REstore lens, problems with near/intermediate vision

[miria]

I had Restor implant 9/9/09. in R eye for cataract. Now , since the surgery, have good distance  (20/30) but poor intermediate and terrible near vision. When I try to read, I only see bar codes, squiggles, not letters. Tried over the counter readers, and use 2.75 (probably could benefit from stronger ones, but that was highest the store had). Before the surgery, I had only a mild Rx for reading,and did not always bother with reading glasses. This was a big shock and very surprising, as restor was supposed to help with both distance and near vision, and near got much worse.
The surgeon says I have an opaque capsule  and that he could do a laser procedure, but I've had several opinions since, and was told that the capsule doesn't explain the problem with near vision, and it could help with acuity but only marginally, minimially,  with reading. Besides, it would make any future lens removal very difficult.

Here is a summary of  several opinions.
One MD says that my pupil does not contract for near vision, and recommended pilocarpine, 4x daily, 1% strength. I had immediate benefit, but after only 2 days of using it, woke up in the night with pain, tearing, red eye, swollen lid. He said I had allergic reaction, and suggests lower dosage with anti-inflammatory drops (prednisolone). I was actually taking prednisolone post-surgery, though at a low dosage  , until the day  before I started the pilocarpine, so I must had have  at least some protective effect of anti-inflammatory drops in my system,. Now it's almost 6 weeks later, since I took the pilocarpine and had the allergic reaction,  the redness etc. is gone, but I continue to have pain (sudden sharp pains, and pulsations/spasms). I am afraid to try pilocarpine again. He said sometimes you can take it for only 6 mo., and the pupil changes and contracts for reading; sometimes you need it indefinitely. Seems pretty powerful and scares me.   Also read of possible retinal detachment as side effect.
THis doctor also suggested replacing the lens with monofocal lens , but I can't understand the logic of that, if Restor is supposed to be the best choice for good near vision. He is considered a top doctor in NY, the Dr. FixIt that other doctors end problemic cases to!. I am now officially under his care. He also suggests a procedure to permanently contract the pupils if nothing else works. That seems far too drastic for me (pupilloplasty) and am afraid to such changes to my eye, and how that could effect both eyes, with one pupil smaller than the other.
I was never told had "large pupils"  before (they don't look especially large or unusual) and never had any related problems with this before surgery?

Can the  cataract surgery change the way the pupil contracts? Did something go wrong during the surgery/? I had no complications after the surgery except problems with near/intermediate vision.Did I have a pre-=existing condition that i did n't know about? I've gotten no answers on this.

Another opinion said power of Restor lens was too weak, and recommends replacing lens with Restor at higher power.
But none of the other doctors mentioned anything about the lens being too weak (15.5D)

All of the doctors said that I would have trouble tolerating glasses/contacts, because there is a very wide divergence between the 2 eyes ( Ithink more than 5+ diopeters). .

The other eye also had a severe cataract which has gotten worse in the last year (the worsening of the cataracts in both eyes is what propelled me to have the surgery). I was supposed to have the 2nd eye done, but am postponing everything until it is clear what went wrong with the first surgery and what lens would be right.

Since the surgery, I use no glasses for distance, as my old glasses prescription  just blurs the eye that had the cataract removed. I read with the other eye, the one with the cataract, sometimes using my glasses, sometimes not. As with  the eye that  had the cataract, both eyes always enabled me to read comfortably, with mild Rx for reading or without reading glasses. I also sometimes try the over the counter reader for the eye that has the Restor lens, but  probably need a stronger one than I have-- but it helps..I use the reader for the computer. Obviously, using either of these glasses for reading only helps one eye, and the other is blurred as it is not the right Rx for the other eye..
Also  was told the many drops I've been taking since surgery had made my eye dry, so now I have been taking Systane.  I also tried Refresh, didn't seem very different from Systane. anyone with esperiences with these drops? Do you have to take them forever?

I am very frightened now of any more procedures-  such as replacing the lens (because I now have had  different suggestions as to what kind of lens with different MDs). The results of the surgery were unexpected, as I don't know if a replacement would help, or possibly create new, unexpected problems.

I am also afraid of doing the 2nd eye, as at least now I am assured that I can read with that eye. It frightens me to think that my natural reading ability could be decreased again. I am a voracious reader and a reading teacher!

