Aa
Cataract in one eye
I was recently diagnosed with a cataract in my right eye. They have no idea what caused, only that it's there. I'm only 33 years old, not that it can't happen in younger people, just my understanding its not as common. To give a full history I used to wear glasses, then contacts, then in 2001 I had Lasik done to both eyes with great results. I've had 20/20 visions till about a couple of months ago when my right eye started to get blurry.
My vision in my right eye isn't "horrible" yet. However, I work on computers day and night and its starting to interfere with my work. My eye doctor had told me about two options the 'mono' lenses and the multi-focal lenses. To be honest, I don't recall the brand he mentioned, I believe it was Alcon thou. He mentioned that people with one "normal" eye have issues with the multi focal lenses sometimes. He also said because I had lasik, getting the right "strength" implant isn't an exact science and theres no guarantee I would have good vision after. That I may need to have lasik again or wear a contact.
With me now doing research on the internet myself I realize just how many lens options there are. I'm wondering if anyone else had similiar experiences or just suggestions in general. Thank you all in advance.
My vision in my right eye isn't "horrible" yet. However, I work on computers day and night and its starting to interfere with my work. My eye doctor had told me about two options the 'mono' lenses and the multi-focal lenses. To be honest, I don't recall the brand he mentioned, I believe it was Alcon thou. He mentioned that people with one "normal" eye have issues with the multi focal lenses sometimes. He also said because I had lasik, getting the right "strength" implant isn't an exact science and theres no guarantee I would have good vision after. That I may need to have lasik again or wear a contact.
With me now doing research on the internet myself I realize just how many lens options there are. I'm wondering if anyone else had similiar experiences or just suggestions in general. Thank you all in advance.
If you are avoiding LRI and going with a standard monofocal IOL, then ORA is an advantage.
And I may be confused here, but is this going to be a Toric lens, which is, again, an extra out-of-pocket cost?
If the IOL is a Toric, then the ORA is definitely an advantage.
And I may be confused here, but is this going to be a Toric lens, which is, again, an extra out-of-pocket cost?
If the IOL is a Toric, then the ORA is definitely an advantage.
Dr. Hagan,
I got a second opinion regarding the cataract surgery for my RE and have decided to go with him since he seems to have a lot of experience with cataract patients who have had previous refractive surgery.
His recommendation was conservative, to go with a monofocal lens and steer away from premium IOLs due to the shape and thinness of my right cornea, and to also steer clear from limbal relaxing incisions for my asigmatism.
He will use ORA, which he's experienced in using.
The last decision I need to make is whether or not to pay $1200 extra out of pocket for him to use LenSX laser to do the surgery. He wasn't really trying to up-sell me on it, but he said he felt the outcome might be a little more accurate and lessen the risk of infection slightly.
I've tried to read up on this and the only downside seems to be the added cost. The $1200 would be a sacrifice but I'm willing to pay it if it's worth it. Some things I read make me hesitate, that there is no real evidence that visual outcome would be better, especially given that I am going with a standard IOL. I am leaning toward using laser to give myself every advantage of best visual outcome since I'll be living with this a long time, but the cost makes me hesitate.
Any thoughts on whether using LenSX laser would be worth it?
I got a second opinion regarding the cataract surgery for my RE and have decided to go with him since he seems to have a lot of experience with cataract patients who have had previous refractive surgery.
His recommendation was conservative, to go with a monofocal lens and steer away from premium IOLs due to the shape and thinness of my right cornea, and to also steer clear from limbal relaxing incisions for my asigmatism.
He will use ORA, which he's experienced in using.
The last decision I need to make is whether or not to pay $1200 extra out of pocket for him to use LenSX laser to do the surgery. He wasn't really trying to up-sell me on it, but he said he felt the outcome might be a little more accurate and lessen the risk of infection slightly.
I've tried to read up on this and the only downside seems to be the added cost. The $1200 would be a sacrifice but I'm willing to pay it if it's worth it. Some things I read make me hesitate, that there is no real evidence that visual outcome would be better, especially given that I am going with a standard IOL. I am leaning toward using laser to give myself every advantage of best visual outcome since I'll be living with this a long time, but the cost makes me hesitate.
Any thoughts on whether using LenSX laser would be worth it?
1 Comments
There is no definitive study that shows the LenSX femtosecond laser lowers complications compared to standard cataract surgery. During the "learning curve" of the first 50-100 cases the complication rate of the femtosecond laser laser is often higher than the standard surgery. Our practice does not feel it necessary and it adds a huge burden of expense on both doctor and patient. So no I don't think its necessary or that it adds a premium of success to the standard cataract surgery. The ORA technology is helpful for IOL power and alignment. If I were having cataract surgery on myself which I don't have or need as of today (5/9/16) I would pass on femtosecond laser but OPT for ORA technology.
Thank you all for your suggestions regarding finding a qualified surgeon for a 2nd opinion. Interesting..... I went to the Trulign surgeon locator at http://trulign.com/en-us/surgeonlocator.aspx and low and behold, there is only one surgeon listed in a 100 mile radius of my zip code.... and that is the surgeon I went to last week! That was a good sign... I will take your suggestions and get a second opinion for my peace of mind.
I managed to dump my wife this summer "launching" her so now she insists I not touch her kayak launching or docking. We decoded to go with SOTs after seeing several deep well kayaks wrapped around trees and underwater in Colorado and Wyoming.
SOTs are my favorite.
Easy on, easy off. You can launch them anywhere you can walk to the water. Grounded on a sandbar? No problem.
Sit sideways dangling your legs in the water? Go for it!
Comfort and ease of use makes the SOT my kayak of choice.
Easy on, easy off. You can launch them anywhere you can walk to the water. Grounded on a sandbar? No problem.
Sit sideways dangling your legs in the water? Go for it!
Comfort and ease of use makes the SOT my kayak of choice.
Got a kayak thing going here. My wife kayaks and since she has two I sometimes go with her. We now us the sit on top and not the "real" kayaks.
Yes do get several opinions. Go with the one you feel most comfortable with and who has the best reputation. Often this is NOT the one your optometrist sends you to whom the optom often has an undisclosed to you "co-management" kick-back/fee splitting arrangement.
JCH MD
Yes do get several opinions. Go with the one you feel most comfortable with and who has the best reputation. Often this is NOT the one your optometrist sends you to whom the optom often has an undisclosed to you "co-management" kick-back/fee splitting arrangement.
