confusion with iol choice and Doctors who don't agree

[Capes55]

I,m the 53 year old male high myope with a posterior subcapsular cataract in my right eye.  I've had it a couple of years.  The last 3 months it's really been bothering me (hard to read, colors dull, in my field of vision almost always as I look from side to side)  I also have an astigmatism issue in the same eye. I think it's around 1.5

My axial length is 29.27mm.  My contact lens prescription is -10.5  My corrected vision is about 20/50

I've been to several 3 local Docs.  The 1st I saw in May 2007.  He said to take out my contact lens for 3 weeks minimum (it's a soft lens, not toric) to get an accurate cornea reading.  I followed all his instructions and was within  a week of surgery, became gun shy and canceled. My concern was for myself...I had total faith in the Doc.  He had a very good reputation.  He was conservative and was planning to correct me to a -1.5. He did not want any chance of correcting me beyond plano, which made sense.

This Doc then referred me to a very reputable Doc in Houston TX.  I saw him August 2007. He said at the time that it wasn't bad enough yet to remove, but that sometimes these things develop rapidly. I see him again at the end of July.

The other 2 local Docs I've seen in the last month.

Doc #1 said...."no need for contact lens to be removed for any length of time, the IOL Master is very accurate"
       Also, he's recommending an alcon Toric IOL to correct my astigmatism.  Says he's had great success with it.
       He would like to correct me to a -1.5, which is ok with me.

Doc #2 said..."the Alcon Toric lens doesn't even come in your power.  He wants to try to get me to a -.5, and told me I will need to go without my contact lens for 2 weeks and then get remeasured.  I don't want ANY chance of being corrected beyond plano.  He said the best lens for me is some alcon 3 piece lens.

I'm getting sick and tired of conflicting points of view!!!!!  All I want is to get rid of my cataract and see good again.  My lifestyle is is really being negatively affected by all of this.  I know I'm at slightly increased risk as a male high myope, but how much physical and mental suffering is enough until I "Pick a Doc, Say a prayer, have faith, and go for it.

Also, I've seen 3 retinal Docs for opinions.  All 3 said no need to tack down retinal before cataract surgery.  Last year 1 said "some minor Lattice degereration"  Most recently, about a month ago, I saw a very reputable retinal Doc in Houston..he said no Lattice degeneration (here we go again!  Who is right?!!!)

Have any of you gone through anything like this?  I feel like I may be a little too well informed, but I need to have total trust in the Doc I choose and also peace of mind that what I'm doing is the right thing to do.

The Med help Doc suggested I postpone as long as possible. I agree.  I just feel that I need to proceed soon.

The whole situation is occupying way too much of my life.

Anyone have any suggestions?

[JodieJ]

With all the medical information available online, patients are now in a position to make better decisions about their health care.  The downside of this (as you are now experiencing) is that the burden of responsibility for such decisions is now shifting to the patient.  So (at least in my opinion) being well informed is never the problem.

I'd suggest that you only consult experienced, board-certified cataract/refractive surgeons with excellent reputations, and then choose a doctor whose surgical goals are compatible with your own.  Like yourself, I was very much bothered by a rapidly developing cataract.  Surgeon #1 had me do all the eye measurements but then decided I should wait a few months before having surgery.  I did not want to wait a few months, so I sought another opinion.  Surgeon #2 strongly recommended the ReStor lens (which I didn't want), and I could hardly wait to leave her office.  Surgeon #3 agreed that I didn't need to wait several months, and he agreed to use an aspheric monofocal IOL (my choice).  So I chose #3 and followed his instructions about leaving my contacts out.  (Yes, doctors do disagree about this issue.)  I was very pleased with my outcome.

BTW, if you really feel strongly about not being corrected beyond plano, I don't think that a target of -.5D would be wise.  All three of the surgeons I saw warned me that the formulas for predicting the correct IOL power were less reliable for high myopes with astigmatism.
  

  

[bad eyes]

Welcome to the fact that medicine is really an "art" as much as a "science."  One method for finding a reputable doctor is to ask ophthamologists which doctor they would pick to do surgery on their own eyes.

