Could this be aneisometrophia ?

Yesterday I had my right eye cataract removed a had a IOL implanted.
IOL was a Alcon AcrySof IQ SN60WF 13.0 D.
My LE myopia is 3.75 and astigmatism is 2.0, and now RE myopia is virtually 0 and astigmatism is 0,5.
Although not fully recovered yet, me RE viewing is very good.
But there is a problem.
With glasses for far viewing (I put a plano right lens on it), the images are sharp an clean, but I see double images the confuses my eyes and brain.
The images are clear, but one of them seems a shadow of the second, and when I move my head, the image change positions.
I also noted that the images seen by RE are a little bigger than the same image seen by LE.
I can make the images "merge" if I stay static and look straight ahead.
This sympton happens just when I use glasses, whithout glasses the image is a little blurried (because of the LE) but it is more comfortable.

Is it an aneisometrophia sympton ?
Could this be fixed by a LE IOL implant ?
Is there another solution for this problem ?

I also has a reading glass.
I took its right lens off (now it wrong anyway ...), and with this glass I don`t note this double vision problem and the image for TV viewing for example is very good, almost as good as the far viewing glass. This reading glass LE power is 2.75.

Thanks for any help.

[Houman Vosoghi, MD]

Yes
Yes
You could wear contacts

Most surgeons would make you a 0 power in the first eye only if they were planning to do surgery on the second eye soon.  This would solve the anisometropia which usually is noticeable when there is a greater than 2.5 diopter difference between the two eyes.

HV

[ledbrv]

Dr. Houman,

First of all, thank you very much for tour answer.

I was almost sure that the sympton I described was due to aneisometrophia.

Before surgery we were not considering to do surgery on the LE right now because cataract appeared just on RE.
But my doctor said that, as RE is my dominant eye, and because it is expected that a cataract appear on my LE, we decided to make my RE 0 power for myopia.

It it worked great, the surgery was perfect, as he explained, the cataract, although growing very fast, was still small and centered on my crystalline, so its removal was very easy, surgery took only 6 minutes.

With less that 48 hours past surgery, with my RE pupil still twice the size of LE pupil, I could read most far texts on street (30 or 40m away) without glasses (my LE is still 3.75). Also on my post surgery review, a prelimary acuity exam showed that my final power should be near 0 power for myopia and 0.5 for astigmatism, of course for the final result I should wait for full surgery recovery. My doctor said my acuity was 20/40 and it should get better.

Anyway, this is the good news, but the bad news is this aneisometrophia.

Beside using contact lens, does implanting a IOL on my LE would solve  this problem  ?
Is it possible that implanting a IOL on LE also cause aneisometrophia ?

Before surgery I have my both eyes measured with IOL Master.
Based on IOL Master report, we choose Alcon SN60WF.
For RE we used a 13.0 (REF (D) -0.18). This was the lens implanted.
For LE, based on IOL Master report, I think a good choice would be a 15.0 lens (REF (D) -0.28).
What difference should I consider ? 15-13=2 ? Or -0.28 - (-0.18)=-0.10 ?
Does  "2.5 diopter difference" aply for IOL  too ?
Or for IOL the rule is different ?
There are other options for LE IOL, for example a 14.5 or even a 14.0 lens, but these lens would cause hypermetropia (REF (D) 0.05 e 0.38 respectively). As for as I know its the worse case, one eye with myopia and the other with  hypermetropia, is that right ?


I think that what was made untill now was the correct path of actions.
I didn`t have a choice, the cataract was growing very fast, I would became blind on the right eye on a few months with a so fast growing cataract.
Also, as I said, the result untill now on RE alone is very good.
But now we will have to deal with this aneisometrophia, but I am confident that we will find a good solution.

Again thank you very much for you help.
The tips and clarification I received here at medhelp was very useful.

[Houman Vosoghi, MD]

Difference would be 0.10 if your calculations are correct.  Not the difference between the lenses.  Anisometropia should be solved.  You definitely do not want hyperopia/hypermetropia (you would likely be unhappy).  Safer to be a little myopic than hyper.  If surgery goes well and lens calculations are correct, you will likely be happy after the surgery and need reading glasses only.