JCH MD
My brother in law had recently had cataract surgery and was glasses free, which leaned me towards the Crystalens/Trulign IOLs for my cataracts. My optometrist recommended the 1st surgeon I consulted.
For 2nd and even 3rd opinions, I looked at the "Surgeon Locator" link at the Crystalens website.
http://crystalens.com/en-us/surgeonlocator.aspx
Check the websites and see which surgeons offer different lenses, to avoid a one lens fits all type of practice. When you get that 2nd opinion, ask LOTS of questions.
For 2nd and even 3rd opinions, I looked at the "Surgeon Locator" link at the Crystalens website.
http://crystalens.com/en-us/surgeonlocator.aspx
Check the websites and see which surgeons offer different lenses, to avoid a one lens fits all type of practice. When you get that 2nd opinion, ask LOTS of questions.
Try contacting a local university opthamology program. They may be able to offer some names.
SoftwareDeveloper and Dr. Hagan, thank you so much for your responses. You have addressed all the various concerns I have and you have pointed me to some very good information, including studies on Trulign lenses as well as other posts on this forum. I am feeling more confident as I go forward in making an informed decision.
The only piece that is still missing is knowing the best way to find a surgeon in the Dallas area with lots of experience with cataract surgery on eyes that have had refractive surgery in the past, preferably with ORA experience as well. I have consulted with one such doctor who will probably do a great job but would feel better about seeking a second opinion from another qualified doctor - for my peace of mind if nothing else.
If you have any advice please let me know. I called Alcon today to ask them what doctors they might recommend who use the ORA system, but they referred me to reclaimyourvision.com which didn't really help because there was no way to filter all the results with doctors using ORA - in fact that wasn't even one of the search criteria.
So other than googling "ORA", "Cataracts", and "Dallas", do you have any advice as I seek a second opinion? Thanks so much for all your time!!!!
The only piece that is still missing is knowing the best way to find a surgeon in the Dallas area with lots of experience with cataract surgery on eyes that have had refractive surgery in the past, preferably with ORA experience as well. I have consulted with one such doctor who will probably do a great job but would feel better about seeking a second opinion from another qualified doctor - for my peace of mind if nothing else.
If you have any advice please let me know. I called Alcon today to ask them what doctors they might recommend who use the ORA system, but they referred me to reclaimyourvision.com which didn't really help because there was no way to filter all the results with doctors using ORA - in fact that wasn't even one of the search criteria.
So other than googling "ORA", "Cataracts", and "Dallas", do you have any advice as I seek a second opinion? Thanks so much for all your time!!!!
1 Comments
You could also try searching for "intraoperative aberrometry dallas". I don't know how close Fort Worth is, I recall hearing that referred to as an overlapping metropolitan area. You could try asking optometrists since of course they can't do surgery, or if you know of a surgeon that doesn't offer intraoperative measurements then ask their office who they would recommend who might. Also some cities like Denver have a local magazine (or perhaps a newspaper) that rates the best specialists by asking local doctors who they would go to for treatment, you might check to see if one around there has done that.
Thank you for your information on RD. I was getting the responses mixed up and I didn't acknowledge your input in addition to Dr. Hagan's. . I appreciate it very much! It is very reassuring to hear from others who have had experience with what I"m going through. Please, if you have any advice for me with regards to the questions I just posted regarding how to find data on effectiveness of Trulign lenses, whether to only go with a surgeon who uses ORA, please let me know. In the meantime I'll surf the other threads to see what else I can find.
4 Comments
In your case if you are dealing with an experience surgeon and a experienced surgical team that has done at least 50 or more ORA the extra cost might be useful to double check the IOL power. I would urge you to read all the posts here from people that paid a lot extra for multifocal and accommodating IOLs are are wildly unhappy with the vision, the glare (called dysphotopsia), the need to wear glasses, the poor night vision. Then make your own decision. Remember as I said in my article there is strong efforts made in many offices by both staff and surgeons to "upgrade" to these extra add-ons. Today in the office I saw 7 patients coming in for their final post cataract operation. All had monofocal IOLs except one with a toric IOL. All were very very happy with the results their vision, their vision with and without glasses. That's really all I have to say.
In terms of ORA, there is another thread where some links have been posted in the last day or so. In terms of IOL choice, as the doctor notes, it is of course important to be aware of the risks if you choose a non-monofocal, but of course even with monofocal lenses some people have problematic halos (someone posted a thread about that this week). Most people who get premium lenses are happy with the choice, so the posts you see online are skewed because its usually only the minority with a problem that post. That said, obviously you could be unlucky and be in the minority. One thing to be aware of is that the average cataract patient in the US is in their mid seventies last I checked, so their needs are typically a bit different than someone around 50 or so who needs to live with the results longer and is likely on average to be more active currently. People around our 50 also have more accommodation to lose compared to someone in their mid 70s, who also has had decades to adapt to losing near vision (vs. in my case still fighting it off with multifocal contacts before I got cataracts to avoid dealing with reading glasses).
Even though they prefer not to need to do a lens exchange since any surgery of course adds risk, overall the lens exchange isn't that much riskier than cataract surgery which is fairly safe. So I figured that at my age it was worth some risk of a better result.
Some doctors are inherently conservative and steer patients towards the least risky option, sometimes to avoid dealing with the minority that have complications.
In terms of the Trulign's performance: Figure 5 shows a chart of average visual acuities at various distances with the Trulign compared to monofocals:
http://crstoday.com/pdfs/crst0613_CS_pepose.pdf
"The mean monocular distance visual acuity in the eyes implanted with the Trulign Toric IOL was 20/25, the mean uncorrected intermediate visual acuity was 20/22, and the mean uncorrected near visual acuity was 20/39. ....
In comparison, the mean distance-corrected visual acuities at intermediate and near with the Trulign Toric are 20/22 and 20/39, close to double that of the nonpresbyopia- correcting monofocals. The data for all of the IOLs in this figure are visual acuities obtained through the patient’s distance correction. This obviates the effect of any residual refractive error and demonstrates the true inherent performance of each IOL as if each patient had achieved a perfect plano refractive outcome. This enhanced through-focus with the Trulign Toric is also evidenced by the lower 1.45 D required near spectacle add for the Trulign Toric IOL compared with the 2.50 D required near spectacle add for the monofocal nonpresbyopia-correcting IOLs."