[John C Hagan III, MD, FACS]

I would suggest leaving your contacts our at least 2 weeks before making the IOL measurements. I would suggest a monofocal ashpericd IOL like the Tecnis. I would avoid multifocal IOLs. I would go with the surgeon that you feel the most comfortable with and whom your research has a good community and professional reputation.

Hey lawyers disagree, judges disagree, half the country disagrees on the best choice for president so its not likely that physicians will agree all the time. It doesn't mean that they are wrong because often there is no absolute right thing.  Every week I tell someone that I think they should start on glaucoma medicines because long term its the safest thing to do but that if they saw 10 really qualified ophthalmologists that probably 3 would recommend further observation and not starting medications.

That's life, that's medicine, that's your choice.

JCH II IMD

[Capes55]

Thank you all for your comments.  I really appreciate your help.  I'm really trying to get over my apprehension about getting my cataract taken care of.  I'm really having difficulty with this, choosing the right Surgeon, etc.  This is a permanent thing and I'm trying to get to the point where I'm at peace with my decision.  I'm at increased risk (male, 53, high myope,etc) I can't change that.  I still believe the benefits outweigh the risks. The only surgery I've ever had was getting my tonsils removed at age 6.  

Hey JodieJ, did you get both your eyes done?  Also, how nearsighted were you?  And  what age were you when you had your surgery?  Have you had a yag procedure since your surgery?   Thanks

[Capes55]

I forgot to ask you, how long did you have to leave your contacts out before your measurements were taken, what was the target post surgery refraction and what were the actual results?

Thanks

[JodieJ]

I developed a cataract in one eye when I was 52.  It was an anticipated complication of the (mostly successful) retinal surgery I had had earlier that year.  I wasn't as myopic as you (-6.75 D) and had about 1.5 D of astigmatism.  My axial length was 25 mm.  I had cataract surgery on both eyes.  It was a choice between cataract surgery and LASIK on my second eye, and I was wary of LASIK involving so much correction.  

I wore toric contacts.  I left my contacts out for 3 days for the first set of IOL measurements.  (Then the doctor decided to postpone my surgery for several months, so I had to find a different surgeon.)  I left my contacts out for 2 weeks for the second set of measurements.  I had to buy some cheap glasses to get through the two weeks; I couldn't see well enough to drive with my old glasses.  My target was something between -.5D and -.75D, and I ended up plano.  My surgeon matched my second eye to the one that already had surgery (per my request, since I had a history of strabismus related to monovision contacts.)  Your target of -1.5 D makes sense to me, given your feelings about being corrected beyond plano.

At the time of my surgery (Sept. '06), the Alcon toric lens did not come in a power sufficient to correct my myopia.  This may have changed, though.  If it is a possibility for you, this might be a good choice.  Otherwise, I'd suggest an aspheric monofocal lens and limbal relaxing incisions.

Yes, I developed PCO in both eyes (like just about everyone I've known under age 55 who has had cataract surgery.)  I had a YAG procedure on one eye, but I'm postponing it on the eye with some residual retinal damage.  I've been told that leaving my vision in this eye slightly blurred would be advantageous, and my past retinal surgery (vitrectomy) is an additional risk for RD.    

[John C Hagan III, MD, FACS]

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[Capes55]

Thank you very much JodieJ for your comments.  I appreciate your help.  Do you happen to know if these IOLs are "1 size fits all"  One doctor wants to put in an alcon single piece IOL.  I asked him if 1 size fits all.  He said yes.

Another Doc did the IOL Master measurements on me 2 weeks ago and said He recommended a 3 piece Alcon IOL.  I believe the IOL Master tells them which IOL is best.  I don't know.  Do you?

I have Big Eyes and a long length (29.1mm,right eye, the one with the cataract)  Also, I noticed on my chart the my anterior chamber depth is over 4mm.  I don't know what that means.

So your cataract was caused by your previous surgery?  

Thank you again for your help.