HV

[ledbrv]

Dr. Houman,

Once again thanks for your help.
Tomorrow I`ll have my second post surgery review.
As far as I can tell, except from this "aneisometrophia", everything is seems to be perfect.
I will talk to my Doctor about using contacts for now, but I am considering have a IOL implanted on my LE on a few months, if my RE were Ok.
As I have astigmatism on LE, do you think a IOL like AcrySof IQ Toric would be a good option ? Or is it safer to put a non Toric IOL e use glasses to correct astigmatism ? IOL Master astigmatism measured for my LE was Cyl: -0.79 D @83º. I don`t mind using glasses, I prefer a safer choice.

[cwatt1]

Glasses are almost always the safest choice, but to the best of my knowledge the newest generation of the Acrysof Toric IQ has been pretty well received, with very little of the rotational stability problems that previous versions had.  The newest version is reported to be able to correct astigmatism as little as -.75D.  Obviously you should discuss this option with your eye surgeon -- if you do decide to go this route you want to be sure he has implanted a number of these in patients and is comfortable doing so.

[ledbrv]

cwatt1,

Thanks for you comment.
Sure glasses is the safest choice, but as I said I just can`t use it anymore, at least not for distance viewing.
The problem, as I explained above, is that after cataract surgery, power differences are bigger then before.
LE is -3.75 and RE now should be near 0 (I am very happy with it!).

My glasses are correct, if I close one eye or the other, the images is very good.
When I use both eyes the image is still good, but they have different sizes on each eye, so it forces my brain to "merge" the images, and it is a lot of work for the brain and for my eyes, on a few minutes I will have a headache.
There is nothing wrong with the surgery or IOL power choice.
As my RE is the dominant eye, the recommendation is to try to make it as close as possible to plano (0 power), and I think we reach this goal.
Before surgery, I think I already had this problem, but as the difference was smaller (2.25), my brain/eyes could deal with it.
So now I have two choices for my LE, contact lens or IOL implant.
If I had cataract on LE the choice would be simple, IOL implant, but I don`t have it on LE.

I`m in doubt if it is safe to use a toric IOL, or if it is better/safer to use a simple monofocal IOL and correct astigmatism with glasses, I don`t mind using glasses.
I was thinking in trying some solutions with contact lens before decide if I stay with them or put a IOL on LE.
On the other hand, as I already had cataract on RE, the probability of having cataract on LE is big, and as cataract surgery can help the control of IOP (I also have glaucoma), maybe IOL implant would be a good choice.
Too many doubts, but I will discuss with my doctor and I am confident that we will find a good solution.

[Houman Vosoghi, MD]

Toric IOLs are just as safe as monofocal IOLs as long as the surgeon is experienced and places the lens in the eye correctly.  It is worth discussing with your surgeon.  Also could consider limbal relaxing incision which could cancel out about half a diopter of astigmatism in my experience which may be enough to keep you out of glasses after the surgery.  Worth discussing.

HV

[ledbrv]

Dr. Houman,

Thanks for your clarification.
Today I discussed with my doctor about toric x non toric IOL.
He thinks that, as my astigmatism as measured by IOL Master is -0.79, it does not worth the little risk of a toric IOL. He said that, for day to day activities I will not notice this level of astigmatism too much, and I can always use glasses to watch movies or drive at night.
But I still have some time to think.
For now, while we wait for full  recovery of my RE, I decided to try contact lens on LE.
It is funny, because I always said that I would never use contact lens (never say never!).

By the way, my RE recovery is wonderful !
WIth less than a week (my surgery was last friday), my RE acuity is 20/20 already.
That Snellen chart never seemed so sharp and clear before, even before cataract.

Once again thank you very much for you opinion and clarifications.
I must say that you and the other doctors I had the opportunity to talk to here are doing a very helpful job.

[Houman Vosoghi, MD]

Thank you.  You may want to consider the limbal relaxing incision then to lower the astigmatism by another -0.25 to -.50 which will make your without glasses vision even clearer.  Thes are easy to do and have very little down side.  Discuss with your doc next time you see him.