A larger version of the same chart is in this presentation to the FDA on page CL-9:
http://www.fda.gov/ucm/groups/fdagov-public/@fdagov-afda-adcom/documents/document/ucm347590.pdf
There is a good chance of good intermediate vision, even if you might need readers for near, and intermediate is used for many things, from social distance to computers to many household tasks, to finding your footing hiking/running on a rocky/icy trail. Although monovision can also be used to improve intermediate, if both eyes have good intermediate that improves stereopsis, 3D perception.
Even though they prefer not to need to do a lens exchange since any surgery of course adds risk, overall the lens exchange isn't that much riskier than cataract surgery which is fairly safe. So I figured that at my age it was worth some risk of a better result.
Some doctors are inherently conservative and steer patients towards the least risky option, sometimes to avoid dealing with the minority that have complications.
In terms of the Trulign's performance: Figure 5 shows a chart of average visual acuities at various distances with the Trulign compared to monofocals:
http://crstoday.com/pdfs/crst0613_CS_pepose.pdf
"The mean monocular distance visual acuity in the eyes implanted with the Trulign Toric IOL was 20/25, the mean uncorrected intermediate visual acuity was 20/22, and the mean uncorrected near visual acuity was 20/39. ....
In comparison, the mean distance-corrected visual acuities at intermediate and near with the Trulign Toric are 20/22 and 20/39, close to double that of the nonpresbyopia- correcting monofocals. The data for all of the IOLs in this figure are visual acuities obtained through the patient’s distance correction. This obviates the effect of any residual refractive error and demonstrates the true inherent performance of each IOL as if each patient had achieved a perfect plano refractive outcome. This enhanced through-focus with the Trulign Toric is also evidenced by the lower 1.45 D required near spectacle add for the Trulign Toric IOL compared with the 2.50 D required near spectacle add for the monofocal nonpresbyopia-correcting IOLs."
A larger version of the same chart is in this presentation to the FDA on page CL-9:
http://www.fda.gov/ucm/groups/fdagov-public/@fdagov-afda-adcom/documents/document/ucm347590.pdf
There is a good chance of good intermediate vision, even if you might need readers for near, and intermediate is used for many things, from social distance to computers to many household tasks, to finding your footing hiking/running on a rocky/icy trail. Although monovision can also be used to improve intermediate, if both eyes have good intermediate that improves stereopsis, 3D perception.
Also, although multifocals usually aren't considered a good bet in people with prior refractive surgery so its not likely a good bet in your case, many surgeons will do scans to see how regular the cornea is to see if they think a patient might still be a good candidate since some are, depending on how regular their cornea is. Multifocals have a higher risk of halo&glare issues, but the latest low add Tecnis lenses have a lower risk than the older lenses that turned many doctors off to multifocals.
=
7 Comments
I would like to ask for a clarification. You said your glasses RX was -3.25 RE and -9.50 LE but you said you had PRK on LE. Don't you mean you had PRK on RE since its so much less myopic than your LE?
As for the risk of RD. Assuming that prior to PRK you were about -9.25 myopia in both eyes your risk of RD (assuming no family hx or RD, no retinal pathology such as holes or extensive lattice, no severe trauma) is about 1 in 500 to 1000. After uncomplicated phaco cataract extraction your risk will be about 1 to 4%. Here is a link to a study and discussion to a study with post cataract surgery risk of RD in high myopes within 7 years of 2.4% http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2699196/
I believe the risk of RD can be reduce using procedures I've used in my practice for many years. I have the retina examined by a retina surgeon. Any risk increasing lesions are treated by the retina surgeon with laser or freezing. Examples are extensive lattice degeneration and retinal holes/tears. After the retina surgeons okays the procedures I have the retina surgeon check the patient again about 7-14 days after surgery since with the cataract gone the view is much better again looking for high risk lesions. The patient knows the symptoms of possible RD such as increased floaters, flashes or loss of peripheral vision. Knows which activities to avoid (such as theme park rides that whip the head about) Using this the risk of RD in high myopes has been no higher than 1%. Know that young high myope males are an especially high risk group in my experience. Do let me know if you posted in error and your RE had the PRK.
As for the risk of RD. Assuming that prior to PRK you were about -9.25 myopia in both eyes your risk of RD (assuming no family hx or RD, no retinal pathology such as holes or extensive lattice, no severe trauma) is about 1 in 500 to 1000. After uncomplicated phaco cataract extraction your risk will be about 1 to 4%. Here is a link to a study and discussion to a study with post cataract surgery risk of RD in high myopes within 7 years of 2.4% http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2699196/
I believe the risk of RD can be reduce using procedures I've used in my practice for many years. I have the retina examined by a retina surgeon. Any risk increasing lesions are treated by the retina surgeon with laser or freezing. Examples are extensive lattice degeneration and retinal holes/tears. After the retina surgeons okays the procedures I have the retina surgeon check the patient again about 7-14 days after surgery since with the cataract gone the view is much better again looking for high risk lesions. The patient knows the symptoms of possible RD such as increased floaters, flashes or loss of peripheral vision. Knows which activities to avoid (such as theme park rides that whip the head about) Using this the risk of RD in high myopes has been no higher than 1%. Know that young high myope males are an especially high risk group in my experience. Do let me know if you posted in error and your RE had the PRK.
You are correct, it was my right (non-dominate) eye that had PRK in 1995, and this is the eye that now has the cataract. Thanks for catching that.
By the way, I'm not completely sure what my prescription is in my right eye. Post-PRK, I wore GP contacts and had wonderful vision in both eyes, but I just couldn't tolerate the discomfort, dislodging, bloodshot eyes, etc... and stopped using them after a few years. Then I switched to daily soft disposables which were supremely comfortable but had compromised vision, especially in my right eye.
I wore -3.25 soft contact in my right eye for a long time because that was the closest that the optometrist could get when refracting me.(My vision was blurry but I assumed it was due to the misshaped cornea.... later due to the cataract which I didn't know I had)
When I went for my first cataract evaluation last week, the doctor wrote me a prescription for glasses since he said I'd need to be out of contacts for a few weeks. The right eye requires a stronger lens than I had expected. The glasses prescription from last week is:
OD:
Sph -7.00
Cyl -1.25
Axis 060
OS:
Sph -9.25
Cyl -2.00
Axis 122
For the first time in 30 years I'm wearing glasses and I'm pretty miserable. Everything looks so distorted because of the thickness of the lenses and the difference between the two - plus the cataract is distorting my vision as well. Wearing the glasses is making me nauseated - I hope it will improve since I have to wear these glasses for a few weeks before the cataract surgery.
