High Myopia & Cataract Surgery

[vk88]

Dear Doctor,

When I had cataract surgery at age 63 on my left eye, its axial length exceeded the range of their ultrasound instrument.  Since my left eye had lost most of its peripheral vision, my doctor just removed the cataract (no IOL).  With –4D glasses the central aphakia left eye was 20/25.  But I have diplopia; and my brain just ignores the small clearer circular image from my left eye.  Since then, my right eye’s myopia progressed from just a -18D contact lens to a -20D contact lens with a -3D glasses over it.  With glasses over a right -20D contact lens, I was able to see 20/40 (right eye) and drive.

  When I turned 70 in 2008 and my right cataract made driving difficult, I opted for cataract surgery on my right eye.  Its axial length was at the edge of the scope's range, 33mm.  After two weeks of no contact lens wearing, the cornea was measured; and a +6D IOL was ordered.  The cataract surgery in early Dec 2008 was successful (no retinal detachment).  But to get to 20/25, I will have to wear glasses -4D (left) and -10D (right), which is on order.  I don’t know how well I’ll cope with these glasses.  I have several options.  Go to a combination of –4D glasses and a –6D contact lens on the right eye; do LASIK on the right eye to bring it to -4D; or stack a -6D IOL with the existing +6D IOL in my right capsule.  What are the pros and cons of these or other options?  Is there a formula to relate the power of glasses to contact lens to IOLs?

  My long-term concern is over the progressiveness of my myopia.  My brother, a high myope, is going thru at age 73 a regimen of single digit ocular pressure, since higher pressure may lengthen the eye further.  My doctor noted that my left eye has stabilized at –4D since the ocular lens was removed in Jan. 2002.  Might it be that the ocular lens is the main cause of my myopia progressing at this stage?  What is your opinion on the causes of progressive myopia (ocular pressure, cataract lens, etc.)?
  Sincerely,  VK

[Michael J Kutryb, MD]

The progressive myopia is due to an inherited weakness of the tissues of the eye and there can be stretching and elongation of the axial length.  Unfortunately we have no way to slow this down at present.  Thankfully, you have had cataract surgery with no complications and that's no easy task with such myopic eyes.  My personal advice in order of preference would be:
1.  Just wear glasses
2.  Wear contacts for as many years as possible then wear glasses after that.
3.  If cornea is healthy and thick enough, have PRK on both eyes (no suction ring on eye and possibly less retinal detachment risk than LASIK.)
4.  Piggyback IOL to make up the refractive error on both eyes - but definitely a much higher retinal detachment risk than 1,2 or 3.

As you can see, my main priority is the safety of the eye.  Convenience ranks second in my opinion regarding your special circumstances.

MJK MD

[vk88]

Thank you, Doctor, for your quick response.  I agree that the first two options (glasses or contact lens + glasses) would be least risky, given my high myopia.  Could you give a qualitative order of magnitude of the risks involved in PRK versus LASIK versus piggyback IOL?  Is the piggyback IOL different from stacking two IOL inside the capsule?  And I presume the riskiest option would be to try to remove the already implanted IOL itself to make the right eye aphakic as the left.  
    I would appreciate knowing about these riskier options in the event I can't tolerate the imbalance in the glasses (-4D left; -10D right) or if my eye gets too dry to tolerate a contact lens.  
  -VK

[kg17]

I have pathological myopia myself, and terribly dry eyes.  I've been able to stay in contacts lens thru a combination of fish/flaxseed oil 1000mg 3 times daily, Restasis (6 months to work), and four punctal plugs.  I also found that daily disposable lenses (Acuvue) are best for dry eyes.

By the way, do you have a good retinal doc?

[JodieJ]

With a Rx of -4 and -10, specially-made iseikonic glasses would make your vision with both eyes much more comfortable.  These glasses work by changing the base curve and thickness of the lenses to equalize the image-size in each eye.  Unfortunately, it's sometimes difficult to find eye care professionals able to prescribe/make these lenses.  You could try contacting a local optometry school.  The College of Optometry at Ohio State University has a special clinic providing this service--perhaps if you called them, they could help you locate an eye care professional and lab.  Or you could contact me for more suggestions.

I agree with kg17 that Acuvue 1-Day Moist contacts are about the most comfortable ones around.  And this year the 1-Day Acuvue TruEye is scheduled to be introduced in the USA.  (They are already available in the UK and Ireland.)  These are disposable silicone hydrogel contacts which are thinner and reportedly more even comfortable than the Acuvue moist lenses.  

[londonbridge]

Thank you for your information about the iseikionic glasses. This could be useful to me  in the future and I will inquire with Mass Eye and Ear about this. As you know I am planning to go for an explant of my one Restor lens on Wednesday. (Still quite anxious about this). I have been pondering what type of glasses I could get with my left eye hopefully winding up a little near sighted for distance/intermediate and my unoperated eye -8. I will need some type of glasses for reading and over the right eye contact which I use for distance and it would be nice to find something to wear for when I cannot wear my contact, since I am limited to about 10-12 hours a day wearing the contact.
londonbridge

[JodieJ]

The biggest drawback of iseikonic glasses is cosmetic--one lens can be noticeably thicker than the other.  This can be minimized by choosing smaller frames and using higher index aspheric lenses.  For something to wear after removing your contact lens, they should work well.

[Myra112]

i don't understand why my doctor is not going to put in an intraocular lens which will  fully correct my myopia in my right eye following cataract removal soon. I currently wear glasses to correct for -11 in my right eye and -8 in my left. He will put in an iol for which I will need to wear a -4 lens. The cataract has developed following 2 retinal detachments in my right eye.  Myra