Cataract surgery and second ERM try?

[oboist]

Hello,
I am a 59 y/o professional musician who would like to be able to read music with both eyes.  I had surgery last July for epiretinal membrane (pucker) due to increasing distortion which was making my left eye useless.  While my surgeon has alluded to the membrane "regrowing," in fact I am quite certain there was a small piece of membrane that he missed (he did say this might have been the case initially, and the distortion has been consistent)..  In addition, post surgery I have had severe aniseikonia (image in left eye is significantly larger as well as distored), myopic shift (correction pre-surgery was -10 and is now -18) and double vision which I use prism lenses over contacts to correct.  It took about four months before I got glasses that helped somewhat, but now I need to deal with the not-unexpected cataract which is causing additional blurring.  

Two main questions:  Has anyone had the combined ERM and cataract surgery?  I would love to know your experience.  It would be really helpful if some has had a second ERM and could comment.   Also, I am uncomfortable having the cataract surgeon my retina specialist recommended do this surgery and would prefer someone with lots of experience with post vitrectomy cataract procedures.  Can anyone recommend someone in New England?  I have to say I am a bit stymied when people suggest "finding a good surgeon" since that seems to be difficult with uncommon procedures.  I've written to the authors of several papers on the subject, but have never received a reply.  

Would appreciate any advice or suggestions.  Because I am so myopic in both eyes, I have found the period of waiting after surgery and then experimenting to find glasses very discouraging.  I'm so tired of not being able to see well!  Thank you.

[JodieJ]

You sound like a good candidate for a second ERM surgery.  I don't know anything about Dr. Kozielec.  If you're not up for a trip to Memphis, then go for it with Dr. K.  Let us know how things work out for you.

BTW, there is some research suggesting that blurring the vision slightly in the affected eye can eliminate the double image.  I attempted to do this on my own, with poor results.  However, it reportedly did work well for cases reported in the medical literature.

[oboist]

I'll be very interested to hear how your vision is after the second peel.  Your description of the distortion you see is similar to mine.  My cataract surgery was very successful, but I was unable to convince the surgeon to deliberately undercorrect with the IOL.  In retrospect, it may not have made much difference.  She did end up undercorrecting by about 2 diopters, and the resulting image is fairly close in the horizontal plane, but the vertical size difference is quite extreme.  The cataract surgeon told me that she's had many ERM peel patients report this same type of distortion, which would make me think  that either many retina surgeons leave behind some membrane, or it in fact is an aftereffect of having had the ERM.  

It's taken me a long time to find glasses that work, and these are not perfect, but my vision is better.  My eyes are able to work together better than they have in three years, but I'm hoping for a bit more improvement next month when I'll have the procedure to clear the capsule (can't remember that acronym).  I only had the bad eye cataract removed since I rely on very acute close vision for making reeds, and even the best reading glasses don't allow the kind of perfect optics I can get with my "good" eye at about 2" away.

I'm still unsure about having a second peel.  The amount of healing time plus the endless rounds of attempts to find the right glasses prescription makes it difficult to keep practicing, and I'm able to function this way.  Not 100% by any means, but tolerable.  I have to say that I find the method used by my current optical shop rather low-tech and it took three tries before they got something that worked at all.  Nice folks, but I didn't like having to make so many trips back.  And I understand that the capsule-clearing procedure may change the prescription yet again.  It gets really expensive, since my insurance will only pay for one pair of glasses, and only that with a lot of hounding.

Good luck to you, and let me know how you do!

Stef

[pirategirl150]

Last Fall, I began to see a slightly blurred secondary scene through my left eye that was superimposed at a slant just below what I was seeing through my right eye. My optometrist did an OCT scan on me and said I had an epi-retinal membrane that needed to be removed immediately. He referred me to a retinal specialist who was supposedly the best in the area. I had a vitrectomy on Mar. 29th, but I have still been seeing a secondary scene, enlarged, blurred, and superimposed at a slant below what is seen through my right eye ever since the surgery.

Follow-up OCTs revealed some remaining traction on the lower left edge of my eye. I suspect that this remaining traction is pulling my retina down and to the right, resulting in the slanted scene. At the 2-month follow-up appointment, I asked the original surgeon whether he would do a second surgery to eliminate the double vision, but he said he wouldn't dream of doing another surgery on my eye. It has been over six months now and nothing has changed, other than the slight worsening of the cataract in my left eye.

My optometrist has now referred me to a different local retinal specialist who is willing to do a second macular peel. It is scheduled for Oct. 21. I am hoping that the slanted double vision will be eliminated so that I can see a coordinated image through both eyes.