Anyway, thanks for the information about Retinal Detachment. There is no family history of retinal problems. I read the article you mentioned and I think I will get my eyes checked by a retinal specialist before and after as you mentioned. In the article, there is a line I was hoping you could explain:
"The intraoperative maintenance of an intact posterior capsule is important in reducing the risk of RRD"
I would love to hear any additional advice you might have for me as I make decisions. So assuming a retina doctor gives me the "ok" to have cataract surgery, my biggest questions are:
1. Is there any good reason NOT to get toric IOLs, other than added expense? I know they can shift but the doc said in the event this happens he would most likely be able to reallign them.
2. Is there any good reason NOT to get Trulign (toric AND accomodating) lenses, other than increased cost? My gut is telling me to give myself every opportunity to be able to see near and far without glasses, but I know Trulign/Crystalens IOLs don't always deliver this. But if the biggest risk to getting Trulign is that I'll be out that money and I'l be left with a very expensive toric IOL that doesn't accommodate, I would be willing to spend the extra money. If, however, the Trulign lenses will result in poorer overall vision than if I had gone with a non-accomodating toric IOL, then maybe I would skip doing Trulign and go for a toric IOL
3. Since it's trickier to determine IOL strength in post-refractive surgery eyes, should I not even consider mono-vision or mini-mono? I'd be open to doing this since I tend to use my rignt (non-dominate) eye to read with when my contacts are out anyway. The doctor didn't seem to think this was a good choice for me (maybe due to the PRK?) and recommended Trulign lenses instead.
4. If my right eye cataract surgery goes well, I am leaning toward getting my left eye done too - or do you think I'd do fine with wearing a contact in my left (dominate eye) until the day comes where it too has a cataract? What would you do in my shoes? Honestly, I would be so thrilled to be able to wake up and see clearly in the morning without contacts or glasses (and I'd be ok if I needed to wear light readers... of course I'd rather not have to, but I'm also realistic) - but I'm a little gun-shy about getting voluntary surgery in my left eye since the last time I had voluntary eye surgery (right eye PRK) it didn't go so well.
Thanks for any advice you can give me. I appreciate your willingness to help people on this forum.
By the way, I'm not completely sure what my prescription is in my right eye. Post-PRK, I wore GP contacts and had wonderful vision in both eyes, but I just couldn't tolerate the discomfort, dislodging, bloodshot eyes, etc... and stopped using them after a few years. Then I switched to daily soft disposables which were supremely comfortable but had compromised vision, especially in my right eye.
I wore -3.25 soft contact in my right eye for a long time because that was the closest that the optometrist could get when refracting me.(My vision was blurry but I assumed it was due to the misshaped cornea.... later due to the cataract which I didn't know I had)
When I went for my first cataract evaluation last week, the doctor wrote me a prescription for glasses since he said I'd need to be out of contacts for a few weeks. The right eye requires a stronger lens than I had expected. The glasses prescription from last week is:
OD:
Sph -7.00
Cyl -1.25
Axis 060
OS:
Sph -9.25
Cyl -2.00
Axis 122
For the first time in 30 years I'm wearing glasses and I'm pretty miserable. Everything looks so distorted because of the thickness of the lenses and the difference between the two - plus the cataract is distorting my vision as well. Wearing the glasses is making me nauseated - I hope it will improve since I have to wear these glasses for a few weeks before the cataract surgery.
Anyway, thanks for the information about Retinal Detachment. There is no family history of retinal problems. I read the article you mentioned and I think I will get my eyes checked by a retinal specialist before and after as you mentioned. In the article, there is a line I was hoping you could explain:
"The intraoperative maintenance of an intact posterior capsule is important in reducing the risk of RRD"
I would love to hear any additional advice you might have for me as I make decisions. So assuming a retina doctor gives me the "ok" to have cataract surgery, my biggest questions are:
1. Is there any good reason NOT to get toric IOLs, other than added expense? I know they can shift but the doc said in the event this happens he would most likely be able to reallign them.
2. Is there any good reason NOT to get Trulign (toric AND accomodating) lenses, other than increased cost? My gut is telling me to give myself every opportunity to be able to see near and far without glasses, but I know Trulign/Crystalens IOLs don't always deliver this. But if the biggest risk to getting Trulign is that I'll be out that money and I'l be left with a very expensive toric IOL that doesn't accommodate, I would be willing to spend the extra money. If, however, the Trulign lenses will result in poorer overall vision than if I had gone with a non-accomodating toric IOL, then maybe I would skip doing Trulign and go for a toric IOL
3. Since it's trickier to determine IOL strength in post-refractive surgery eyes, should I not even consider mono-vision or mini-mono? I'd be open to doing this since I tend to use my rignt (non-dominate) eye to read with when my contacts are out anyway. The doctor didn't seem to think this was a good choice for me (maybe due to the PRK?) and recommended Trulign lenses instead.
4. If my right eye cataract surgery goes well, I am leaning toward getting my left eye done too - or do you think I'd do fine with wearing a contact in my left (dominate eye) until the day comes where it too has a cataract? What would you do in my shoes? Honestly, I would be so thrilled to be able to wake up and see clearly in the morning without contacts or glasses (and I'd be ok if I needed to wear light readers... of course I'd rather not have to, but I'm also realistic) - but I'm a little gun-shy about getting voluntary surgery in my left eye since the last time I had voluntary eye surgery (right eye PRK) it didn't go so well.
Thanks for any advice you can give me. I appreciate your willingness to help people on this forum.
I'm kind of in a time bind today so I'll answer you question in part. The most common operative complication of cataract/IOL surgery is tearing of the posterior capsule (the back wall of the lens) with or without vitreous loss. It occurs in perhaps 1% of cases. If this occurs in a high myope the risk of RD may be as high as 10-15%. All surgeons do everything possible to avoid a capsular tear but even the most gifted surgeon will have it occur in one out of 100 to 200 cases. 20 years ago the tear rate was 3-5% so its much safer now. More later.
