cataract surgery complication

[MissyVision53]

I'm in my mid-50s and recently had cataract surgery (just the basic lens, no lenX, no multifocal, no crystallens). My reading vision improved, however, I haven't driven yet because light sources (headlights, trafficlights, houselights, signs, christmas tree lights, appliance lights...) look like solar eclipses or circles of light that are black in the centers.  I also have white flickering. if i look at christmas tree lights, the led lights look like a bunch of large ugly sunflowers with black centers or mini-solar eclipses.  I could tolerate the white flickering but the donuts with black circles, the solar eclipse-looking lights are pretty disturbing.  I saw the opthalmologists for a couple of post surgery followups (he tested for pressure which was normal, and said there was no inner edema and the exam was normal at the last checkup) and was told that this may or may not go away, but it may last for my entire life. they said that i might be seeing a reflection off of the lens implant. there was about 3 months from the time they measured my eye to when they could squeeze me in for the cataract surgery.  has anyone else had this upsetting experience? Have any ophthalmologists reading this treated patients with this?  My world sure looks like a completely different place with black centered "donuts" all around. I would trade having an untreated cataract for this mess in my vision in a heartbeat.  Being out when there is much traffic is very difficult to watch. All I want are answers and to see normally again:  what is the official diagnosis/name?  will this go away?   is it safe, possible, or advantageous to have the current recently implanted lens removed and have a different one put in?  or is the complication risk too great to have this done?  Thank you for your input--it is much appreciated!

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

I cannot provide any additional information.

Every community of any size has a surgeon that specializes in post IOL insertion problems. For example   Doug Koch MD at Baylor,  Robert Osher MD and his group at Cincinnati Eye Institute,  Manus Kraft MD and his son in Chicago.

I will have no further comments on your case and wish you every success.

JCH MD

[MissyVision53]

I was hoping to get your input again on my vision adventure.  I am facing a critical decision regarding surgical treatment.  Since I wrote last, I saw a specialist at a large teaching hospital.  He suspected that the AR40e lens was tilted. He ordered an anterior segment ultrasound, corneal topography, anterior segment optovue, corneal topography pentacam & oct macula cirrus os.  I am negative for keratoconus, negative for irregular astigmatism. He said that I have "several dysphotopsias," I do not have negative dysphotopsia.  My Brain MRI showed asymmetrical visual signals, whatever that means.  A wavelength(?) test showed the tilted lens & the blue coloring on the test was like that of a coma.  He said that I have spherical aberration.  The eye with all of the issues has developed dry eye and I am experiencing some macular traction and am currently on nepafenac drops and artificial tears.
Symptoms: When I look at leaves on trees, I see green spherical shapes, dandelions-spherical shapes yellow outer edge, dark in the centers, I see the same shapes indoors all over my jade plant leaves, there are 20 on the handle of my food processor, they are on jewelry, pipes, anything shiny or contrasted, lights, glass vases. I experience flickering that is more than just simple glistening. My doctor suggested prescription blue blocking glasses which give me relief from the flickering which is non-stop when light   hits the eye from certain angles.  With a perfect refraction as you suggested in an earlier post, the spherical aberrations improve but its been impossible to totally get rid of all of them.  
I feel as if my eyes are not working together at all since the cataract surgery. I'm comfortable in my own home but I have trouble doing the gardening I loved and its exhausting doing grocery shopping, so my family has taken over that. My depth perception is off so I walk into people and things sometimes.

My doctor and I discussed an IOL explant.  If I am going to get this done, he recommends this before the 6 month point, which I will be at in just a couple short weeks. An ophthalmology nurse informed me today that I already passed the safer time period, that it would have been prior to 4 months and that significant fibrosis has already occurred.   My doctor is thorough but I am beginning to be quite  frightened of an explant.  My corrected vision with the glasses can bring my  reading vision to 20/20.  The sense that my eyes are fighting with one another, perhaps from the tilted lens, or due to it being a close up IOL and my right eye is for distance... Perhaps I am unable to adjust to monovision? (my brain mri showed asymmetrical visual signals whatever that means)  I asked my doctor how many explants he has performed and he has done 5 of them.  I called around to other ophthalmologists to see if I might be able to locate a doctor who has performed considerably more explants and was not able to locate anyone who has done more.  He seems like a competent doctor and he did reassure me that if he could not put a one piece aspheric lens in that he would either replace it with a 3 piece aspheric (do those exist?) or stop and leave the current one in. I believe that the lens that is currently in is 3 piece and with it tilted I get quite a distracting light show going on.  Ideally, the goal would be to have the new aspheric lens for distance and I would wear readers.  
He told me that approximately 5 to 10% of patients develop macular traction with an explant and that my percentage risk may be a little higher since I already have some pulling there.
I was wondering if you might know of a couple of experienced surgeons who have done considerably more explants.  Also, do you think the risk of explant surgery outweighs the benefits?  The fact that I'm having difficulty locating surgeons who have a lot of experience doing these makes me think that it is too risky and that I might end up with worse problems than I currently have.
I was so independent prior to my cataract surgery.  I'm only in my mid 50s and I drove everywhere, loved to go to concerts, shop, garden.  Now I trip on the different elevations outdoors, run into folks in crowds, bump into shelves in stores. I'm hoping I'll be able to take grandkids to amusement parks and hope to live long like my folks and enjoy the benefits of good vision.
Do you think it is best to have an explant for a tilted lens with spherical aberration & positive dysphotopsia?  it seems to me that it will always be difficult to get that perfect refraction due to the tilt.  How great are the risks with explant surgery?  Do you know the names of some surgeons who have done many of these?  Is the risk of infection greater with an explant than with removing the God-given lens?
Anyways, I would greatly value your input on this.  Its such a huge decision whether to proceed with an explant in the hopes of better vision and yet I fear blindness so much if things don't go well.  
Thanking you in advance for your valuable opinions on what could be a life-changing decision, positive or negative..

