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Avatar universal

Toric lens cataract surgery led to increased and still increasing astigmatism

(A) With Surgery day as Day 0, and using the Negative cylinder convention, these are some data points for  Sphere, Cylinder and Axis for  my LEFT eye :
1.  Day negative 45, from Long standing optometrist :   :   -9.50   -2.25  162
2.   Day  +8 from Surgeon : :  +1.75  -3.25  170
3.  Day +12 from long standing optometrist ::   +2.50   -4.00   164
4.  Day +16 from USC Eye Clinic :    +2.50  -4.25  165
5.  Today  Day +20, With the right eye completely covered or closed, I see multiple visions when trying to read
through my left eye, and all ranges of over the counter reading glasses fail.
(B)  Day Zero surgery   Acry Sof iQ TORIC  via  Alcon
       Model  SN6AT5   POWER :  7.0 D   3.00 CYL
      Length 13.0 mm   Optic  6.00 mm
      UV With Blue Light Filter .  
(C)  The surgeon's staff seems very reluctant to  provided me with their Pre- and Post-opt  measurements,
Please help me understand  what happened here, and my options for this LEFT eye, with the RIGHT eye to follow
Many Thanks  
29 Responses
Avatar universal
I can imagine how frustrated you are.  I too had a lot of problems after my cataract surgery and had to press for more information.  You say that the staff is reluctant to share measurements.  You have a right to your records.  I was asked to complete a form and was able to pick up my records a week later.  Be sure to get your IOL Calculation Report as well as pre surgery and post surgery examination records.  Make an appointment with the surgeon and ask him/her explain the reports and discuss if the target was missed, and if so, what are the next steps.  If you are not happy with that discussion, seek a second opinion.  I would hesitate to proceed with your other eye until you feel adequately informed.  

I have no experience with toric IOLs, but it is strange that your astigmatism is getting worse.  Perhaps the lens rotating and that may explain your monocular double vision.  I would not expect over the counter readers to remedy this since they do not correct astigmatism.
Good luck and keep me posted.
Avatar universal
To clarify further, I chose the Toric monofocal to correct for Far vision with the astigmatism removed. The understanding was that I would lose my long loved ability to squint and read but that reading would be accommodated by over the counter reading glasses.
The removal of the cataract was itself a great success, my left vision though still blurry for dustance is bright and without any glasses over any eye, dominates the right eye with cataract.
Avatar universal
Please see my response to my originap post
Also,for a Toric lens monofocal correction set to Distance, it is possible that someone ended up with mild nearsighted, say negative 1.5D, with the ability to still read close.
Avatar universal
My surgeon wryly remarked that the surgery was successful, but the patient could not see.  Astigmatism will cause distortion at all distances.IF your astigmatism had been corrected, then over the counter readers would work.  Clearly, this is not the case.  

My original lenses were Crystalens which caused terrible glare.  After a difficult year ( 4 YAGs, PVD, and a retinal tear), a different surgeon exchanged both lenses with monofocal IOLs biased toward close vision.  I wear progressive glasses and have good vision at all distances.
Avatar universal
For the interim period until both eyes are cataract free and better aligned in power, I am following up on a great suggestion to further the domination of the left repaired eye via a bifocal prescription for Far and Near, with a dummy vanity lens over the right eye.
MANY THANKS CBCT for your very helpful feedback.
Avatar universal
You're welcome.  Best wishes for a happy resolution.
Avatar universal
Have they mentioned how far the lens is rotated, if they plan to rotate it to where it should be  or what they suggest doing about it and when?  Since you give the lens power I'm guessing you got the wallet card for the lens  and it seems likely you got the lens they intended   (given how far off you are, that just made me wonder if you got the wrong one).

I don't know offhand if any sort of post surgery issue like swelling can lead to some of the added astigmatism.
  
Obviously even aside from the astigmatism, the lens power was off, which suggests caution before the lens power is chosen for the other eye. In the case of highly myopic people the IOL power  formulas may not work well as well as they do for most people. You don't indicate whether the other eye is also myopic, but usually both eyes are if one is. This cataract surgeon has a page talking about the problem and the ways they attempt to correct for that

http://www.doctor-hill.com/iol-main/extreme_axial_myopia.htm

I also see that apparently Dr. Hill will consult for other surgeons on lens power choices. I wish I had been aware of that before my surgery, though I only wound up slightly off in what used to be my more myopic eye, +0.5, it would have been nice to have gotten the power right to get a bit more near vision from that eye (the other eye is plano).

re: " am following up on a great suggestion to further the domination of the left repaired eye via a bifocal prescription for Far and Near, with a dummy vanity lens over the right eye. "

Given your left eye was myopic (though I can't tell how much of that might have been due to the cataract since it was from only 45 days preop, I had a large myopic shift due to my cataract), I would have guessed that your right eye would be rather  myopic as well since usually (not always) there isn't too much difference between them.

