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huge shimmery structures after monofocal iol implant - very worrieds
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huge shimmery structures after monofocal iol implant - very worrieds

Last month I had Tecnis monofocal lenses placed in both eyes (the right eye had a cataract, the left eye was just beginning one). I deliberately avoided multifocal and accommodating lenses because of their starburst and halo problems.

But a couple of days ago (that's 16 days after the left eye operation and 11 days after the right eye operation), I began to notice something I'm finding really disturbing. If I look straight at a light, everything's fine - not even the hint of a halo or starburst. But as soon as the light is almost out of my vision, my whole field of view is momentarily filled by a series of rays, ending in a huge, wavy arc going right round the edge of my vision. For a fraction of a second, that's almost the only thing I can see.

It's hard to describe the structure - the best I can come up with is to say it's like what you see when you cut an orange in half, only I'm just seeing a part of it, not the whole circle. It's also a bit like part of a 'dandelion clock' when it's seen against the light. The light rays themselves are very delicate and 'shimmery', rather like the patterns made by sunlight reflecting from water onto a wall or something.

If I walk along the street at night, every time I pass under a street-light, just as it's about to pass out of view overhead I suddenly get this structure, almost completely filling my vision. It only lasts for maybe half a second, but it's very disturbing.

It's hard to be sure, but I can't help thinking this has just started a few days ago. A couple of days after the second operation, I took an evening walk which ended long after dark, and I definitely walked under quite a few street-lights - I'm sure I'd have noticed this if it had been happening then.

The irregular structure of these rays and arcs suggests to me that they're maybe not caused by the lenses, but of course I'm no expert.

After carefully choosing these Tecnis monofocal lenses because of their good performance as regards flare, halos, starbursts, etc, I'm really worried about this development. It's not just a minor annoyance - I'm finding it pretty scary.

Any advice or opinions on this problem will be very gratefully received. Thanks.
10 Comments Post a Comment
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233488_tn?1310696703
You need to start by having a thorough examination with dilation and corneal topography and a careful refraction by your surgeon. Also need to be sure your IOL is well positioned and the posterior capsule not opaque. If you have a significant refractive error you may need glasses and considerations hould be to wave-front ground glasses (like Zeiss iScript).

If he doesn't come up with much ask him for an out side his office second opinion. You have a very high quality IOL in your eye and other causes need to be excluded before attributing this to IOL dysphotopsia.

JCH MD
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Avatar_m_tn
Thank you for that advice, Dr Hagan, and sorry for the delay in my response - to tell you the truth, I'm so worried about this problem that until now I've been afraid of even reading your reply, in case it was one that offered no hope.

Just to address what you've said: my vision is pin-sharp in the left eye (I downloaded and printed a Snellen chart and tested myself, and it seems to be about 20/15), while the right eye was about 20/60 but is now perhaps 20/40 (my guess is that it's due to astigmatism). This night-time problem, though, seems to be the same in both eyes.

I've no way of knowing for sure, but I don't think this there's any post-capsular opacification, as I wasn't having seeing these shimmery structures before the cataract operations. My surgeon said that because of the edge design of the Tecnis IOLs, the chance of PCO was only 1 in 30. If PCO has occurred, could it have done so in just a fortnight?

My follow-up examination is on the 15th of this month. I'd be grateful if you could suggest anything I could ask him when I see him.

Just as a piece of further information, I think I should tell you that this surgeon has done over 15,000 cataract operations, and has a string of very impressive qualifications - from what I was able to find out, he appears to be a very well-respected surgeon indeed, which is why I chose him.

This probably isn't relevant, but I think I should add that I live in the UK. Thank you.
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233488_tn?1310696703
Sometimes when the surgery is done the posterior capsule is cloudy and a yag is done relatively soon after IOL surgery. The incidence of PCA has fallen dramatically in recent years.

create a "pin hole" lens by sticking a 18 gauge or similiar sized needle through a think piece of cardbord (read on internet how to create a pin hole lens)  then look at the vision card. If the vision is a lot better it strongly suggests the problem is uncorrected residual refractive error that glasses, contacts or surface lasik might correct.