If it works, I will follow up with cataract surgery to restore my left eye to the best acuity possible. If the 2nd macular peel doesn't work, I will simply try to ignore the enlarged and slanted scene that is projected just under what I see through my right eye by my left eye. Ignoring it works pretty well most of the time, except that I cannot ignore it in high contrast situations, such as when I'm driving at night.

This problem has made it impossible for me to drive at night for the past six months. I am a graduate school professor and all my classes are offerred at night.  I am 58 years old and didn't begin wearing glasses or contacts until 1998, when I was 46 years old.

The Dr. I am considering for the 2nd surgery is named Dr. Gregory Kozielec. I live in the Dallas-Ft. Worth area.

Jaci

[JodieJ]

I couldn't have been happier with my experience in Memphis.  If I had seen Dr. Charles initially, I believe that I would have avoided a lot of problems.  Based on my personal experience with five of the "best" retinal specialists in metro Chicago, I suspect that many (most?) vitreoretinal surgeons do lack the techniques for peeling small pieces of ERM (as Dr. Charles suggested).  Please don't go with a surgeon who expresses reluctance to operate!  I've communicated with people who did experience reduced acuity and holes in their vision following a second ERM surgery.  Do consider a trip to Memphis.  Dr. Charles' staff are very helpful to out-of-town patients.  (My Illinois Blue Cross worked just fine in Tennessee, and my travel expenses were tax deductible.)  Your follow-up would be with a local retinal specialist.

I think that any good, experienced cataract surgeon would do a fine job with your cataract surgery.  I don't think that you need to see a specialist--most experienced surgeons have seen their share of post-vitrectomy patients.  You might set up consultations with 2 or 3 surgeons, and then choose the one you're most comfortable with.  Don't worry about your second eye--you can wear a contact lens.

Your distortion and larger image size are related to traction and wrinkling from the ERM.  The underlying photoreceptors are pulled inward toward the fovea and compressed.  Incoming light bounces off more receptors, creating a larger image in that eye.  Some recent evidence suggests that the long-term presence of an ERM can cause irreversible damage such that the photoreceptors never return to a normal configuration.  (Frankly, I'm not expecting more improvement in my image size difference.)

Your diplopia is related to the difficulty of fusing two different-sized images.  The larger image size in your affected eye involves only your macular vision; your peripheral vision in that eye is normal.  This is the reason that prisms are thought to be ineffective for retinally-induced diplopia--prisms displace the central image as well as the intact periphery.  (Your case contradicts this theory.)

My objection to using only prisms is that it leaves other symptoms of aniseikonia (like spatial disorientation and a loss of depth perception) untreated.  By changing the powers of your contact lens and glasses' lens, you could significantly reduce the image size in your affected eye.  This might eliminate your diplopia (worked for me!) and reduce your spatial disorientation, too.  There's much more information about this at the opticaldiagnostics website.  You can also download Dr. de Wit's paper, "Retinally Induced Aniseikonia."

But don't worry about making any changes until after you have recovered from your cataract and ERM surgeries.  You do not have a 3+ year delay between ERM surgeries, so (at least theoretically) your prognosis for eliminating the aniseikonia is better than mine.  Please keep me posted.  I'll be happy to answer any of your questions.

    

[oboist]

Just realized I didn't answer a couple of your questions.  Yes, I think the cataract is responsible for the "myopic shift".  A couple of months ago, the cataract was not causing much blurriness, but it's continuing to progress fairly rapidly.  Not the usual "yellowing" but just thickening enough to make things look fuzzy.  I am reluctant to have the other eye done to match since I rely on the very clear (corrected) vision with that eye for reading music, and with it uncorrected for making reeds (perfect vision at about 3" from my eye).  Not sure what the difficulties will be leaving one eye undone, but with the option of a contact lens for that eye, plus glasses, which I need for the prisms and presbyopia, I should be OK.

Don't understand why prisms are thought not to work for retinal problems.  If what you see is two images, regardless of the cause, the prisms just line them up for you.  Pretty straight forward.  You are so right that there is a lot of bad information out there!

[oboist]

Thanks for all the good information and encouragement.  Good timing, as I'm seeing my retina surgeon today.  I'm planning to ask him to recommend someone to do a second ERM, since he has said he's never attempted a second try.  Jodie, I'm so glad your second surgery was so helpful.  Last I'd read, the jury was still out.  I'm assuming you were as happy with your experience in Memphis as everyone else seems to be.

