation ability dealing with eye dominance issues bothers me.
I have thought thought that  maybe it's related to my light Iris color and that I can be easily affected by dilation, and like a camera, my distance focus is affected. After a few days my pupils are brought in closer and my distance vision gets better and no light headedness. My feeling is to use this non dilated focus level between the two eyes to pick my maximum Diopter difference. What do you think?

The other benefit of doing first cataract eye  is it leaves the door open to make better choices using Lasik in the future if it is needed.  I have read that up to a 1.5 Diopter difference the brain is able to bring into clear focus throughout the range. That brings me to a target of -1.0 for my dominant eye. I like the thought of this point! A  -0.5 target would be sweet for me as JodyJ a poster here has a 2.0 difference but I don't know her dominance level. Your opinion here would be greatly appreciated.

God bless you dearly, Mitch

[Joan M Pernoud, MD]

Dear Mitch,

The fast evolution of this field leaves an incredible variety of options and each surgeon has their own system for trying to get to the best possible outcome. If every variable in calculation was perfectly determinable, everyone would do the same technique and plan but even the most talented and experienced doctors will get refractive surprises at times. These things are just not perfectly predictable even under the best of circumstances. Eye meetings are filled with great doctors trying to figure out the "perfect" technique!

If I were you, I would leave your left eye alone and consider allowing the new doctor to do your other eye after having all your records sent so any needed adjustment can be made to the lens power. Having a near prescription in your nondominant eye is not a bad thing and many people request exactly that and it will potentially make you nondependent on glasses to read. You should not expect "perfection" of a high degree because "perfection" is in the eye of the beholder (no pun intended) and it is just not where the state of the art is yet.

If, after your other eye is done, you really cannot live with your vision (doubtful), you could try doctor #2's ideas but they sound pretty aggressive to me and I would think long and hard before getting that lens explanted....maybe get opinion #3 or 4. You may not even be happy if you get the -1.2 you were looking for because it may not be as great as you thought it would be.             Good luck!