ReSTOR and Pilocarpine

[cwatt1]

I have read other posts in the archives here about pilocarpine and pupil size.  But please let me follow up with an additional question.  3 weeks ago I had a ReSTOR IQ +3 implanted in my left eye after cataract surgery.  Prior to doing this, my surgeon measured my pupil, and my angle kappa, and pronounced me a good candidate for the lens because the angle was such that my line of vision would not hit the inner concentric ring of the lens.  Post-op distance vision is currently between 20/30 and 20/25 but seems to be improving.  Near/intermediate vision was/is still a problem, and my eye surgeon scheduled me for an argon laser pupilloplasty to eliminate a slight (about 1mm) decentration of the lens

I had this procedure 3 days ago.  My eye may still be a bit inflamed, but my vision improved very little, if at all.  When I saw my eye surgeon yesterday he instilled pilocarpine in my operated eye, which constricted my pupil so that my near vision improved greatly.  It also seems to have helped my distance vision.  My surgeon told me my pupil was still a bit enlarged, and I had some inflammation from, the laser procedure.  I'm supposed to continue the pilocarpine 2x day for 1 week, along with a 2x day dose of prednisolone.

In your experience, does pupil size that was enlarged with pupilloplasty reduce to normal?  I don't want to have to take pilocarpine indefinitely to artificially shrink my pupil, although I must say my vision in the ReSTOR eye is quite acceptable after applying the pilocarpine.

[cwatt1]

Thanks again, Dr. Vosoghi.  I'm seeing my eye surgeon on Thursday.  When I saw him last week he indicated that the pupilloplasty had lined up the lens with the pupil pretty well.  Distance vision is not too bad (about 20/25 or 20/30) but near vision is still pretty blurry.  Could this be due to some residual astigmatism?  During my cataract surgery I also had LRI to correct about 2.5D of astigmatism.

[Houman Vosoghi, MD]

I think it is more likely that the lens is decentered nasally 1mm than your pupil being more temprally situated.  Pinhole allows only straight beems of light to enter your eye, cancelling the refractive error that results from multiple lights from multiple trajectories hitting the cornea/lens at different angles.  You have to look up Snell's law to really understand this I think.

HV

[cwatt1]

Thanks, Dr. Vosoghi.

Actually the purpose of the pupilloplasty was not to enlarge the pupil to allow more light, but to shift the pupil over nasally about 1mm so that it lined up with the decentered lens.  My pupil is apparently more temporally situated than most peoples'.

Out of curiosity, why would looking through a pinhole improve vision?

[Houman Vosoghi, MD]

Pilocarpine could improve anyones vision by creating a pinhole effect.  It can sacrifice night vision and give you brow aches also.  I don't have much experience with pupiloplasty and am having trouble imagining how that helps a decentered lens.  Maybe by enlarging the pupil and exposing more of the optic?  Give your surgeon the chance to do it his way and see how things go as he probably has some experience with these lenses.  You can always get a second opinion down the line if it didn't work.  Staying on pilocarpine permanently is usually not a good option.

HV