Besides seeing a retina physician I would get a second opinion from the best cataract/refractive surgeon ophthalmologist you can easily reach. This is especially true if your optometrist sent you to the cataract surgeon. Many to most optometrists "co-manage" cataract and refractive surgery. This means they get a splitting of the surgical fee in return for providing nominal eye care. It's legal but in my opinion unseemly and it directs the patient not necessarily to the best surgeon but one willing to split the surgical fees.
I would suggest you NOT consider a multifocal lens for the many reasons outlined many times here: its much more expensive, it it more complication prone, the optics are not as good, the night vision is worse, dyphotopsia much more common. A toric IOL would be okay. When you see the retina surgeon and get your second opinion from another cataract/refractive surgeon ask if there is ANY cataract formation on your other eye. Likely there is. Also BTW your increase in myopia in the RE from -3.25 to -7.25 is due to the cataract. Most cataracts make the eye MORE myopic and its called pseudo (false) myopica. More later
I would suggest you NOT consider a multifocal lens for the many reasons outlined many times here: its much more expensive, it it more complication prone, the optics are not as good, the night vision is worse, dyphotopsia much more common. A toric IOL would be okay. When you see the retina surgeon and get your second opinion from another cataract/refractive surgeon ask if there is ANY cataract formation on your other eye. Likely there is. Also BTW your increase in myopia in the RE from -3.25 to -7.25 is due to the cataract. Most cataracts make the eye MORE myopic and its called pseudo (false) myopica. More later
At least one study suggests that it isn't clear from exisiting data (at least at that time) that cataract surgery does increase the risk of retinal detachment in high myopes.
http://www.healio.com/ophthalmology/cataract-surgery/news/print/ocular-surgery-news-europe-edition/%7Beba0a53b-ec0c-4615-9d80-8b32ce13e0d2%7D/cataract-surgery-not-apparent-risk-factor-for-retinal-detachment-in-highly-myopic-eyes-study-finds
'Cataract surgery not apparent risk factor for retinal detachment in highly myopic eyes, study finds ...
Although retrospective, the study is by far the largest available on the topic. The relatively high incidence of RD confirmed the results of the majority of published studies, in which RD rate ranges between 0% and 3.2%. Only two studies, one by Colin and one by Ripandelli, showed different results, “but I don’t think they have a negative influence on this discussion,” Dr. Neuhann said. “However, in order to decide whether this risk rate is elevated by cataract surgery, we need to know the frequency of spontaneous retinal detachment in high myopic eyes.”
No large epidemiological study has ever demonstrated that the retinal detachment rate following cataract surgery is different from that of spontaneous retinal detachment in myopes with comparable axial length.'
I haven't explored further to see whether later studies contradict the point they make. Studies on retinal detachment after cataract surgery note higher rates for high myopes than others. Their point is that the rate of RD for high myopes is already high, so the rates need to be compared to the rate of non-operated high myopes.
http://www.healio.com/ophthalmology/cataract-surgery/news/print/ocular-surgery-news-europe-edition/%7Beba0a53b-ec0c-4615-9d80-8b32ce13e0d2%7D/cataract-surgery-not-apparent-risk-factor-for-retinal-detachment-in-highly-myopic-eyes-study-finds
'Cataract surgery not apparent risk factor for retinal detachment in highly myopic eyes, study finds ...
Although retrospective, the study is by far the largest available on the topic. The relatively high incidence of RD confirmed the results of the majority of published studies, in which RD rate ranges between 0% and 3.2%. Only two studies, one by Colin and one by Ripandelli, showed different results, “but I don’t think they have a negative influence on this discussion,” Dr. Neuhann said. “However, in order to decide whether this risk rate is elevated by cataract surgery, we need to know the frequency of spontaneous retinal detachment in high myopic eyes.”
No large epidemiological study has ever demonstrated that the retinal detachment rate following cataract surgery is different from that of spontaneous retinal detachment in myopes with comparable axial length.'
I haven't explored further to see whether later studies contradict the point they make. Studies on retinal detachment after cataract surgery note higher rates for high myopes than others. Their point is that the rate of RD for high myopes is already high, so the rates need to be compared to the rate of non-operated high myopes.
If you use a toric IOL on your RE and want to use it for reading then you're looking at a post op refractive error of -2.50 to -3.00 depending on how much magnification you want for very small print and how close you would like to hold your reading material and understanding that better reading vision means worse intermediate and distance vision. With a -9.50 refractive error in your LE I see nothing but trouble in having -9.50 LE and -3.00 RE. Glasses and contacts are all going to be difficult. If your surgery goes really well and you are very happy then you many end up having Cataract/IOL surgery LE or if no cataract what is called refractive lens exchanges which is removing a lens that doesn't have cataract and putting in IOL. Most people can get insurance coverage if its pre-authorized and note is made that the eyes cannot work together with glasses and contacts.
Thank you so much Dr. Hagan. It had never occurred to me that the increase strength of my right lens is due to my cataract. I read the article you cited about RD and I feel a bit better in that it's likely that the risk of RD wouldn't necessarily be more if I got cataract surgery than the risk I already have by virtue of being highly myopic.
Thank you for your input on lens strength if I were to try to achieve monovision with the toric IOLs. The more I think about it, the more I am most interested in getting the Trulign toric accomodating IOLs in both eyes. (In answer to your question, the doc said I do have the start of a cataract in my LE but it's not causing problems at all.) I'm open to a clear lens exchange assuming my RE surgery goes well. I'd love to know any potential downsides to getting Trulign lenses, other than the added cost and the eye exercises you need to do post-surgery. Of course there is the potential that they don't really accommodate mid and near distances as well as the marketing brochures give hope for. But is it at least worth a shot? My cataract isn't going to get any better, so it needs to be replaced with something, so should I at least TRY to get an accommodating lens? My gut response is.... yes, I'd like to at least try.
Before I do it, though, I would love to see some objective data on the effectiveness of Trulign lenses at varying distances in a scientific study of a lot of people who have opted for Trulign. My hope is to be able to see distance and mid-range without glasses, and if I need to wear reading glasses for extended reading, I'm ok with that. Where would I be able to find data that shows objective research on the effectiveness of Trulign lenses? I know they're still pretty new, but surely there must be data out there somewhere that summarizes the outcomes of a lot of eyes with Trulign lenses, not just isolated success stories here and there. (Maybe I should post this on a separate thread?)
