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Expectations for upcoming cataract surgery
Hello, I am new to the community and I am quite happy to find this place. I apologize in advance for the long/rambling post, but I find it therapeutic. I wish I had found it two months ago! My questions are about cataract surgery and expectations. First, a little about me. I am a 42-year old, myopic (-5.0, -5.5) male that has experienced rapidly progressing, bilateral cataracts. No one else in my family had them at this age, and there is no history of steroid use. My myopia was quite stable for years before the cataracts. I also have astigmatism (about 1.75 in both eyes) and diagnosed with keratoconus almost 17 years ago, but seems to be stable. The keratoconus is more pronounced in the left eye. I have a "long eye" with axial length of 27 mm. So, while not the best vision possible, I still had decent correctable vision with glasses. Even now I can still see near at acceptable clarity with glasses removed...labels, small print, smartphone, etc. The retina is still in good shape.
I first noticed the hints of a vision problem about two years ago and thought it had to do with eye strain from computer-related work (I am fixed to a computer screen for most of the day). I was shocked to learn I had cataracts at such an early age. I first noticed a problem while driving and my distance vision just wasn't as sharp. And then the night vision problems started. I definitely have glare issues and it makes driving in the dark a problem. I thought the nuclear cataracts would slowly progress and I would have lots of time before surgery was needed. I was very, very wrong.
I have long had vision issues, so I have worn glasses almost my entire life. But I am now very concerned about basically swapping one problem for another (see at a distance, but not intermediate or near). Because of the keratoconus and the long eye, I am not a good candidate for premium ot toric lenses (according to the surgeon). She also recommended against the AK process for me as it would be hard to predict what would happen in conjunction with the keratoconus. So, I will be getting the monofocal lenses (I don't remember the brand right now). I inquired about accommodating lenses, but her practice stopped implanting the accommodating lenses last year as they were experiencing complaints and difficulty in proper alignment in the eye during surgery. I have asked if there are reports about that in the literature, but I cannot find that sort of negative study searching PubMed. Is it true that surgeons are experiencing problems placing the accommodating lenses? Should I postpone to get a second opinion concerning the accommodating lenses? I am 42 and feel as though I get one shot at this and I want to get the best that I can get given my other eye issues. If it is monofocal, so be it.
The office does have the femtosecond laser option, but the surgeon didn't really push it. She said in her hands she really didn't see much difference in outcomes. Any thoughts on that? I can see how in theory the laser has advantages, but if there is a learning curve, an inexperienced doctor might actually make the outcome worse.
I think the plan is to correct me to -0.5 to -1.0 and not try for "perfect" distance vision with the first surgery on the right eye. I was told that the "long eye" and other issues makes hitting "perfect" difficult and better to remain a little nearsighted. I will still need to wear glasses for the astigmatism so life without glasses wasn't ever a possibility for me. Sadly.
I am really concerned about retaining the acuity at various distances. I have read the horror stories of people needing multiple variations of reading glasses to see at different levels.
The other thing I have noticed is how nonchalantly people are about this surgery when I talk about it. "Oh, my grandmother had that done and the next week she was fine!" I am sure for her, it was quite a big change after years of gradual visual decline. I have vision problems, but with my glasses I was corrected to 20/25 just two years ago and had decent vision. I also have another 20+ years of a career to worry about. I still see this as a major surgery with very real possible complications that some people tend to trivialize. Anyone else experience this? The doctor has informed me that my gender, age, degree of myopia and axial length are all high risk factors for retinal detachment (approaching 3%). To be honest, this absolutely frightens me the most. I still have to talk to the doctor about a retina specialist for follow up and at what intervals it is needed. How long is the enhanced risk for RD for folks in my risk group? It sounded as if it was a life long increase in the probability of RD. Fun!
Again, sorry for the long post. I guess I am looking for thoughts about accommodating lenses vs monofocal and whether I should opt for the femtosecond laser. Thanks!
Bickle_T
I first noticed the hints of a vision problem about two years ago and thought it had to do with eye strain from computer-related work (I am fixed to a computer screen for most of the day). I was shocked to learn I had cataracts at such an early age. I first noticed a problem while driving and my distance vision just wasn't as sharp. And then the night vision problems started. I definitely have glare issues and it makes driving in the dark a problem. I thought the nuclear cataracts would slowly progress and I would have lots of time before surgery was needed. I was very, very wrong.