[JodieJ]

I did lots of research before I had cataract surgery.  However, since I'm not an eye care professional, you should definitely review my suggestions for accuracy with someone who is.

From what I recall, all of the newer Alcon IOLs have a 6 mm diameter.  (So, yes, one size fits all.)  This size is much less likely to produce glare than a smaller IOL, such as the 5 mm Crystalens.  Some retinal surgeons (should you ever need one) prefer a larger diameter IOL because it makes it easier to visualize the periphery of the retina.  In my opinion, Alcon's two best IOL models are the aspheric Acrysof IQ and the Acrysof toric (which unfortunately may not come in the power you need).  Both are 1-piece, making it easier for the surgeon to implant.  I believe that the 3-piece Alcon is an older model, and I'm not sure why it was recommended for you (so definitely ask).

No, the IOL Master does not tell which IOL is best.  That choice is dependent on the experience and preferences of the surgeon (hopefully following discussion with the patient).

AMO (a major corporate rival of Alcon) also makes an excellent aspheric monofocal lens, the Tecnis.  (This is Dr. Hagan's preferred lens.)  If you haven't already seen it, check out the patient information video at www tecnisiol com (dots omitted to evade the censor).  The Tecnis also has a 6 mm diameter.  (Both the Tecnis and the AcrySof IQ have data demonstrating improved contrast sensitivity/night vision.)

My surgeon only used Alcon lenses, and I've been very satisfied with the performance of my aspheric Acrysof IQs.  Yes, my retinal surgery (vitrectomy) caused a cataract to develop rapidly by exposing my lens to oxygen.  But needing cataract surgery has really been a "blessing in disguise" for me, and I've never experienced any of the post-surgery problems that I feared (glare, halos, ghosting, etc.)

BTW, I had been advised that I would either need LASIK or lens replacement in my good eye.  However, I found that I was very comfortable wearing a contact lens in that eye between surgeries.  Given the increased risk of RD, I think you should try this option before rushing into surgery on your second eye.

I'd also suggest that you stick with the type of correction that you're used to.  If both of your eyes are corrected for distance with contacts, do the same with IOLs.  Or if you're happy with monovision, stick with that.

Best wishes for an excellent outcome.  

[John C Hagan III, MD, FACS]

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[sally987]

Hi JodieJ!   I am just reading through some old posts and had a question regarding your statement "My target was something between -.5D and -.75D, and I ended up plano." I was wondering how your vision would be different if your target numbers had been reached.  What would be the advantage of not being plano?  Would it make intermediate vision ever so slightly better?  I have enjoyed reading your posts, thank you so much for helping so many.

[JodieJ]

I have a history of developing double vision from monovision contact lens wear, so I wanted both my eyes corrected to the same target.  (This is rare and probably relates to a genetic vulnerability.)  With both my eyes plano, everything within arm's length is blurry.  Being a little nearsighted would have given me slightly better intermediate vision (but I'd probably still need glasses for reading and seeing my monitor.)  I think that most people would be happiest with a mini-monovision correction.  

[sally987]

Thanks for explaining that.  My doctor has recommended -.5 or -.75 in one eye and plano in the other.  Would this be a mini mini-monovision?  I didn't do well when I recently did a short trial of toric contacts set at -1.25 and plano.  I wasn't dizzy or anything, I just missed having binocular distance vision and realized I didn't want that.  BUT, it sure would be nice to keep a little bit more mid vision, if possible, w/o being so obvious to my distance vision.  Have you heard of this combo?  I had never tried toric contact lenses before and I absolutely loved the crisp vision they gave me in the distance eye.  I hope that toric iols can give me that same sharp effect.  I wore hard contacts from age 14-42, and progressive glasses ever since (current age 54).  My gas permeable contacts from long ago would ride high on my eyes (I suppose a result of my astigmatism) and I would have to blink them down from time to time; and my glasses have never been sharp like those toric contacts I sampled.   I am very excited about the possibilities for better vision (but I don't want to get my hopes up too high~).

[JodieJ]

The type of correction that your surgeon is suggesting sounds like a good idea to me.  You could try it with disposable toric contacts.