If so, it isn't clear why you say a dummy "vanity lens" over that eye, seeming to imply it won't have a lens power. Are you just hoping to tune out that eye and ignore it until surgery perhaps? Or are you wearing a contact lens in the right eye perhaps and the glasses over top? In that case you could still opt for a bifocal lens in the glasses so the eyes match. (though I'm guessing you don't wear contacts or you'd just use contacts in both eyes, multifocals perhaps).

If you are  +2.5 in your left eye and rather myopic in your right, it isn't clear that glasses will work well, due to the different powers in each eye providing images of very different   sizes (anisometropia) which usually (if the lenses are a few diopters difference) leads  to problems with your brain not able to merge the images well (aniseikonia).



Avatar universal
Thank you, SoftwareDeveloper.

For my right eye, the values on Day negative 45 and Day 12 were both  -8.50 -3.00 170, but on Day 16 at USC the right eye values were -7.25 -3.75 165.

I have never worn contact lenses nor had Lasik or any type of eye surgery. On Day 16 the USC personnel suggested that in addition to the prescription for the Left eye, I could also have a contact lens on the right eye. But since I have never worn contacts and I expect my repaired left eye with prescription to further dominate the right eye, I opted for the dummy right eye vanity lens. I will be very cautious driving during this interim period.
Many Thanks..
Avatar universal
Follow up comments
As far as I can see, no pun, the left eye has been healing very nicely, no swelling or other worrisome symptoms.
My next visit to the surgeon is on Wednesday 4/29 or Day 23, 3 days from now, some 65 miles away by cab
Avatar universal
Yikes stripes!   65 miles by cab!  Where do you live?  Perhaps there is alternative transport that is cheaper?  Let me know and I will research.  Sometimes there are services for seniors (not sure if you qualify) or other medical or social services. Or, you might offer to pay a neighbor.
Avatar universal
I am considering replacing the volatile toric lens with the tried and tested monofocal with a mild nearsightedness, and then use prescription to also address astigmatism etc. Surely this outcome will be more predictable than another toric lens replacement..????
CBCT..the doctor worked wonders for some close friends currently not available
  I will also seek a second opinion from a closer source like USC.
Many Thanks to All for your feedback.
Avatar universal
Are you in Los Angeles?  Sam Maskett MD is one of the best.
Avatar universal
Thanks CBCT. I will follow up.
With the toric lens approach, I also paid for the in surgery option of recalibration of the measurements after the cataract was removed.
But in my particular situation, even this precaution did not help with the results beyond the removal of the cataract.
Sigh!!!
Avatar universal
Toric lenses are well tested (as with may things, they have been available and used longer in the rest of the world than in the US so they aren't quite as new as some might think). The results you are dealing with aren't typical.

Since you have an appointment coming up, the issue is to get them to give you more information about their diagnosis and what they plan to do about it. Depending on their answers,  if possible you might  wish to get a 2nd surgeon's opinion or to consider using another surgeon for any fixes and the other eye.  

It seems like the lens may  be rotated drastically enough to make the astigmatism worse rather than better, so the question is whether they plan to rotate it to fix that. Its also possible there is some other issue with your eye that is still healing is causing some of problem (though it seems less likely).  

One option, depending on the state of your eye is a lens exchange for one with the right power that they then hopefully insert with the correct orientation so it does correct the astigmatism, or a piggyback IOL if there is some risk with removing this lens.  There is always a risk though with any sort of surgery though. Once they decide about what to do about this lens, there still may be residual astigmatism and refractive error. Obviously you could wear glasses, or you could consider lasik or an implantable contact lens if you want a more convenient solution.  

They should explain why the lens power is off so far. It may be that the formulas used to try to guess the lens power disagreed with each other,as they sometimes do for highly myopic people.  The lens power formulas aren't exact, they are based on statistics based on how well different IOL powers have worked in other eyes in the past. There are different formulas derived from different sets of data and  different statistical methods. For most people with more average eyes the formulas will work well and tend to agree with each other, but for highly myopic people they may not for the reasons that web page I linked above describes  (in addition to the fact there is less data since fewer people are that myopic). Unfortunately not all doctors are up on the latest literature and may not be aware of the issues that the article I linked to mentions. Usually the other eye will be similar to the first in terms of its anatomy (though mine were fairly different),  so  it may be that the error in this eye can hopefully give them information to help make a better lens power choice for the second eye. As I noted, apparently Dr. Hill (and perhaps other surgeons) will consult with other surgeons on lens power choices (presumably for a fee.. though if this doctor goofed with the first lens and is involved in the 2nd one, perhaps they'd cover the fee).