I have long had vision issues, so I have worn glasses almost my entire life. But I am now very concerned about basically swapping one problem for another (see at a distance, but not intermediate or near). Because of the keratoconus and the long eye, I am not a good candidate for premium ot toric lenses (according to the surgeon). She also recommended against the AK process for me as it would be hard to predict what would happen in conjunction with the keratoconus. So, I will be getting the monofocal lenses (I don't remember the brand right now). I inquired about accommodating lenses, but her practice stopped implanting the accommodating lenses last year as they were experiencing complaints and difficulty in proper alignment in the eye during surgery. I have asked if there are reports about that in the literature, but I cannot find that sort of negative study searching PubMed. Is it true that surgeons are experiencing problems placing the accommodating lenses? Should I postpone to get a second opinion concerning the accommodating lenses? I am 42 and feel as though I get one shot at this and I want to get the best that I can get given my other eye issues. If it is monofocal, so be it.
The office does have the femtosecond laser option, but the surgeon didn't really push it. She said in her hands she really didn't see much difference in outcomes. Any thoughts on that? I can see how in theory the laser has advantages, but if there is a learning curve, an inexperienced doctor might actually make the outcome worse.
I think the plan is to correct me to -0.5 to -1.0 and not try for "perfect" distance vision with the first surgery on the right eye. I was told that the "long eye" and other issues makes hitting "perfect" difficult and better to remain a little nearsighted. I will still need to wear glasses for the astigmatism so life without glasses wasn't ever a possibility for me. Sadly.
I am really concerned about retaining the acuity at various distances. I have read the horror stories of people needing multiple variations of reading glasses to see at different levels.
The other thing I have noticed is how nonchalantly people are about this surgery when I talk about it. "Oh, my grandmother had that done and the next week she was fine!" I am sure for her, it was quite a big change after years of gradual visual decline. I have vision problems, but with my glasses I was corrected to 20/25 just two years ago and had decent vision. I also have another 20+ years of a career to worry about. I still see this as a major surgery with very real possible complications that some people tend to trivialize. Anyone else experience this? The doctor has informed me that my gender, age, degree of myopia and axial length are all high risk factors for retinal detachment (approaching 3%). To be honest, this absolutely frightens me the most. I still have to talk to the doctor about a retina specialist for follow up and at what intervals it is needed. How long is the enhanced risk for RD for folks in my risk group? It sounded as if it was a life long increase in the probability of RD. Fun!
Again, sorry for the long post. I guess I am looking for thoughts about accommodating lenses vs monofocal and whether I should opt for the femtosecond laser. Thanks!
Bickle_T
OK, the first eye was done today. So far the vision is still quite blurry with halos and some ghosting. Not much pain in the eye other than the sensation of a lash in my eye. The actual procedure itself was unremarkable with no complications (that I know of). My follow up appointment is tomorrow morning at 9 am. My doc is also supposed to call me later tonight between 8 to 9 pm to follow up on how I am doing.
Other than the blurry vision, my first impression has to do with the colors. I wasn't really expecting that. Looking at things that are "white" I notice in the unaltered eye that it is actually quite yellow compared to the IOL implant eye. I thought that because I was younger, that the differences in color would be minimal. I was quite wrong. Looking forward to the vision getting a little clearer in the coming days. The left eye surgery hasn't been scheduled yet as we were waiting to see things went with the right eye.
Other than the blurry vision, my first impression has to do with the colors. I wasn't really expecting that. Looking at things that are "white" I notice in the unaltered eye that it is actually quite yellow compared to the IOL implant eye. I thought that because I was younger, that the differences in color would be minimal. I was quite wrong. Looking forward to the vision getting a little clearer in the coming days. The left eye surgery hasn't been scheduled yet as we were waiting to see things went with the right eye.
re: "This person dropped out of school and quit his job and was contemplating suicide last we spoke as he simply couldn't handle anything anymore because of how bad his vision was post op while technically correctable to 20/20. He was considering all types of experimental surgeries in other countries to try to get back some of what he had lost."
Hopefully this person does have the perspective that some of those approaches are likely good bets (some aren't considered "experimental" elsewhere even if the FDA hasn't approved), and that a lens swap might also be worth a try worst case. It involves risk, but is better than suicide obviously. I don't know if perhaps this person lacks the funds to pursue alternative options (which likely wouldn't be covered by insurance even if they were available in the US) and feels desperate due to that , which would make the level of reaction easier to understand.
In the meantime I hope they didn't just try 1 pair of progressive glasses and give up. Not all progressive glasses are created equal, and there are options like multifocal contacts. Those can work better in a low add, in case (s)he tried a high add and it didn't work for them. A low add might give useful intermediate vision even if not near.
Obviously needing surgery that young can be traumatic (it was a shock when I needed it at even at 49. Since one eye had good vision I postponed the surgery until I was 52). However I have to suspect that if this person's vision is correctible, that this level of reaction may indicate they might be prone to clinical depression in general (which can lead to disproportionate reaction to events) or some other issue magnifying the reaction, which they might consider getting help with.