Last question for you.... My ophthalmologist who discovered my cataract told me that it would be helpful if I had all my records from before my PRK surgery for the cataract surgeon to best determine what strength IOL to implant. This was distressing news because my PRK was done in 1995 and that surgeon has long since retired and I have NO records of any kind other than my memory of wearing -9.0 (RE)and -9.5 (LE) contact lenses before my surgery. I have since read that the usage of Optiwave Refractive Analysis can be helpful in determining IOL strength in eyes that have previously undergone refractive surgery. The surgeon I met with last week uses this technology (in conjunction with other measurements) for determining IOL strength and also for positioning of the IOL during surgery. As I seek a second opinion, do you think it is important that I seek out only surgeons that use ORA due to my previous refractive surgery? If not, how do I find the most qualified surgeons in the Dallas area? I don't know how to find data regarding numbers of successful cataract surgeries performed, etc....
Forgive me for asking about so many things, and especially if these topics are covered in other threads that I haven't seen yet. I just appreciate so much your response to my questions.
Thank you for your input on lens strength if I were to try to achieve monovision with the toric IOLs. The more I think about it, the more I am most interested in getting the Trulign toric accomodating IOLs in both eyes. (In answer to your question, the doc said I do have the start of a cataract in my LE but it's not causing problems at all.) I'm open to a clear lens exchange assuming my RE surgery goes well. I'd love to know any potential downsides to getting Trulign lenses, other than the added cost and the eye exercises you need to do post-surgery. Of course there is the potential that they don't really accommodate mid and near distances as well as the marketing brochures give hope for. But is it at least worth a shot? My cataract isn't going to get any better, so it needs to be replaced with something, so should I at least TRY to get an accommodating lens? My gut response is.... yes, I'd like to at least try.
Before I do it, though, I would love to see some objective data on the effectiveness of Trulign lenses at varying distances in a scientific study of a lot of people who have opted for Trulign. My hope is to be able to see distance and mid-range without glasses, and if I need to wear reading glasses for extended reading, I'm ok with that. Where would I be able to find data that shows objective research on the effectiveness of Trulign lenses? I know they're still pretty new, but surely there must be data out there somewhere that summarizes the outcomes of a lot of eyes with Trulign lenses, not just isolated success stories here and there. (Maybe I should post this on a separate thread?)
Last question for you.... My ophthalmologist who discovered my cataract told me that it would be helpful if I had all my records from before my PRK surgery for the cataract surgeon to best determine what strength IOL to implant. This was distressing news because my PRK was done in 1995 and that surgeon has long since retired and I have NO records of any kind other than my memory of wearing -9.0 (RE)and -9.5 (LE) contact lenses before my surgery. I have since read that the usage of Optiwave Refractive Analysis can be helpful in determining IOL strength in eyes that have previously undergone refractive surgery. The surgeon I met with last week uses this technology (in conjunction with other measurements) for determining IOL strength and also for positioning of the IOL during surgery. As I seek a second opinion, do you think it is important that I seek out only surgeons that use ORA due to my previous refractive surgery? If not, how do I find the most qualified surgeons in the Dallas area? I don't know how to find data regarding numbers of successful cataract surgeries performed, etc....
Forgive me for asking about so many things, and especially if these topics are covered in other threads that I haven't seen yet. I just appreciate so much your response to my questions.
Many people successfully get an IOL in only one eye and wear a contact lens in the other with no trouble, however not all do. I'd suggest the thing to do is to hope for the best, that you can adapt well to having an IOL in only one eye (which is likely), but prepare for the worst in advance, i.e. the possibility you might need to get the other eye operated on even though its still clear (i.e. seeing if the doctor is comfortable with that and checking on whether insurance will cover it).
One potential problem area is when there is a large difference in refraction between the two eyes after one has an IOL implanted for good distance vision (plano, no distance correction required), and the other eye needs a strong prescription.
I checked to see if you'd posted more info about your situation, and see that your profile indicates that your eyes have fairly different prescriptions now and that you "had to wear" contacts after the PRK that left them that way. That suggests you might be familiar with the reason for concerns, that if you wear glasses when the eyes have fairly different prescriptions the image size in each eye may be different and your brain may not be able to merge them easily. The issue is anisometropia (the prescriptions being different in each eye) leading to aneisokonia (perceiving different image sizes). Usually in such cases when you wear contact lenses the difference in image size is less than in glasses, small enough not to be a problem. Everyone's tolerance to prescription differences between their eye's is different, but since you are coping with a fairly large difference now, hopefully that means you can cope with a bit larger one if your IOL eye is set for good distance vision. There isn't that much difference between correcting vision at the IOL plane and at the corneal plane with a contact lens, so the image size is likely not enough to be a concern if you wear a contact lens in the other eye, but there is no guarantee since some people are more sensitive to differences.
Image size isn't the only issue. I don't know if you are as young as the first poster on this page who hadn't yet hit presbyopia, if so it might be hard to adapt to having a lot of accommodation (ability to focus to see near) in your natural eye and not in the IOL eye. Again, I think most adapt to it, though I recall young adult posting here who had a great deal of difficulty adapting to an IOL in only one eye and that seems like it may have been the reason.
Even if you have presbyopia already, an IOL is different from a natural lens in other ways, especially a multifocal, so although most people with a IOL in one eye have no trouble adapting, some people do have issues with the difference in optics between the eyes feeling odd. In my case I had a bad cataract in only one eye when I had my first surgery, the other was still 20/20 correctible with about a -6D contact lens. Once the bandage came off the first eye, I felt a weird sense of imbalance between the two eyes that is hard to describe, I'm not sure if it was the difference in prescription or the difference in optics with the IOL (especially since my other eye had a multifocal contact lens). I may well have been able to adapt to it quickly if I'd given it a chance, but because I'd traveled to Europe to get my surgery I decided to go ahead and get the 2nd eye done to avoid needing to travel back if I didn't adapt quickly. As soon as the bandage came off the 2nd eye, the feeling of imbalance was gone.
One potential problem area is when there is a large difference in refraction between the two eyes after one has an IOL implanted for good distance vision (plano, no distance correction required), and the other eye needs a strong prescription.