It is possible that rather than being an unavoidable mistake since lens power choices aren't an exact science, that instead they made an error along the way or ordered the wrong lens. Its useful to know that to consider whether you want the same surgeon to do the other eye (even if you do stick with the same one, if it was say perhaps a staff member and not the surgeon who made an error and this will ensure they are careful next time,  if they need to admit a mistake it may lead them to be even better about trying to fix the problems to make up for it).

re: "The surgeon's staff seems very reluctant to  provided me with their Pre- and Post-opt  measurements"

That might be  a concern , perhaps suggesting they realize they made mistakes, though some doctor's staff are just not helpful so it may mean nothing. In the US you have a right to get a copy of your records, they may merely make you sign for them
Avatar universal
Many Thanks CBCT and SoftwareDeveloper.
Since my retirement in 2012, I teach actuarial math part time at UCLA, and am on break till the Fall quarter.
I am optimistic that the USC recommended bridging option of basically one eye vision will be comfortable enough to allow a timely research of all my options with multiple "vendors". I will keep you informed.
Royster
Avatar universal
re: "I also paid for the in surgery option of recalibration of the measurements after the cataract was removed. "

I guess you were posting that while I was posting my prior message. That seems really puzzling then that the results could be this far off, it could be there was postop rotation of the lens for some reason. I will note that in general the issue of whether intraoperative measurements lead to better results or not is still under dispute among some surgeons (sometimes new technology takes a while to be polished to match its potential):

http://bmctoday.net/crstodayeurope/2014/09/article.asp?f=pointcounterpoint-does-intraoperative
"POINT/COUNTERPOINT: DOES INTRAOPERATIVE ABERROMETRY MATTER?
Point: For those who consider themselves refractive cataract surgeons, this technology helps to nail the target refraction.
By Stephen G. Slade, MD; and Jonathan H. Talamo, MD
Counterpoint: Intraoperative aberrometry is not yet the best answer to guide the surgical refractive plan in cataract surgery. "

http://bmctoday.net/crstodayeurope/2013/03/article.asp?f=pointcounterpoint-is-intraoperative-aberrometry-worth-the-investment
"Point/Counterpoint: Is Intraoperative Aberrometry Worth the Investment?
Surgeons weigh in on the value of this technology in cataract surgery."

Given the concern of some that the approaches aren't yet far enough along in general, I have to wonder if eyes with less common characteristics (as highly myopic eyes are) with less  data available to   calibrate things might be even more of a concern.  However the basic issue of getting lens rotation at least far closer than yours is would  I  assume be handled well enough that any issues will be minor, not like what you have.
Avatar universal
Many Thanks, SoftwareDeveloper
Being relatively grounded, and in between teaching classes, I will follow up on all your references.
In the life insurance industry, I would be an old guy with unusual health issues seeking life insurance. I would have driven the medical underwriters nuts.
Gracias..
Avatar universal
Many Thanks CBCT for the suggestion to visit Samuel Masket at Advanced Vision Care.
Perhaps due to my unusual eye dimensions and texture, the toric lens rotated out of alignment but has now settled down.  Further a correcting rotation now of 86 degrees clockwise will lead to the intended optimal results.
Many Thanks
Royster
Avatar universal
Did you get an appointment?  He da man!
Avatar universal
...'I also paid for the in surgery option of recalibration of the measurements after the cataract was removed'

That is intriguing. I have always wondered how in surgery measurements can be accurate when, usually, we try to do our keratometry/topography measurements with the eye in the most natural state possible (ie in clinic, before pupil dilation, sitting down on a chair in front of the machine)

I am speculating that this machine gave an erroneous read-out...this can only be confirmed by reviewing your case notes and any intraoperative video.

If that is the case, then a simple lens rotation (your spherical equivalent is close to zero) or lens exchange if ideal implant toric power is different, should solve your problem. I would strictly follow normal calculations based on pre-operative measurements and not intraoperative measurements.
Avatar universal
The other possibility is this:
Assuming your pre-operative cylinder is mainly due to corneal astigmatism, it looks like the magnitude of the cylinder almost doubled, with the axis remaining almost the same.

This can happen if the implant is accidentally implanted with the axis at 90 degrees to the ideal axis. In such a case it should be a simple matter to rotate the lens by 90 degrees and then the problem is solved.

Avatar universal
Yes CBCT, I received a graph showing how the Astigmatism varies with the orientation of the lens and the minimum value at the optimal orientation. LIke a V.
Wanlien3, since the postsurgery Astigmatism increased steadily before leveling off, it is doubtful that a large initial error was made.Rather the trend line suggests a continuous unidirectional rotation.
Many Thanks To All for your feedback.
Royster
Avatar universal
Yay!
Avatar universal
Whether or not a large initial error was made in the orientation of the lens, there is still the issue of the spherical power being off quite a bit. Since you had intraoperative measurements, I'm wondering if some glitch with that new approach played a part in that. However it does seem like if the intraoperative measurements conflicted much with preop calculations that they would have been cautious.
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