Hopefully this person does have the perspective that some of those approaches are likely good bets (some aren't considered "experimental" elsewhere even if the FDA hasn't approved), and that a lens swap might also be worth a try worst case. It involves risk, but is better than suicide obviously. I don't know if perhaps this person lacks the funds to pursue alternative options (which likely wouldn't be covered by insurance even if they were available in the US) and feels desperate due to that , which would make the level of reaction easier to understand.
In the meantime I hope they didn't just try 1 pair of progressive glasses and give up. Not all progressive glasses are created equal, and there are options like multifocal contacts. Those can work better in a low add, in case (s)he tried a high add and it didn't work for them. A low add might give useful intermediate vision even if not near.
Obviously needing surgery that young can be traumatic (it was a shock when I needed it at even at 49. Since one eye had good vision I postponed the surgery until I was 52). However I have to suspect that if this person's vision is correctible, that this level of reaction may indicate they might be prone to clinical depression in general (which can lead to disproportionate reaction to events) or some other issue magnifying the reaction, which they might consider getting help with.
re: "Crystalens DOES NOT always accomodate. You might end up with a pricy monofocal"
Yup, though for some the idea that it *might* is worth the extra cost, especially younger patients who might be using the lenses a few decades (which was my motivation for expending the effort to go abroad for a better lens choice). I posted this Crystalens info on my thread about getting the Symfony abroad, but to save time wading through that thread I'll repost it here. This FDA document
http://www.fda.gov/downloads/AdvisoryCommittees/CommitteesMeetingMaterials/MedicalDevices/MedicalDevicesAdvisoryCommittee/OphthalmicDevicesPanel/UCM346413.pdf
lists some studies on the Crystalens which show some studies whose results aren't as good as some of the glowing reviews of it look for the ones in the March 2014 update.
There is also concern I'd read among some (pure speculation, no evidence on it one way or another) about whether over decades of aging anything would interfere with the physical movement of the lens, something non-accommodating lenses don't require.I hadn't searched to find the study behind the figure in this presentation, but it notes:
http://www.slideshare.net/alanglazier/accommodating-intra-ocular-lenses
that about half of Crystalens patients require reading correction. That may be in part because as it notes: ' "Pushing” does not equal “Sustaining” '. This issue is that even someone with their natural lens still who is presbyopic for instance may be able to theoretically read a particular print size without glasses, but that the muscle effort to focus may be a strain to do for an extended period of time, and the Crystalens at least partly seems to require the same sort of accommodative effort. (though I recall there being speculation that some of its near benefit comes from some extended depth of focus, which doesn't require accommodative effort to take advantage of. I hadn't checked more recent studies to see if they've resolved how much of the Crystalens results come from what accommodation).
Yup, though for some the idea that it *might* is worth the extra cost, especially younger patients who might be using the lenses a few decades (which was my motivation for expending the effort to go abroad for a better lens choice). I posted this Crystalens info on my thread about getting the Symfony abroad, but to save time wading through that thread I'll repost it here. This FDA document
http://www.fda.gov/downloads/AdvisoryCommittees/CommitteesMeetingMaterials/MedicalDevices/MedicalDevicesAdvisoryCommittee/OphthalmicDevicesPanel/UCM346413.pdf
lists some studies on the Crystalens which show some studies whose results aren't as good as some of the glowing reviews of it look for the ones in the March 2014 update.
There is also concern I'd read among some (pure speculation, no evidence on it one way or another) about whether over decades of aging anything would interfere with the physical movement of the lens, something non-accommodating lenses don't require.I hadn't searched to find the study behind the figure in this presentation, but it notes:
http://www.slideshare.net/alanglazier/accommodating-intra-ocular-lenses
that about half of Crystalens patients require reading correction. That may be in part because as it notes: ' "Pushing” does not equal “Sustaining” '. This issue is that even someone with their natural lens still who is presbyopic for instance may be able to theoretically read a particular print size without glasses, but that the muscle effort to focus may be a strain to do for an extended period of time, and the Crystalens at least partly seems to require the same sort of accommodative effort. (though I recall there being speculation that some of its near benefit comes from some extended depth of focus, which doesn't require accommodative effort to take advantage of. I hadn't checked more recent studies to see if they've resolved how much of the Crystalens results come from what accommodation).