Anyone had similar problems-- with Restor and near vision?
With pupil contraction? Mydriais?
Pupilloplasty?
Pilocarpine?
Ability to tolerate glasses or contacts with a wide diopeter divergence?

[JodieJ]

Addendum to above:  Many people have major problems with the newest model of ReStor.  Try searching for posts by disappointed66, londonbridge, and Restornomore.  All three recently had their ReStors explanted and replaced by monofocal IOLs, with excellent results.  Explanting an IOL is not dangerous but should be done by an experienced surgeon.  Your doctor's suggestion to replace your ReStor with a monofocal IOL sounds good to me--much better than trying to make a lens with defective technology perform acceptably.

You sound like an excellent candidate for mini-monovision with monofocal IOLs.  There are two versions of this.  The first involves setting your dominant eye for distance vision and your non-dominant eye for intermediate vision.  My friend who has this correction only needs glasses for prolonged reading and seeing small print.  The second version of mini-monovision involves near vision in one eye and intermediate vision in the other.  With this version, you would only need glasses for distance vision.

[JodieJ]

Many people with ReStor posting on this forum have had problems with near vision.  For some people, near vision does improve with time; for others, it never improves.  Dr. Hagan posted a study which found that monovision with monofocal IOLs provides better near vision (on average) than ReStor.  Since ReStor is a bifocal implant with distance and near vision segments (but no intermediate vision segment), I don't think that intermediate vision is ever great.  I guess people just learn to adjust their viewing distance for many intermediate vision tasks.

Although glasses won't work for you, a contact lens in your unoperated eye should work well.  People with greater than a 7 diopter difference have been successful wearing a contact lens for months or even years.

It's my non-professional opinion that there is nothing wrong with your pupil.  I'd be inclined to attribute your poor near vision to faulty ReStor technology.

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

Pilocarpine is usually not helpful.

No glasses won't work with a 5 diopter difference in the two eyes.

"not uncommon" these forums are filled with people having trouble with multifocal IOLs especially the ReZoom and the old ReStor.  In fact these IOLs generate 23 TIMES more complaints than monofocal IOLs

JCH MD

[miria]

Thank you for your response.
What is your experience with pilocarpine? Is it dangerous? I have pain for 6 weeks since the allergic reaction, and the doctor is recommending another try but with a smaller dosage. Is the effect of pilocarpine  permanent  or does it have to be taken indefinitely? Would having one pupil permanently smaller create imbalance in my eyes? Dizziness? Double vision ?(I had double vision when I was on pilocarpine  for 2 days, which  got better).

Do you think glasses or contacts are feasible with a wide difference between the eyes/(5+ diopeters). The doctors are all  discouraging about this, but it would seem the most benign path if it were possible. What do you think?

You said my experience is not uncommon.   What specifically are you referring to?

How common are diffficulties with near vision with the Restor? I have good distance 20/30-- was 20/80 before surgery-- and am much more comfortable than before the surgery with distance. Intermediate is poor, but I was told it might be  a problem (though I was not told about what intermediate entails-- just about computer work- not about cooking, shopping, and all the day-to-day activities that are now hard). I thought "waxy" vision refers more to general blur for distance, which I fortunately do  not have. Am I mistaken about what "waxy" vision means?

Is the pupil not contracting for reading a common problem? I've combed the archives and saw no mention of it unless trauma induced. Could the surgery have created this? The Restor  lens? I was never toldI had "big pupild" before the surgery and this problem.

You suggested I search the archives, which I have. I assume  I have the newest version of Restor, since I had the surgery Sept 09 . Acrysof IQ , model SN6AD1. I assume that the surgeon would use the latest version, but possibly not.

Thank you for your attention. I am so distressed by this, especially with different opinions and advice.

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

Your problems are not usual.  Use the search feature and read about problems with ReStor IOLs especially the older version.

Given that Eye MDs that have examined you don't agree I can't tell what the problem is. Generally start with the easiest solutions first, drops, glasses. If non of these work the consider IOL exchange. Remember that ReStor has been associated with "Waxy vision"

Don't do anything to the second eye till you work through these problems.

JCH MD