Question about epiretinal membrane & Laser to strengthen lattice areas in fellow eye

[Sue_405]

Good afternoon,
I had RD of the right eye and vitrectomy surgery to repair with gas bubble. It is healing well, but I was told by my surgeon that I have macular pucker in that eye which was present prior to surgery. My surgeon also told me I would probably need surgery to correct this sometime in the future. This is very distressing to me since I am youngish (53) and never had any eye issues. Since the surgery I do notice slight distortion in vision of some lines like the edge of a countertop etc. Other visual issues with that eye is a hazy quality to vision.
My question and I hope Dr Hagan can chime in is this:
Will laser to strengthen the lattice area of non RD eye which my surgeon has encouraged me to have cause a pucker to form in that eye? This eye has had no PVD as of yet but does have lattice. Also, could the laser surgery cause any issues with vision? I am not nor was i previously high myopic and the thought of change in vision for the eye not operated on is giving me a lot of concern. My surgeon encouraged me to get a 2nd opinion and a 3rd if I want as well.
My other concern is the pucker and whether I would eventually need surgery. I saw a post from Dr Hagan in which he mentioned that very few cases of pucker or epiretinal membrane require surgery.
Thank you for any insight you can give.

[John C Hagan III, MD, FACS, FAAO]

There are many causes of a epiretinal macular membrane (ERM macular pucker).  If OCT showed the ERM prior to the the retina surgery than it was present BEFORE the RD surgery. On the other hand ERM can develop after retinal surgery and is quite common.  Laser to peripheral lattice could cause an ERM but is relatively rare.  Being young and having a RD in one eye dramatically raises the risk of RD in your other eye. The risk can be as high as 10-20%  Get all the opinions you need.   If the distortion in the RD eye becomes unacceptable then you would be looking at ERM removal surgery

[Sue_405]

Thanks for your quick reply Doctor!
I am starting to realize that this is not a one & done situation for me. More surgeries (cataracts, etc) are likely in my future.
In your opinion, is ERM removal generally successful?  My other concern are any complications but since my vision is pretty good right now, I won’t worry too much.
And thanks for your factual info on the laser procedure. My surgeon was very understanding of my impulse to protect that eye but also gently encouraged me to have it done when I’m ready. I appreciate the manner of good doctors in these scary situations. It’s a special gift from God to us patients.
Your response was helpful so thanks again!

[John C Hagan III, MD, FACS, FAAO]

The distortion in your vision is the ERM.  As long as it is tolerable, I doubt your surgeon will want to do anything.  ERM surgery is hard to generalize because the membranes come in a wide variety of sizes, shapes, and degree of damage to macula. So can't generalize.  

[Sue_405]

Thanks for your response, Doctor.
I understand the distortion issue but the OCT did not show a lot of membrane. Not much different from before the surgery. And I only required reading glasses and no distance correction prior to surgery. I also wonder why my mid distance is blurry. For example, my reflection in the mirror is blurry and in some lights hazy.  I wonder  if the 360 degree lasering has anything to do with that.
If you could kindly let me know your opinion, I’d appreciate it again!

[John C Hagan III, MD, FACS, FAAO]

If you have a macular pucker it WILL show up on OCT. If you don't have one on OCT you don't have one. The OCT is that accurate. To see all distances (far > 20 ft, intermediate and near) with both eyes you would need to wear no line multifocal glasses all the time.

[Sue_405]

Thanks for your help Dr Hagan.
If I could ask a question about the laser for the non RD eye.
In your experience are there times that the laser to strengthen lattice causes blurrier vision, particularly up close? I am very hesitant to have the laser but also equally hesitant not to have it.
Thanks again!

[John C Hagan III, MD, FACS, FAAO]

It would be very very rare for that to happen.  Most likely the blurred vision would have a different cause.

[Sue_405]

It’s been a few weeks, but I finally saw another retinal specialist to get a 2nd opinion on the laser treatment for lattice in the non RD eye.
I went thinking he would recommend the preventive laser, however he told me that he does not recommend it to his patients in my same situation. He encourages them to wait & come in if any new flashes & floaters since there is a 10% chance of RD in the fellow eye so a higher risk but still with odds in the patient’s favor. He did also say that some of my side effects could be due to the laser. Obviously not the distortion, but the more mid & up close blurriness & decreased night vision.
I work at an ophthalmologist office, and my surgeon and the other specialist I saw are the 2 retinal specialists we refer to.
Having had two opinions now just leaves me wondering if I should get a 3rd!
Dr. Hagan if you have any insight to offer, I would appreciate it.

