cataract surgery after having had lasek

Approx. 15 years ago, I had lasek done on my right eye only.  It was done to correct a -6.75, make it match my slightly myopic left eye, and leave me slightly undercorrected and able to work comfortably on a computer.  The goal was also to be able to shop and drive a little, free of glasses if I chose.  The results were perfect and exceeded my expectations.  

About ten years ago, I started having spells of double vision that overtime slowly became chronic.  I switched from the opthamology clinic that had performed the lasek to an opthamology group that specialized in pediatric strabismus, inc. surgery and botox.  Four years ago, I  went into prism glasses for distance vision (close and mid vision was still fine and I could work and putter in house and yard without glasses of any kind).  The strabismus is mild, only 4
BO in each lens, and seems to have stabilized.  At the same time, i.e. four years ago, cataracts were determined on both eyes, with the "problem eye"---the right eye--having two types of cataracts.  I also began to become slightly more myopic in the right eye and was an uncorrected -2.00 in that eye.  Actually that was fine with me because I had an even better ability to read, work on computer, prepare food, put on makeup, etc.  The change meant that my distance vision was worse, but since I had to have prism glasses anyway, having distance correction again in my glasses was a fine enough tradeoff for my lifestyle.

Two and a half weeks ago, I had cataract surgery in the right eye.  My doc had all the lasek and pre-lasek records from the first clinic.  I thought I had made clear to him that I wanted to remain myopic in that eye, even staying at -2.00 was fine.  He stated that he would, indeed, aim for an undercorrection but that cataract surgery after lasek was "tricky" and the end result could be off by as much as one diopter.  I agreed to proceed.  My assumption was that by "tricky" he meant that he would have to do extra work to select the IOL, maybe different measuring or something.  Unfortunately, I didn't ask.  In fact I realize now I was rather cavalier about the whole thing.  At the very least I probably should have returned to the clinic of docs where the Lasek had been done.

I was shocked to completely lose my near vision in that eye but hoped the final vision would improve over time.  I went back after two weeks to have the first botox shot in that eye and was told by the doc that I will most likely end up slightly hyperoptic in that eye.  He didn't want to do a complete exam for another two weeks until the effects of the botox could be known.  He apolgized for the miss and said he was upset, too.

What I want to know now is whether or not this big a miss ( my guess is at least 2 diopters) is a reasonable outcome for an eye compromised by Lasek?  Secondly, I would consider an explant and would like to know your broad opinion, inc. misgivings, etc?  If I do this, I would most likely go back to the opthamologist group that did the Lasek or I would go to a specialized clinic out of town.  I live in a town of fewer than 100,000 people, and there are only three opthamology groups within a 30 mile radius that supposedly have the latest in equipment and technique.

Adjusting to this loss of near vision will be horrendous for me.  I trade the stock market and futures markets, managing money for myself, my family, and a few friends.  I have three 24 inch monitors going with live data and charts, i.e moving lines, flashing lights, changing numbers and verbiage.  I also need to be able to swivel and look at a television monitor off and on thru the day.  I tried computer glasses two years ago and it was a vestibular nightmare.

The loss of vision is shocking.  I can't even make out my keyboard very well or prepare food, as in chopping vegetables.  The distance vision is amazingly good, but as I said, this matters little to me since I most likely will always be trapped into wearing prism glasses for distance vision.  One last thing.  I'm not a perfectionist and did not have unreasonable expectations (I think, anyway).  I've lived my entire life with a sloppy visual system and managed to function quite comfortably and head-ache free with less than great vision at either end of the spectrum.   I was prepared to adapt to a .5 to 1.0 miss of the targeted vision result.

Any advice would be greatly appreciated, and please feel free to take you time in responding.  I've already made an appt. with my old clinic for an evaluation two weeks from now.  At the very least, I  suppose I'll still have cataract surgery done on the other eye.  That eye did not have a lasek procedure so should be easier to deal with, but I'm thinking right now I want leave the clinic I'm with and return to my old clinic for that second cataract surgery.

TIA for you help.

Kate

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

Choosing an IOL always involves some inexactitude and very short, very long eyes with previous RK or lasik or trauma dramatically increase the difficulty of picking the desired post op refractive error. You were advised of the preoperative inexactitude.  

JCH MD

[kate479]

Thank you for responding.  Would you also be able to give me your thoughts on having my IOL replaced?  Actually how you feel about explants in general, the risks associated, etc.  I'm under the impression that a replacement should get a better outcome simply because the surgeon now knows how the eye responded to the first IOL.  Is this correct?

Also, are there surgeons who specialize in explants?

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

To offer a helpful reply I would need to know your existing post operative refractive error and the best corrected distance and near vision in both the operated eye and the eye that still has the cataract. (designate which is which)

Yes most metropolitan areas has an ophthalmologist that specializes in post operative complications.

Removing an IOL and putting in another is a major operation.  If you can be made "happy" with glasses most people would avoid the risks, expense of a second operation on the eye.

JCH MD

[JodieJ]

If you don't want to wear prism glasses for distance vision, your double vision can probably be corrected by a painless, 45-minute procedure.  (I was shopping at the mall the same day, wearing dark glasses.)

I have no personal experience with IOL exchange.  I do know several people who have done this, all with excellent results.  But find a surgeon who is experienced with this procedure.  Doing it early in the healing process is better than waiting.

[kate479]

What is the 45 minute procedure for strabismus you mentioned?

The prescription in my prism glasses is only 4BO on each side, and my current doc considers this too minor to consider surgery on the eye muscle.  His requirement is to be greater than ten diopters total.

I tried the botox shot for the first time just last week (six days ago) for the strabismus.  It produced results within four days and I'm really enjoying having unobstructed 20/20 vision.  Also better peripheral vision when driving.  It would indeed be wonderful to permanently correct this annoying strabismus and avoid having periodic botox shots to keep the alignment in place.  And, to get rid of the strabismus would soften the blow of losing my near vision from the cataract surgery because the distance vision this particular IOL produces is amazing.  In other words, it would be nice to just walk outside with no glasses of any kind and see normally.

As for doing an exchange, how would I go about finding a surgeon who specialized in this?  Since I had Lasek previously done on this eye, is it possible my situation can't be improved no matter who I go to?

TIA.

[kate479]

It will be a few weeks until I have the measurements you requested because I'm now experimenting with a botox approach for the strabismus problem.  My doc started with what he stated was a "very mild strength" and after six days, it is working wonderfully.  I have one image and fantastic, clear distance vision.  My mood has lifted and I'm feeling less cranky about losing so much near vision from the cataract surgery.

Would you mind sharing your opinion of having regular botox shots to treat strabismus?  I can't seem to Google up much info on it.  I know it's not usually a permanent fix, but don't know if there are long term safety issues from repeated injections.

Thank you and all for this wonderful forum.  I deeply wish I'd found it BEFORE I had cataract surgery done, but even after the fact, it's wonderful and so helpful to read all the questions of other members and to have a few of my own questions answered by an expert.

:)
Kate

[JodieJ]

I guess that doctors have different criteria for eye muscle surgery.  My prism correction was less than yours--3BI in each eye.  I had surgery on only one muscle in one eye.  It was a total success, and I made the prism lenses into a paper weight.

Ask your surgeon for a referral to someone experienced doing IOL exchanges.  Or call the ophthalmology department at a teaching hospital and ask them.