HV

[ledbrv]

Ok. I will talk about imbal relaxing incision on my next surgery review.
Thank you.

[ledbrv]

Dr. Houman,

Just a curiosity.
In my case, without glasses my vision is a little blurry (because LE is -3.75 and now RE is plano) but I feel very comfortable (no eyestrain or headaches).
The glasses causes aneisometrophia/aniseikonia.
As I`ve learned from you and my doctor, contact lens and IOL would solve this problem.
Why does it happen ? I mean, what is the difference from glasses to contacts/IOL that that make glasses cause this sympton and not contacts/IOL  ?
Is it the distance from lens to retina ? (big for glasses, small for contacts/IOL).
Or is it caused by imperfections/limitations of glasses construction ?
From the optical perspective alone, does IOL is better than contacts ? Or they are equivalente ?
Is there a chance that IOL/contacts also cause aneisometrophia/aniseikonia ?
Thanks in advance for your help.

[Houman Vosoghi, MD]

1) it is from the effect of minimization from the nearsighted lens (opposite effect as a magnifying glass) compared to normal sizes seen by the plano eye.  This difference in perceived sizes of objects confuses the brain and leads to the symptoms of anisokonia.  IOL is in the (or near) the nodal point of the eye and focuses directly on the retina and does not have effects of minimization or magnification that external lenses have.  Similarly, since a contact lens contacts or becomes one with your cornea/eye, it lacks the minimification effect of a loose lens held in front of your eye.  Yes theoretically, IOL is better than contacts optically speaking but you are unlikely to tell the difference in reality.  IOL and contacts do not lead to the problem you are having with glasses.

HV

[ledbrv]

I am waiting a LE contact lens I order last week.
I never used contacts before, so I hope I can adapt to it.
It will be a B&L PureVision Toric.
As I learned, it is one of most easy to adapt contacts, I hope so.
If it works for me, it will allow me to wait my RE recovery and also try monovision.
But based on my own experience with IOL on RE, I am almost sure I will have a IOL implanted on my LE on a few months.

Once more thank you for your attention.

[JodieJ]

If you have problems adapting to the Pure Vision toric, you might have an easier time with Focus daily torics.  It is a 1-day contact, so you throw it out at the end of the day.  If that doesn't work, you might try 1-day Acuvue moist.  It does not have astigmatism correction, so you will have to use your spheric equivalent power.

Wearing a contact lens in one eye works for almost everyone between cataract surgeries.  But inserting a contact lens first thing in the morning is not necessarily something you'd want to do long-term.  Why are you waiting a few months to do your second eye?

[ledbrv]

Thanks for you suggestions.
I will take into account your tips on contacts.
The problem is, I m am from Brazil, and things are a little hard to get here.
I want to wait a full recovery of my RE, If contacts works for my LE  it will buy me some time. I also need a better vision as fast as possible.
I don`t have cataract on LE, so surgery is not mandatory, besides a surgery always has  its riskys, even on my case, where the RE surgery was perfect.
I also have to decide if I want monovision or not. It seems a good idea, and contacts would allow me to try it. If I don`t like it, it is reversible, IOL implant is not.
But you are right, an IOL implant is much easier to maintain than contacts, in fact there is no maintenance with IOLs.

[JodieJ]

I have a couple more suggestions for your consideration.  I really loved monovision, although it initially took me a couple of weeks to get used to it.  Mini-monovision (intermediate vision in non-dominant eye) is an easy adjustment for most people.  Your distance vision won't be quite as good, especially with full monovision, and it might not be the best option unless your distance eye is at least 20/25.  In any case, you can experiment with contacts.  By the way, if you need a toric contact in your second eye, you might benefit from a toric IOL.

I developed a cataract in one eye only following retinal surgery.  I had cataract surgery in my second eye (which didn't have a cataract) two weeks after my first surgery.  I had been very nearsighted, and it was bothersome for me to have to insert a contact lens immediately after waking.  But others have no problem doing this for months or even years.

Hope your final outcome exceeds your expectations.