[John C Hagan III, MD, FACS, FAAO]

Don't get too bent out of shape.  There is often disagreement, even among retina specialists about which lattice to treat and which not to. Remember depending on how hard a eye MD looks lattice is found in about 6-8% of the population but only about one person in 8000-1000 has an RD. I have lattice in both eyes, am a moderate myope and have retinoschesis. I see a retina specialist every 6-12 months and over the years have seen 4 different, highly qualified ones. None have recommended treatment. Of people that do have RDs only about 1 out of 4 does the tear originate in or around the lattice area.  If it would make you feel better to get a third opinion by all means do so. Just remember the old adage "you can see 3 different doctors and get 4 different opinions.

[Sue_405]

Thank you doctor!
That Old adage is literal truth! Haha

I guess I either decide or get a 3rd opinion for myself.

For what it is worth my surgeon feels the prevention is necessary because he said to seek a 3rd opinion if the 2nd disagreed.  He also feels a RD would be highly unlikely in that eye after having the barrage laser.  I do want to avoid another eye with vitrectomy if I can.

All things for me to think about.

Thank you again!

[John C Hagan III, MD, FACS, FAAO]

Good luck. If you have time later come back and post your decision as an aid to other facing the same problems.

[Sue_405]

I will do that!
My decision has been hampered by something else however. This may sound strange but I have been having facial neuralgia symptoms. They started as itchiness and burning across my whole face. Now there is a tingling sensation all along the outer edge of the right side and slightly on the left temple. I also get a burning sensation in my mouth. The earliest symptom was a lot of greasiness of my facial skin. It has been a bit of a nightmare to deal with. I saw a dermatologist who said it is nerve endings and she prescribed steroid cream which sort of helped but the most effective has been a cream with menthol and camphor. Hard to tell what triggers it but definitely anxiety and fatigue will.
So my big concern is did the 360 laser in my right eye have anything to do with this? I would get a slight tingling sensation at night on that side of my face prior to surgery. Very slight and only prior to falling asleep.
So if i go ahead with the laser for the weak spots in the left am I risking more nerve issues?
I know this is a strange question and probably not heard of but i don’t even know who to ask. The dermatologist mentioned that with this going on it may be best to wait, but she also is not an eye doctor.
Thanks for any help with this you can offer.  

[John C Hagan III, MD, FACS, FAAO]

There are a number of facial pain (neuralgia) syndromes. Tic doloreaux  (sp?) is the most common. I suggest you see a neurologist as I doubt that a dermatologist is the right physician for that problem. Barrage laser or focal laser should not have any affect on it.  If those symptoms were less than a week old Shingles (Herpes Zoster) can start that way but after a week you should see the characteristics blister like areas on the skin and mouth. So you and your primary care work on getting in to neurologist

[Sue_405]

Thank you Dr Hagan!
This was basically what I was thinking and you confirmed it. I made an appointment with my PCP for next week. I also put a call into my retinal surgeon to see if he had any insight or had encountered this before.
This is not an easy process, but it helps to get good advice.
Your insight is much appreciated.

[John C Hagan III, MD, FACS, FAAO]

Best of luck. If you get an 'answer' please post again.

[Sue_405]

So...after seeing my PCP today I have been told that I am dealing with anxiety issues. To be fair, I have lost about 13 pounds without trying due to frequent vowel movements .& I am struggling with anxiety and I do not deny this. The facial issues were basically lumped in with that since everything started around the same time.  I was strongly encouraged to try an anti-depressant to lift my seratonin levels for 6-9 months. I am not interested in taking meds at this time. I have scheduled some time with a counselor (first session on October 7th). I think trying this along with getting back to regular exercise (something I did frequently prior to my surgery) would be a better route to go right now. As far as the facial symptoms, I recently started taking a B complex vitamin along with my multi vitamin. I have noticed a difference for sure since skipping the B for 2 days seemed to spike symptoms back up. The greasiness has gone down dramatically and the tingling is much less. Still get a funny taste in my mouth but much less. I do have many people praying for me as well so I want to give thanks to God for the improvements.
I’m not surprised that my doc wanted to prescribe this, since it has been about 3 months of struggles for me and bloodwork and other tests showed no underlying illness. I would like to see about my B levels or even hormonal levels, but I was only strongly encouraged to try the anti-depressant. So I have mixed feelings about the visit overall.

I did get a 3rd opinion on the laser treatment, however. This specialist sided with my surgeon. He  was a younger doctor but gave a common sense approach. He did not discount my concerns with laser side effects which he said are valid, but he knows that another  RD & vitrectomy is not guaranteed to be as successful as on my right eye. I’m starting to tell myself that any side effects from the laser are far better than a vitrectomy.   Hopefully this perspective will get me there. And deciding and getting it done may just be the medicine I need to get back to being myself.
Thanks Doctor for being on this forum, I look forward to your response. And sorry for such a long post, I have posted all this rambling in the hopes it will help someone else sometime.