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

Yes, but most IOL decentrations, especially monofocal, cause no problems at all unless very much displaced.

JCH MD

[MissyVision53]

Thank you, again, for your valuable input.  I'm leaving today to see another cornea specialist this week and will share your input.  If the dysphotopsia doesn't resolve, I may check out Wills Eye Hospital.  
If the IOL is only slightly decentered, is this something that is easily seen on a slit examination?  

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

It is very unusual to have your degree of problem with dysphotopsia with a modern monofocal IOL that is not decentered and clear posterior capsule. I can tell you that what patients I have taken care of have NOT decided to remove the IOL as another IOL would need to be put in place or you would have to wear contacts and glasses. Over time (6-12 months) they all have either adjusted to it or it has gone away.

In PN  suggest you see a cornea/refractive surgeon at the Wills Eye Hospital.   They are as good as any in the world.

JCH MD

[MissyVision53]

Thank you for your assistance, Dr. Hagan.  I looked up Dysphotopsia and believe that is the problem...Positive Dysphotopsia, in particular.  I do not experience temporal darkness.  However, I do see spherical prisms on all light sources, and all reflected light.  I do not have Keratoconus.  My astigmatism is 130.  I have tried using my new eyeglass prescription with glare protection and it has not helped. Raindrops or water on faucets looks like frog eggs, road salt pieces look have the sperical shapes, I even see them on my silver and gold fillings when I brush my teeth.  Plastic water bottles, plastic bags, all have the "donuts."  Christmas lights look like large sunflowers.  I am beginning to try to find ophthalmologists who are experienced with dealing with positive dysphotopsia.  I visited one very nice doctor last week and she suggested that I get an MRI done of my brain.  I did that and the optical pathways are fine. She did every office test possible, Orbscan topography, a macular OCT, which was negative for CME, took many pictures of the eye and things came back normal. The vision in the eye is 20/70, when uncorrected.  My wonderful internist thought the dysphotopsia may resolve in about 3 months.  I think my PCP is great, but some of the articles I've read recently online seem to indicate that when you have severe positive dysphotopsia, that it does not resolve in 3 months or even 3 years, so it is best to have the lens explanted.  The most recent ophthalmologist I saw was surprised I was having so many problems considering that this is a 3 piece lens implant AR40e, She said that the lens is not decentered and there is no posterior capsular opacification.   I am not thrilled about the prospect of a lens explant, however, the halos, glare, reflections off of buttons, screws (even on the TV shows), earrings, pots, pans, ect. are very disconcerting.  Driving is out of the question,  I am frightened when I think of having it explanted.  If  I do this, is there a lens that is just as safe as the AR40e but has an edge that would cause less dysphotopsia?  Is there also a way to find out what surgeons have done many successful explantations?  If I decide to proceed with an explant, is it better to do this sooner than later...in case there will be less adhesions if it is done sooner?  Or, is it best to wait a few more months just in case I am lucky and the extreme dysphotopsia resolves?  I am searching in Ohio or Pennsylvania if you happen to know someone in our area who has a lot of experience with this.  Thank you very much for your help!  I appreciated your previous answer.  You were the first one who mentioned dysphotopsia and that is what I'm experiencing.  Unfortunately, it is not at all a mild case of it.  The "donuts" or prism spheres really are everywhere, on tree branches (in that case it seems that the difference in contrast seems to also show the donuts.), snow looks like little donuts, I even saw them on shiny ground beef.  My prescription is -1.75 +0.25 at axis 130.  I have polarized sunglasses and wear them outside even on gray days and in the grocery store because light is so bright.  I learned that the prescription polarized glasses do not make the prism dark centered lights spheres disappear, but it does shrink them slightly.  I am seriously considering explantation, if I felt confident in the surgeon.  What are your thoughts on this?  Thanking you in advance for your valuable input.

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

Use the search feature and archives and read about "Dysphotopsia" and "Temporal darkness" which your problem resembles. You should be wearing glasses with an extremely careful refraction.  An eye with a perfect implant that needs glasses and has uncorrected astigmatism, myopia or hyperopia can cause this. If you still have problems with "perfect" glasses on then I would get a second opinion to be sure you do not have a decentered IOL, posterior capsular opacification. If those are normal would suggest a cornea topography to see if you have corneal disease such as early Keratoconus or irregular astigmatism.

JCH MD