Selecting a cataract surgeon/vision specialist after vitrectomy.

[Beckyyoh]

I started this thread in response to answers in my earlier question. 'When to have cataract surgery? Loss of accommodation at 58" Dr. Hagan -Why did you say to  focus my efforts on finding the best cataract/refractive surgeon instead of just cataract surgeon?  I would have thought that they were separate specialties. The cataract will be more of an issue in the not two distant future, but right now the aniseikonia and double vision is my most disturbing problem. If I remember correctly, you had told another poser in the forum to go to a strabismus specialist. In my upcoming appointment with my primary care doctor, I am hoping to get one of the HMO optometrists to do aniseikonia testing. In my first post on this forum, Anomolychick thought I should get someone to prescribe a glasses/ contact lens combination to equalize the image size difference between right and left eyes. She recommended that i do this before cataract surgery so the power could be incorporated into the IOL and eliminate the contact lens. This makes a lot of sense and currently glasses work  because the cataract is still in an early stage butt as the cataract progresses i may not see well enough to tell.You also mentioned the kickback/ co-management issue. My health care is through a large HMO with a team of optometrists. Specialist referrals are mostly through University of Wisconsin Hospital and Clinics - a teaching hospital.  Is this an issue with the HMO - teaching hospital specialists that i am dealing with? In a couple of articles that I saw online, cataract surgeries after vitrectomy require more more care than surgeries on virgin eyes. The fact that the eye has been operated on and that the sline filling the eye offers less sport than the vitros gel increase the risk of complications. Can you point me to resources or offer suggestions on how to find a good surgeon? I know there are multiple websites with grades of doctors but wondered if you have additional suggestions. Are there additional questions that I need to ask because of the vitrectomy. Do HMOs usually pay for patients to have multiple appointments to shop for a specialist?

[JohnHaganMD]

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[Beckyyoh]

Thanks to both of you. All of our specialist referrals from our HMO have been to the UW and follow-up appointments have been at the UW specialist's office and not the HMO. I don't know if the HMO  optometrist referred me to the specific surgeon or just the department. In any case, I was very fortunate and all of the staff have seemed very professional. The fact that nobody has addressed the double vision is why I have asked these questions. It sounds like getting a name from the retina surgeon would be a good idea since his patients would have had retina surgery and some would have had the size issues.

[JohnHaganMD]

Thanks for the comments and insights. JCH MD

[chazas]

I know this was directed to Dr. Hagan, but I thought I'd chime in.  I also had my IOL implanted after a vitrectomy (with scleral buckle gas bubble for retinal detachment), in the same surgery as another vitrectomy for an ERM peel.  

My surgeon(s) (the retinal and anterior segement surgeons were different) were both from the University of Kentucky, which is a teaching hospital.  I felt the retinal care was outstanding, but was not as happy with the IOL procedure, primarily because of a big refractive error that I have suspicions (but cannot prove) could have been at least somewhat avoided.  When I was having the IOL measurents done, the nurses who were doing the measurements were clearly having a very difficult time getting things done right, and had a discussion right in front of me as to which formula/computer to use.  They sounded like they didn't know what they were talking about.  I know with my myopia and the buckle I was a difficult case, but I still kick myself for not having brought it up with the surgeon.  I should have insisted that he do it himself in front of me,  I have no idea what controls he exercised behind the scenes.   But the retinal surgeon is a wonderful professional and human being, and continues to keep up with my progress by email.  

I'm now back in DC getting care from private medical retinal and anterior segment groups - I chose the best I could find.  I'm having PRK tomorrow to correct the residual error in the IOL eye tomorrow, and the same doctor will eventually do the IOL/cataract surgery in my other eye.  I think he's great personally, but I have still had issues within the practice I've had to advocate for. Two separate assistants of his declared that I could not be refracted better than 20/200.  I disagreed strongly and was referred internally to their "best" optometrist for a refraction, who confirmed that I could get much closer to 20/20.  

My lessons are that no matter how good your doctors are, you need to take charge of your own care.  Research, ask questions, be polite but don't accept anything at face value.  It's your body, not theirs.

Finally, my Kentucky surgeon told me that for an experienced team, IOL implantation in an eye that formerly had a vitrectomy really isn't that different.  While I question the IOL calculations, overall my DC doctors have been extremely complimentary of the quality of the surgical work the Kentucky team did, so it sounds like she was right.  My advice to you on this is to make sure your doctor has handled situations like this before and is comfortable with them.  

Good luck.  

[JohnHaganMD]

No all corneal surgeons do cataract surgery and corneal surgery.  Some, but not all, cataract surgeons do corneal surgery in the sense of refractive surgery at the same time as cataract surgery.  Because of your special situation a corneal surgery might be able to offer things such as operative femtosecond laser, post op lasik, intraoperative abberometry. Your case is not the "plain vanilla" cataract surgery.

If true double vision is the biggest problem then the type of specialist to see would be a adult strabismus/pediatric ophthalmologist.

Most HMOs want to keep everything "in house" and you likely will not have the ability to "shop the best for you". If you are referred out of the HMO system they usually have contracts with certain sub-specialists and again you have no choice.  One of the reasons HMO have fallen out of favor and patients biggest objections is lack of choice.  The ophthalmology department at U of Wisconsin is first rate but you may have trouble getting referred there.