[ledbrv]

Right now I am already experimenting something like a HUGE monovision. This is because my LE is -3.75 e my RE (dominant) now, after cataract surgery, is plano (20/20). My distance view is not that bad, in fact it is much better then before surgery, I can even drive at night without glasses, which I can`t use anyway,  but I know it can get much better. So, I was thinking maybe on mini-monovision, or, as I don`t mind using glasses, I could wear a reading/multifocal glasses to work. I was told that monovision is a good solution to read price tags at supermarket, but to work at least 8 hours a day at computers (my case) a reading glasses would be more comfortable. I also love to watch movies, so a almost perfect distance vision would be great. I have to think carefully. The LE IOL astigmatism power, if I decide to do a surgery, would be -0.75. My doctor thinks it is small and, for the most time, it would not notice it, so we could use a non toric IOL, the remaining astigmatism could be easily corrected with glasses.

Thanks a lot for your tips.

[JodieJ]

What you have now is not any version of monovision--it's just bad vision.  The maximum difference between the eyes for monovision to work is 2.50 diopters (e.g., plano and -2.50).  However, I've read that when the difference between the eyes exceeds 2 diopters, you begin to lose some clarity of intermediate vision.  Everyone may be different--I can only give you my own experience.  With full monovision with contacts (plano and -2), it seemed as if I had continously good vision at all distances--very much like wearing progressive glasses.

Having .75 diopters of astigmatism can noticeably blur your vision.  Try it out with a non-toric contact.  You can try out various powers of contacts to see which works best for you.

[ledbrv]

Of course. You are right. I didn`t explain it right. What I mean is, if even with -3.75 on my non dominant eye I can do a lot of things without problem, with a correct diopters (+/- -1.0) for monovison I will not notice it. Sure I have bad vision now, but to tell the truth, my dominant eye is so dominant, that  for distance vision, I don`t feel too much difference with my LE open or closed. For comparision, I a have a better distance vision now without glasses than I had before cataract surgery with glasses. Anyway, I if decide to do monovision, I will choose a mini-monovision. I work with computers, don mind to wear glasses and want the best possible vision. With these criteria you could say that I don`t want monovision, but with my -3.75 I can see the advantages when I need to do fast reading and my reading glasses are not with me. As for astigmatism, -0.75 is the IOL power if decide to implant it, for contacts or glasses my astigmatism power is -2.0, so my contacts will be toric, but maybe the IOL does not need to be toric.

[ledbrv]

Of course. You are right. I didn`t explain it right. What I mean is, if even with -3.75 on my non dominant eye I can do a lot of things without problem, with a correct diopters (+/- -1.0) for monovison I will not notice it. Sure I have bad vision now, but to tell the truth, my dominant eye is so dominant, that  for distance vision, I don`t feel too much difference with my LE open or closed. For comparision, I a have a better distance vision now without glasses than I had before cataract surgery with glasses. Anyway, I if decide to do monovision, I will choose a mini-monovision. I work with computers, don mind to wear glasses and want the best possible vision. With these criteria you could say that I don`t want monovision, but with my -3.75 I can see the advantages when I need to do fast reading and my reading glasses are not with me. As for astigmatism, -0.75 is the IOL power if decide to implant it, for contacts or glasses my astigmatism power is -2.0, so my contacts will be toric, but maybe the IOL does not need to be toric.

[ledbrv]

Of course. You are right. I didn`t explain it right. What I mean is, if even with -3.75 on my non dominant eye I can do a lot of things without problem, with a correct diopters (+/- -1.0) for monovison I will not notice it. Sure I have bad vision now, but to tell the truth, my dominant eye is so dominant, that  for distance vision, I don`t feel too much difference with my LE open or closed. For comparision, I a have a better distance vision now without glasses than I had before cataract surgery with glasses. Anyway, I if decide to do monovision, I will choose a mini-monovision. I work with computers, don mind to wear glasses and want the best possible vision. With these criteria you could say that I don`t want monovision, but with my -3.75 I can see the advantages when I need to do fast reading and my reading glasses are not with me. As for astigmatism, -0.75 is the IOL power if decide to implant it, for contacts or glasses my astigmatism power is -2.0, so my contacts will be toric, but maybe the IOL does not need to be toric.