I checked to see if you'd posted more info about your situation, and see that your profile indicates that your eyes have fairly different prescriptions now and that you "had to wear" contacts after the PRK that left them that way. That suggests you might be familiar with the reason for concerns, that if you wear glasses when the eyes have fairly different prescriptions the image size in each eye may be different and your brain may not be able to merge them easily. The issue is anisometropia (the prescriptions being different in each eye) leading to aneisokonia (perceiving different image sizes). Usually in such cases when you wear contact lenses the difference in image size is less than in glasses, small enough not to be a problem. Everyone's tolerance to prescription differences between their eye's is different, but since you are coping with a fairly large difference now, hopefully that means you can cope with a bit larger one if your IOL eye is set for good distance vision. There isn't that much difference between correcting vision at the IOL plane and at the corneal plane with a contact lens, so the image size is likely not enough to be a concern if you wear a contact lens in the other eye, but there is no guarantee since some people are more sensitive to differences.
Image size isn't the only issue. I don't know if you are as young as the first poster on this page who hadn't yet hit presbyopia, if so it might be hard to adapt to having a lot of accommodation (ability to focus to see near) in your natural eye and not in the IOL eye. Again, I think most adapt to it, though I recall young adult posting here who had a great deal of difficulty adapting to an IOL in only one eye and that seems like it may have been the reason.
Even if you have presbyopia already, an IOL is different from a natural lens in other ways, especially a multifocal, so although most people with a IOL in one eye have no trouble adapting, some people do have issues with the difference in optics between the eyes feeling odd. In my case I had a bad cataract in only one eye when I had my first surgery, the other was still 20/20 correctible with about a -6D contact lens. Once the bandage came off the first eye, I felt a weird sense of imbalance between the two eyes that is hard to describe, I'm not sure if it was the difference in prescription or the difference in optics with the IOL (especially since my other eye had a multifocal contact lens). I may well have been able to adapt to it quickly if I'd given it a chance, but because I'd traveled to Europe to get my surgery I decided to go ahead and get the 2nd eye done to avoid needing to travel back if I didn't adapt quickly. As soon as the bandage came off the 2nd eye, the feeling of imbalance was gone.
2 Comments
SoftwareDeveloper - Thanks for the response. I think I'm going to go ahead and get the cataract surgery in my right eye since the cataract is pretty pronounced and causes distortion that can't be corrected with contacts. I'll see what happens with my left eye and whether I can wear a contact successfully or have cataract surgery in that eye, too.
Since I'm so nearsighted (-9.5 in my left "clear" eye) I've read that there is an increased risk of retinal detachment, but I really don't know if this risk should prevent me from having the cataract surgery in that eye, especially if my vision is really weird after getting just one eye done.
I'm 50 and have had to use reading glasses for close-up and computer stuff for about 5 years. I wear 1.5 drugstore readers over my contacts. For this reason, I think I'm going to go with Trulign lense, which are Crystalens with toric correction. I know that the accomodation doesn't always work that well, but I want to give myself the best chance for vision at varying differences.
I would be more likely to request monovision and use my right eye for near vision and my left eye for far, but because of the PRK surgery, I know that getting the IOL strength is not an exact science. This whole process, including the decisions, is so stressful since I feel that whatever I decide, I have to live with the rest of my life for the most part.
I think my doctor is annoyed to have a patient with so many questions. I get the impression he's used to have compliant 8o year olds who just go with whatever he recommends. However, this doctor has experience in using the ORA technology which, from my limited research, helps to determine IOL strength and placement, especially for patients who have had previous refractive surgery.
Anyway, it's reassuring to read that others have gone through similar experiences. If anyone has any more information or experiences to add, I'd love to read about them.
Since I'm so nearsighted (-9.5 in my left "clear" eye) I've read that there is an increased risk of retinal detachment, but I really don't know if this risk should prevent me from having the cataract surgery in that eye, especially if my vision is really weird after getting just one eye done.
I'm 50 and have had to use reading glasses for close-up and computer stuff for about 5 years. I wear 1.5 drugstore readers over my contacts. For this reason, I think I'm going to go with Trulign lense, which are Crystalens with toric correction. I know that the accomodation doesn't always work that well, but I want to give myself the best chance for vision at varying differences.
I would be more likely to request monovision and use my right eye for near vision and my left eye for far, but because of the PRK surgery, I know that getting the IOL strength is not an exact science. This whole process, including the decisions, is so stressful since I feel that whatever I decide, I have to live with the rest of my life for the most part.
I think my doctor is annoyed to have a patient with so many questions. I get the impression he's used to have compliant 8o year olds who just go with whatever he recommends. However, this doctor has experience in using the ORA technology which, from my limited research, helps to determine IOL strength and placement, especially for patients who have had previous refractive surgery.
Anyway, it's reassuring to read that others have gone through similar experiences. If anyone has any more information or experiences to add, I'd love to read about them.
Many of the pages that talk about increased risk of retinal detachment after cataract surgery are based partly on old studies back before modern less traumatic surgical techniques came into use. There is still some increased risk, I don't know offhand a good cite for it, but in my case I didn't consider it an issue since I knew I'd have to have cataract surgery on the other eye eventually anyway.
re: "getting the IOL strength is not an exact science"
Yup, I wish I'd explored that more before I got my surgery and made sure they weighted the odds to be more likely to err on the side of myopia in my first eye rather than the slight hyperopia I have. I lose a little bit of near in that eye. There seem to be more laser enhancement approaches to consider for myopic correction than hyperopic (e.g. I don't know if its worth considering, but SMILE for instance is currently only approved for myopic correction and not hyperopic), it sounds like myopic correction is easier.
re: "I have to live with the rest of my life for the most part"
That is the best way to think of it, however in reality the odds are a lens exchange will be possible later on if appropriate, even if you shouldn't count on it. I figure surgery gets safer all the time, and lenses get better, so perhaps in 10-15 years they'll have lenses worth the slight risk of an upgrade.
Obviously I grasp the stress of figuring this stuff out, having been 49 when I was diagnosed and opting to go out of the country for the a new lens 2.5 years later, the Symfony, figuring I've got a some more decades than the typical cataract patient to live with the choice.