Prism glasses are really annoying, but they make it possible to use both eyes together and eliminate most of the diplopia.  I found an excellent young Australian woman (can't remember her actual title, but she specializes in prescribing prism lenses) in the pediatric ophthalmology sector of the same practice as my surgeon.  The actual ophthalmologist in charge was pretty useless, but apparently he was smart enough to let this bright young person do her job!  I have lingering questions about what caused the diplopia, but whatever it was, it's there to deal with.  Having the two images line up allows my good eye to dominate the image and ignore the distortion enough so that I see a clear image but still get some depth perception, although I still find myself misjudging distances and positions of things at times.

I would still love to get advice on finding a cataract after vitrectomy specialist.  In this area, there are very few doctors who have been "rated" on the sites, and I don't know anyone else who has had this issue.

[JodieJ]

I had a second ERM surgery to remove pieces of an ERM remaining in my eye after an initial ERM peel.  (This was not ERM regrowth.)  My initial surgery in 2006 restored my acuity to 20/20, but it left me with a 15+% larger image in my affected eye.  This caused many problems, including an eye which teared constantly and some intermittent double vision.  My initial surgeon seemed to be clueless about what was causing my symptoms, so I consulted several other "top" local (Chicago) vitreoretinal surgeons.  All of them strongly advised me against having additional surgery, warning me about the possible dire consequences.  ("You can probably find someone who would be willing to dig around in your eye, but you'd certainly lose acuity, and you'll probably end up with holes in your vision.")

It was not until 2009 (following the advice of my general ophthalmologist) that I consulted Dr. Steve Charles in Memphis.  He disagreed with the advice of his Chicago colleagues ("Rubbish!'), suggesting that they lacked the techniques for peeling small pieces of ERM.  I had successful surgery to peel the remaining ERM and ILM the following day.  The next morning I could read the 20/20 line with my affected eye, and I had no holes in my vision.  But my image size difference was unchanged.  Dr. Charles thought that it would take up to 18 months to achieve my final result.

It's been 11 months since my second surgery, and my image size disparity has been reduced by about 50% (from about 15+% to about 8% as measured by the Aniseikonia Inspector).  (All my improvement occurred during my 5th month post-op.)  After reading all the published papers on the topic which I could find and then writing to the authors, I've learned that a second successful ERM surgery does not guarantee that distortion or an image-size disparity will be reduced--i.e., there may be permanent macular damage from the ERM.   The cases with the best prognosis are those with a short duration of symptoms.  SO PLEASE DON'T DELAY YOUR ERM SURGERY.

I've read about good outcomes with combined ERM/cataract surgery.  Dr. Charles has written that outcomes tends to be better when each procedure is done separately.  (So I suspect that Dr. O has given you excellent advice.)  If you chose an experienced, board-certified cataract surgeon, I think you'll do fine.  (BTW, is cataract development the reason for your increased myopia?)  I was a high myope like you, and my Blue Cross paid for the cataract surgery for both my eyes (although one eye had no cataract)--and I was thrilled with the results.

I'm astonished to learn that prism glasses work for you. (Great!)  According to the literature, prisms are ineffective at correcting double vision due to macular problems.  (But so much of the literature on this topic is wrong.)  In my own case, wearing a -3 glasses lens over a +3 contact lens reduces the image size in my affected eye by about 5%, thereby eliminating my symptoms.  (The same effect can be obtained without a contact lens by manipulating the base curve and vertex distance of a glasses' lens.)  There's excellent information about correcting an image size difference with glasses/contacts at Dr. Gerard de Wit's website (www opticaldiagnostics com).

Please feel free to contact me if you have more questions.  I'd be extremely interested in learning your outcome after your second ERM surgery.  



  

[Ray T Oyakawa, MD]

The risk of complication for cataract surgery increase after a pars plana vitrectomy.  I would recommend separate surgeries.  Cataract first, then the ERM.

I have been through both.

Dr. O.

[eyesonyou]

I am really sorry to hear that you experienced further difficulties after the ERM peel.  I don't think they make musical scores in large print, and I can understand the frustration.

I am having an ERM peeled in my left eyes in two days.  But my experience was the opposite of yours.  My cataract in that same eye was already so advanced that it would impede the retinal surgeon's view while removing the macular pucker.  So first I had the cataract removed in January.

You are certainly correct in every way of needing to feel comfortable with your cataract surgeon.  I wish I could advise more.

In the meantime, I will follow your situation here, and I will be posting about my post-surgery experience.