[John C Hagan III, MD, FACS, FAAO]

I am not an expert on treatment of facial neuralgias.  If your surgeon and the retina surgeon both feel laser prevention is indicated, you should feel much better about proceeding forward. If your lifestyle and vitamin changes don't help your anxiety/depression over the next several months do consider anti-depressants or regular psychiatric visits. Best of luck.

[Sue_405]

Hello Dr Hagan,
It has been some time since I have posted.
I indeed had the laser procedure in my non-surgical eye and it was fine. I almost felt I made a big deal for no reason.
Unfortunately, I am still struggling with facial issues. I started therapy for the anxiety which is worlds better than it was. I never took meds because I didn’t feel comfortable with it.  I had many physical symptoms besides the facial burning. Right now I would say the anxiety is 90% better along with the other physical issues. I asked my PCP if i should see a neurologist and she asked if I wanted to see a neurologist. Not sure why she never just sent me to one. I said sure by this time i think i should. I will continue with therapy because it could be a physical symptom of stress and anxiety and will subside over time. But sitting around and waiting is not always  the best option especially when it has been this long. I got an appointment for the end of May but I fear just getting some diagnosis and meds given to me without a thorough explanation. I appreciate the therapy because they seek to explain how your neurological fight or flight system will create sensations because of fear. It takes a really long time to recover however.
But my PCP is extending my disability for now so she has been very kind in that way.
Just thought I would update regarding the laser etc.
best to you!

[John C Hagan III, MD, FACS, FAAO]

Thank you and a evaluation by neurologist is certainly in order. Good luck. These are anxiety producing times.

[Sue_405]

Hi Dr Hagan,

It has been a while since I posted. My anxiety issues are much better and the physical sensations are improved. I never saw a neurologist since the physical sensations on my face started to show improvement or they changed to other symptoms. Since they change and move around and happen less, I feel good about my therapist’s assessment that these are more psychosomatic in nature. I will continue to not fear them and work on allowing my body to return to a calmer state.

This is not my reason for posting however. I had an exam with a cataract surgeon today here in my state and am planning to have the cataract in my RD eye removed. Obviously I need to choose an IOL. The surgeon I saw was trained at Will’s Eye Institute and was the first cataract surgeon to offer the new LAL IOL in my state. I really liked this surgeon and I have scheduled my surgery. My question is concerning the IOL. I have read your article and after consulting  with the surgeon I believe a lens to correct distance only is the best choice. I did not have a distance Rx before my surgery and neither does my other eye. However, I do not know what the correction for the lens should be. I am looking at the LAL since it can be adjusted after surgery. It may start at Plano the surgeon stated and then be adjusted to my final desired vision.
My question concerns the cost of the lens because of such a low Rx is it worth it? I will also still need reading glasses which I figured anyway. I may need a slight astigmatism correction as well. I never had one in my glasses but it depends on the measurements at my next appointment.

Any insight you could give would be much appreciated, Dr Hagan. I know you do this without any compensation and I appreciate it so much.

[John C Hagan III, MD, FACS, FAAO]

I have never said that it is best to insert an IOL to correct for distance or near or intermediate.  It varies with the individual and the expectations.  My feeling is the Light Adjusted Lens (LAL) is the best choice for patients that can afford the substantial extra cost and that have access to a top rated surgeon.  You and your surgeon should discuss targeted optimal post surgery refractive error.

[Sue_405]

Hi Dr. Hagan,

Thanks for your response.  I saw it right after and am still seriously considering the LAL lens.  I think the technology is amazing and hope that the "dirty fish bowl" vision I have in my right eye can be clear once again!  I also know that correcting for distance is the best choice for me.  I never had a distance Rx and am used to progressives for computer and up-close work.  I work at an optometrist office with an optical shop and am so looking forward to picking new glasses once I have healed from surgery.
I have 2 follow-up questions:
#1- What about the LAL lens makes it the best choice for patients (not considering the cost of course) in your opinion?
#2- In my job, I have been the "patient" for people training on the OCT and Auto-Refractor machines.  Everyone has a hard time getting readings/pictures on my right eye which is the one with the cataract and had a retinal detachment (macula on).  Do you know why this would be?  I have had multiple OCTs and auto refractions done without any problems when I have my eye appointments.  These are refurbished machines so wondering if that could be why or would it be more likely user error? Or is the cataract playing a role?  

As always, thanks for your help!

[John C Hagan III, MD, FACS, FAAO]

1. The LAL primary advantage is changes can be made after surgery without having to go back into surgery and removing first IOL and replacing it with second.  Also in people that have damage/disease (such as previous Radial Keratotomy) where IOL power hard to predict can adjust after surgery.  
2 If the OCT and auto-refract were the problem it would have problems with most/all patients.   Problem is usually: patient can't fixate, pupil is too small, damaged or diseased cornea, significant cataract, blood in the vitreous, retinal disease or damage, technician inexperience