Floaters causing bad night vision in only "good eye"

[sjsjin]

I'm about 20 mos post-op after cataract replacement surgery in both eyes, and 12 mos post-op after a PPV for an RD involving the macula in my left eye, in-office laser to "fix" a peripheral tear a few weeks later, followed by another PPV as the tear repair was botched and allowed my retina to become 40% detached again. OCT shows subretinal fluid directly under the macula has failed to dissipate completely, and scar tissue within and on top of the macula. I have significant aniseikonia as in the center of my left vision field appears to "squashed" horizontally, worsened by "fun house mirror" distortion and a large blind spot immediately to the right of center. To read or work at a computer, I must completely occlude the left lens of my reading glasses. My left eye was less myopic and very dominant prior to all the surgeries, but my brain seemingly cannot make the now "better" image from my right eye dominant.

The aniseikonia results in double vision and bad depth perception beyond roughly arm's length, so I occlude only the center of the left lens of my glasses when driving so I retain some peripheral vision to my left. My right eye now has so many floaters that my daytime central vision is completely clear only 10-20% of the time, with the balance ranging from somewhat cloudy/hazy to the point I cannot discern the road or a vehicle more than a few car lengths ahead of me--it simply disappears into a grayish blob.

When the sun sets, my vision worsens dramatically. If an oncoming vehicle is within a quarter mile or so, the glare is worse than when I had the cataracts and now the glare is constantly spinning and moving around. I cannot see any road markings, potholes, etc. more than 20-30 ft ahead. If I am in heavier traffic at a stoplight, all I can see are headlights, signal lights, and glare--and no markings, edge of the road, curbs, etc. I've had too many close calls (one involving a pedestrian that was totally obscured by the floaters and glare) to continue driving after sunset now.

My job required such extensive independent travel and driving in unfamiliar territory that I was forced to give it up. I have been turned down for even temporary disability until I find a role that doesn't require travel by the insurer. The denial letter makes it clear that they will only consider the fact that my retinal surgeon reports VA in the right eye as 20/25, and 20/50 in the left. The value for my right eye is the best individual result over about 4 office visits when my vision was uncompromised by floaters. When the pinholes are flipped into place, I see nothing but a sharper image of "webby" floaters that darkens and completely obscures all characters of any size on the chart. The VA for my left eye is with averted vision and taking as much as 10-15 seconds to discriminate each individual character. Even with that, I cannot discern the difference between Y and V, or between H, M, and N.

My retinal surgeon says he has no way to quantify how poorly my vision degrades in low light or in the presence of oncoming headlights. He said there is far too high a risk of an RD in my right eye, which was more myopic than my left and has a severely tilted nerve, for him to ethically perform a PPV to remove the floaters. He referred me back to my regular ophthalmologist who also seems to be at a loss as to how I might be helped, or how to quantitatively support my contention that I could no longer safely do my job. We did try Alphagan to limit dilation of my right pupil at night, as I told him the problem was clearly worse under very low light, but that was of no help whatsoever.

Are there any standard tests with acceptance by insurers that quantify degradation of night vision in glare from point sources? All my regular ophthalmologist has is a BAT tester, and that doesn't simulate the problem properly.

Also, the tech at my regular ophthalmologists contends that the people at the retinal office are not administering the standard VA test properly so the results reported are not indicative of my true visual function. She claims that VA should be reported as what I can read immediately, without strain or use of averted vision. The retinal office staff always encourages me to take my time and provide a best guess when using averted vision.

How should the VA test be administered and results reported in my situation? The insurer says that with 20/25 vision in my right eye and 20/50 in my left, there is obviously no basis for a disability claim. All my retinal surgeon will put in writing is that I must drive with one eye only, and that eye has a number floaters that make me "uncomfortable with night driving", which the insurer doesn't consider as a valid reason for not driving at night.

Thanks for any input you can provide!

[sjsjin]

Thanks very much, Dr. Oyakawa!

[Ray T Oyakawa, MD]

I would suggest you get a stereo acuity test (general ophthalmologist). A microperimetry which should show some loss of central vision since you have distortion, a multifocal ERG which should confirm the loss of central vision. Using one eye will lead to loss of depth perception and will take a long time to get used to parking and stopping at the right distance (it is harder to adapt to this as your age increases).  You will probably have to get an attorney familiar with disability.

Dr. O.