Macular pucker & cataracts

I am 76 and in good health, but near sighted,with an astigmatism and now cataracts that are at stage two. Six years ago my eye doctor told me I had a macular pucker. Then two years ago she said it had repaired itself. It could no longer be seen. This year I have a new doctor that at first said I had no macular pucker, but after he diagnosed 2nd stage cataracts and suggested the Restor lens he did a test that did show (in a picture) the macular pucker.  The doctor then suggested Crystalens in the eye with the pucker and Restor in the other eye.. I also have a bad astigmatism which he would correct. I heard that the cataract surgery might worsen the macular pucker and put everything on hold. My question is this: Is it safe for me to go ahead with the cataract surgery or should I wait and see if the macular pucker heals some more?  Would getting the cataracts removed with the correction of the astigmatism or using a multifocal lens  add to the chance that an operation such as a vitrectomy would become necessary?  What would be the safest route?   Thank you  Lois Konet

[John C Hagan III, MD, FACS, FAAO]

No surgery is every totally safe. I can't tell you when to have surgery. Most surgeons would not put a multifocal or a accommodating IOL in an eye with macular disease like a pucker.

You will need to discuss your situation with both a retina Eye MD and a cataract/IOL surgeon Eye MD.  That's two separate opinions.

JCH MD

[LoisK735]

Is astigmatism surgery along with something called a Crystalens usually ruled out when doing cataract surgery on someone with a macular pucker?

[John C Hagan III, MD, FACS, FAAO]

crystalens is a premium (extra cost) accommodating IOL and should be used with caution in an eye with ERM.

Astigmatism surgery or a toric monofocal IOL are not contraindicated by ERM but the benefit may be less apparent to you if the ERM is of significant size.

JCMD

[LoisK735]

Thank you so much for for your help.. I would welcome any other comments from you or others regarding getting cataract surgery when you have a remnant of a macular pucker.  I know I will have to have the cataracts removed sooner or later, but I will wait for awhile because of your advice.   LoisK735

[JodieJ]

Definitely avoid multifocal IOLs (like ReStor) with a macular pucker.  Dr. Oyakawa has reported on this forum that the Crystalens is okay with macular problems.  However, it's been my personal experience that limal relaxing incisions to reduce/alleviate astigmatism offer only a temporary cure.  It's been five years since my cataract surgery, and most of my astigmatism that was eliminated by limbal relaxing incisions has subsequently returned.  My suggestion to you would be monofocal Acrysof toric IOLs.  I'd also suggest that you get a second opinion from another cataract surgeon--a combination of ReStor and Crystalens doesn't sound like a great recommendation to me for someone with your condition.

[LoisK735]

Thank you Jodie for your imput. I had no idea that the relaxing incisions would only temporarily resolve my astigmatism.  Is the Acrysof Toric IOL a permanent fix for this condition? LoisK735

[JodieJ]

My results with limbal relaxing incisions may not apply to everyone.  But I've read that some regression with limbal relaxing incisions is not uncommon.  At the time that I had cataract surgery, the Acrysof toric lens was very new and did not come in the power that I needed.  (I was very nearsighted with moderate astigmatism.)  I think that a toric IOL is the most reliable (and permanent) way to correct moderate/severe astigmatism.  I'd suggest that you consult a surgeon who is experienced with toric IOLs.

[LoisK735]

OK Jodie,  Thanks, Will do that.  Anyone else have some comments on this please let me know.  LoisK735

[PlasV]

Lois, everything I've read suggests that multifocal lenses should be avoided if you have retinal problems or glaucoma problems. In addition to not so perfect focus at all distances, the multifocal lenses typically cut your contrast sensitivity, so if you have problems now distinguishing between subtle differences in shades of gray or close colors, the problem might easily get worse.

FWIW, I asked about accommodating IOLs, but my ophthalmologist said that they have had a number of problems with them and patients getting used to them, and they have stopped offering them for now.

Also, ask your ophthalmologist about aspherical monofocal implants instead of spherical.

I had cataract surgery, and it did not affect my epiretinal membrane (pucker). However, one possible retinal complication to ask your ophthalmologist about is post surgical CME (Cystoid Macular Edema). There are medication protocols to use to minimize this possibility.

[Luvtoski]

You seem knowledgeable about Cataract surgery post ERM surgery.  I had ERM surgery 10 months ago and Cat surgery last week.  My vision in that ERM eye has now improved, but I still have remaining blank spot near my central vision.  My OCT showed my retina thickness before Cat. surgery to be 308 in Fovea but 375 with the average central thickness--which is not back to normal..but had stabilized the past few months.

I am concerned about CME from the Cat. surgery and are on Durezol , Nevanac and Vigamox.   Durezol drop schedule is quite aggressive to help prevent CME.  I won't find out about CME until my 4 wk. post Cat. surgery appt. where he does another OCT.

My question is:  Did you have any CME issues ?  If so, what regimen did your doctor put you on ?
Also, are your Cat. surgery eye and non-surgery eye working well together yet?
Thank you !

[PlasV]

I can't comment on your CME question, as fortunately, I had very little problem in that area. The protocol I was referring to was the pre and post-op NSAIDs and steroid drops to hopefully forestall any CME problems.

Cat surgery was done in both eyes a week apart. The non-erm eye is good, the erm eye needs attention. We did cat first so the surgeon will have a better view of the retina without the cat diffusing the image.

Good Luck.

[Luvtoski]

Thank you PlasV, and good luck to you also.