Thanks for the comment. To paraphrase Donald Rumsfeld, "We go into cataract surgery with the eyes we have, not the ones we wished we had." So, I have very limited choices, and in a way, I guess that sort of helps in the decision making process. My cataracts are progressing quite rapidly. I feel if I waited even another year or two, I probably could no longer drive. As it is, my night driving vision is getting very bad and the oncoming headlights are nearly blinding at times. And if I wait, other complication may arise. If I keep the cataracts in, I am virtually assured rapidly degrading vision.
I talked with the surgeon earlier today just to touch base. She will be implanting the Tecnis aspherical monofocal in my right eye in the first surgery. Given the error introduced in the calculations by my "long eye," she will not be targeting plano...more like -0.5. I told her to err on the side of nearsighted as that is the most familiar to me. I never expected to be "spectacle free" after my procedure given the astigmatism that will remain after the implantation (remember, due to other corneal defects, I am not a good candidate for LASIK or AK incisions...and toric might complicate other issues in the future). If I end up -1.0 to -1.5, it is probably OK for me. Not optimal, but livable. If we hit -0.25, it will be great. I have lived 95% of my life with glasses and if I have to keep wearing them, so be it. I just want decent acuity and clarity and the ability to keep driving day or night...and to do some tasks on the computer and read. If I have to wear readers so be it.
Hopefully the collagen cross-linking treatment for keratoconus is eventually FDA-approved and I can pursue that. I have heard that afterward, there is sometimes improvement in the astigmatism (and better vision) in addition to the corneal stabilization.
I talked with the surgeon earlier today just to touch base. She will be implanting the Tecnis aspherical monofocal in my right eye in the first surgery. Given the error introduced in the calculations by my "long eye," she will not be targeting plano...more like -0.5. I told her to err on the side of nearsighted as that is the most familiar to me. I never expected to be "spectacle free" after my procedure given the astigmatism that will remain after the implantation (remember, due to other corneal defects, I am not a good candidate for LASIK or AK incisions...and toric might complicate other issues in the future). If I end up -1.0 to -1.5, it is probably OK for me. Not optimal, but livable. If we hit -0.25, it will be great. I have lived 95% of my life with glasses and if I have to keep wearing them, so be it. I just want decent acuity and clarity and the ability to keep driving day or night...and to do some tasks on the computer and read. If I have to wear readers so be it.
Hopefully the collagen cross-linking treatment for keratoconus is eventually FDA-approved and I can pursue that. I have heard that afterward, there is sometimes improvement in the astigmatism (and better vision) in addition to the corneal stabilization.
Crystalens DOES NOT always accomodate. You may end up with a pricy monofocal. The hinge issue can cause them to miss the target refraction but you already have very long eyes so chances are they will miss it anyway. (In other words I don't think you'd be any worse off.) I woudl definitely get a second opinion. Or a third, or a 5th. You are a complicated case because of the kerataconus and surgeons have various experiences and therefore various comfort levels. Of course, monofocals at 42 with already slightly compromised vision could be devastating. I'm not sure a toric is off the table. I traveled to europe at 29 for cataract surgery. They wanted to give me monofocals too and while I do have some problems I'm really glad I didn't let them. I literally have PTSD just thinking about how bad my vision could have been with them. I met someone through this forum who did get monofocals, (part of his issue was his cataracts were very mild and not affecting his vision and the doctor ignored the fact that he was 25 in making the decision for surgery.) This person dropped out of school and quit his job and was contemplating suicide last we spoke as he simply couldn't handle anything anymore because of how bad his vision was post op while technically correctable to 20/20. He was considering all types of experimental surgeries in other countries to try to get back some of what he had lost. And then other people are 25 and perfeclty happy with it. Your mileage may vary. You may want to wait until you really can't deal with the cataracts anymore before you jump, that way you know you dint have a choice.
Thanks for the comment. I think the surgeon has the experience. As for the accommodating lens, she took out a model lens and demonstrated the sort of implantation problems they were seeing. The hinges sometimes wouldn't attach correctly and sort of buckle so the lens didn't sit flat properly. That is my best explanation of what she showed me. I wish I could wait another couple years for other lens options to be approved but I don't have that luxury. And the idea of traveling to Europe isn't all that attractive to me. I am seriously considering postponing the scheduled surgery to find out more about Crystalens and the pros and cons for another physician.
Most insurances will cover 2nd & 3rd opinions. Find good surgeons who have experience in many IOLs and get as many opinions as you need to satisfy your questions.
I got the Crystalens Trulign toric lenses in Sept 2014 and am very, very happy with the outcome. But, I was moderately far-sighted with moderate astigmatism, so my experience may not have much bearing on your eyesight.
My 1st and 2nd opinions both were very down on the multifocals, but had no bad things to say about accomodating or toric IOLs.
Good luck in your search.
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