Among choices in this country, since I had good luck with multifocal contacts, if I were doing it today I'd likely go with the Tecnis low add multifocal since the acuity results are more predictable (and I think I'd heard high myopes may have less accommodation with the Crystalens), and have lower risk of halos than older high add multifocals. However the Crystalens/Trulign might be something I'd research more if I were doing it here now. There are now corneal inlays intended to deal with presbyopia to give people more near vision that have also been tested with monofocal IOLs, so I suspect they might also improve near vision for a Crystalens if you don't have good results. The Kamra inlay has been approved by the FDA, but the Raindrop is also in the process of getting approved and I suspect it might be a better bet, that it reduces contrast sensitivity less than the pinhole approach used by the Kamra. I know Dr. Hagan who posts on this site doesn't like the idea of inlays, many surgeons are conservative, but there are surgeons who've had them implanted in their own eyes since they consider the results good.
re: "getting the IOL strength is not an exact science"
Yup, I wish I'd explored that more before I got my surgery and made sure they weighted the odds to be more likely to err on the side of myopia in my first eye rather than the slight hyperopia I have. I lose a little bit of near in that eye. There seem to be more laser enhancement approaches to consider for myopic correction than hyperopic (e.g. I don't know if its worth considering, but SMILE for instance is currently only approved for myopic correction and not hyperopic), it sounds like myopic correction is easier.
re: "I have to live with the rest of my life for the most part"
That is the best way to think of it, however in reality the odds are a lens exchange will be possible later on if appropriate, even if you shouldn't count on it. I figure surgery gets safer all the time, and lenses get better, so perhaps in 10-15 years they'll have lenses worth the slight risk of an upgrade.
Obviously I grasp the stress of figuring this stuff out, having been 49 when I was diagnosed and opting to go out of the country for the a new lens 2.5 years later, the Symfony, figuring I've got a some more decades than the typical cataract patient to live with the choice.
Among choices in this country, since I had good luck with multifocal contacts, if I were doing it today I'd likely go with the Tecnis low add multifocal since the acuity results are more predictable (and I think I'd heard high myopes may have less accommodation with the Crystalens), and have lower risk of halos than older high add multifocals. However the Crystalens/Trulign might be something I'd research more if I were doing it here now. There are now corneal inlays intended to deal with presbyopia to give people more near vision that have also been tested with monofocal IOLs, so I suspect they might also improve near vision for a Crystalens if you don't have good results. The Kamra inlay has been approved by the FDA, but the Raindrop is also in the process of getting approved and I suspect it might be a better bet, that it reduces contrast sensitivity less than the pinhole approach used by the Kamra. I know Dr. Hagan who posts on this site doesn't like the idea of inlays, many surgeons are conservative, but there are surgeons who've had them implanted in their own eyes since they consider the results good.
I'm just wondering if you ever got the cataract surgery, or if you are still waiting? I am in a similar situation in that I have one cataract with the other eye still clear. I'd love to hear how your situation turned out and if you are happy with the result.
Thank you all for the comments.
@walkietalkie - We tried glasses/contact in the bad eye. It did not clear the blurriness enough to be worth the cost and trouble of them.
@Ray T Oyakawa, MD - Do you know any experienced doctors in the North NJ area. The person I'm seeing was recommended by my Primary care doctor, while I trust his judgement I'm not tied to him in anyway. I don't have diabetes, as that was one of the first things I asked my doctor about, since I read it can cause them.
Now that I've read abit more about the technologies and such, I think I'm going to try to hold off as long as I can. Hopefully in the next year a new lens or technology will come out that makes it even better. Of course I say this now, a week from now it could be driving me nuts..
@walkietalkie - We tried glasses/contact in the bad eye. It did not clear the blurriness enough to be worth the cost and trouble of them.
@Ray T Oyakawa, MD - Do you know any experienced doctors in the North NJ area. The person I'm seeing was recommended by my Primary care doctor, while I trust his judgement I'm not tied to him in anyway. I don't have diabetes, as that was one of the first things I asked my doctor about, since I read it can cause them.
Now that I've read abit more about the technologies and such, I think I'm going to try to hold off as long as I can. Hopefully in the next year a new lens or technology will come out that makes it even better. Of course I say this now, a week from now it could be driving me nuts..
Is your blurry vision correctable by glasses? If cataract is still early perhaps you want to wait. I had lasik about 12 yrs ago and now have early cataract. I read that doing cataract surgery for post lasik patients is a bit tricky. I am waiting till science is more exact or when the surgeons can gurantee the results to 0.5% error ( similar to insurance NAV)
I had an experience similar to yours recently. First I must say that you should discuss with your doctor the best lens option. Once he discards the options you just can not choose, there is no right or wrong answer.
In my case, my choice was a monofocal lens just on the right eye and I am very happy with the choice, of course I need reading glasses, but its ok, I would need it anyway.
I learned that there are many people that can not adapt to multifocal, so I was afraid to try.
I had a small annoying problem Due to the big power difference (3.75 on LE and now "0" on RE), I can`t use glasses to correct LE, but a contact lens on LE solved this problem very well.
In my case, my choice was a monofocal lens just on the right eye and I am very happy with the choice, of course I need reading glasses, but its ok, I would need it anyway.
I learned that there are many people that can not adapt to multifocal, so I was afraid to try.
I had a small annoying problem Due to the big power difference (3.75 on LE and now "0" on RE), I can`t use glasses to correct LE, but a contact lens on LE solved this problem very well.
MEDICAL PROFESSIONAL
I have seen patients about your age for cataracts due to diabetes. I have implanted Crystalens with good results. HOWEVER, you must find an experienced Crystalens surgeon.
Both eyes will work better together since you still have accommodation in the good eye. A multifocal IOL does not stimulate accommodation.
There are a number of programs to calculate IOL power for post LASIK patients. However, the targets results are not as good as a virgin cornea. This can touched up with a PRK on your flat if needed.
Dr. O.
Dr. O.
Both eyes will work better together since you still have accommodation in the good eye. A multifocal IOL does not stimulate accommodation.
There are a number of programs to calculate IOL power for post LASIK patients. However, the targets results are not as good as a virgin cornea. This can touched up with a PRK on your flat if needed.
Dr. O.
Dr. O.
Have an Answer?
You are reading content posted in the Eye Care Community
Top General Health Answerers
Kansas City, MO
Grand Prairie, TX
San Diego, CA
Discharge often isn't normal, and could mean an infection or an STD.
In this unique and fascinating report from Missouri Medicine, world-renowned expert Dr. Raymond Moody examines what really happens when we almost die.
Think a loved one may be experiencing hearing loss? Here are five warning signs to watch for.
When it comes to your health, timing is everything
We’ve got a crash course on metabolism basics.
Learn what you can do to avoid ski injury and other common winter sports injury.