JCH MD
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Avatar_m_tn
Hi ive had the same problem its nothing to do with pco,all it is ,is your pupils go abit larger than the lens at night,a certain lights i.e street lights,interior car light on at night,spot lights in dim room,causes it,when pupil bleeds over the edge of lens at night,these types of lights reflect the edges of thr lenses,im just coming up to 2 years of surgery,and this problem has settled down alot,and not as noticeable now,get it slightly still now but liveable,and forget about it,you are at very early days,then lens hasn't settled yet,i.e buried it self in the tissue yet.take up to 9 months for that,dont knock what you got,you vision is superb as this stage,you eye which is slightly worst will improve overtime took me upto 8 months to get sharp vision,just ride it out things will get even better,remember yours eyes have to adapt to a new way seeing,anymore questions message me got so much info to give from my own experience
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Avatar_m_tn
P.s  sorry about spelling didnt read it back before sending lol
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Avatar_m_tn
Thanks for that encouraging reply, jaysta.

For the record, though, I don't think it's light spilling around the edge of my IOL, for a couple of reasons.

First, it also happens in fairly bright conditions - in a brightly-lit corridor where I live, for instance, every overhead light does it. It isn't very noticeable, but I think that's just because the images are against a bright background, whereas under streetlights, they're against a dark background. I even get it indoors in the daytime, when light from a window strikes my eye at a certain angle.

Secondly, I was very careful to discuss with the surgeon the possibility of light spilling around the edges of the lenses before agreeing to have the ops. I told him that I was a keen amateur astronomer, and so most of my hobby was carried out when my eyes were dark-adapted and my pupils were therefore at their most dilated, and asked me if his chosen lens would be big enough for spillage not to occur.

He replied that if you use a larger lens, you start getting aberrations, but added "but your pupils aren't especially large" (though he didn't measure them with a pupillometer, I realise now). So, even though I stressed how important my astronomy was, he seemed to think his chosen lens would be OK.

I've found that my lens, the Tecnis monofocal, is 6mm, which I think is pretty standard. Are there significantly bigger IOLs out there? It's pretty hard to find out, even with Google.

Just one more thing: as well their tendency towards halos and starbursts, another reason I was careful to avoid accommodative lenses was because I'd read they had a smaller diameter than monofocals. If light really is spilling around the edges of my lenses anyway, I would have been better off going for the accommodative lenses.
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Avatar_m_tn
I have some questions for you? Were you okay after the first eye or did you notice any unwanted visual disturbances? Are you near sided? What power or diopter was the IOL?

There are two types of dysphotopsia, postive and negative. Positive gives you a bright arc and negative gives you a dark arc. Try to google Uncovering the mystery of negative dysphotopsia  in Eye World, November 2011 for more information.

There have been studies on edge designs and edge changes etc. over the year as manufacturers try to balance PCO with visual disturbances in search of the perfect lens. Most disturbances go away or are transient. You also need to know that once your cataractous lens is removed and an IOL placed in the capsular bag, the bag is floppy so to speak. Over a period of six weeks it will encapsulate the IOL or shrink wrap it.

In the meantime you could have what is called pseudophakodonesis which is simply movement of your lens until it settles into place. If you are myopic or have a large eye it would happen more than a hyperopic or small eye. Once the capsule shrinks and it stabilizes it goes away.

Some think the anatomy of the eye comes into play where there is a larger space from the iris to the IOL in the bag than others which allows for the light coming in from the temporal side has more room to hit the IOL edge. Surgeons have actually done a piggyback of a low diopter silicone IOL on top of the IOL in the bag to fill that space. Another option is to just replace the IOL.
I think you should just wait it out and not worry about it. Neuroadaptation takes place as well. The one thing your doctor can do is to dilate your eye, make sure the IOL is within the capsular bag and the edges of the bag are over the surface of the IOL and that is well centered and not tilted. He or she could also give you something to bring your pupil down for a short time as well. The IOL selection is superb and your follow up will answer many questions on the 15th. Give it time. You just had a change to the visual system you grew up with
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Avatar_m_tn
Thank you for that very helpful reply. To answer your questions:

1) I had my first and second ops 5 days apart, and had an evening walk a couple of days after the second op, which ended with me walking past and under quite a few streetlights late at night. The only visual disturbance I can remember was a very bright horizontal bar through each light when viewed through my left eye (the second one to be operated on, the op being just two days before this walk). I'd noticed this bar with the other eye, and the surgeon had said this was just due to wrinkles in the capsular bag ("like a wrinkled bedsheet", he'd said), and that they'd soon go.

So when I saw this bar with the second eye, it didn't bother me, because it had already all but vanished from the first eye. It eventually disappeared from the second eye as well.

But crucially, on that walk I just cannot remember seeing any trace of the problem I'm now having - and I'm pretty sure I'd have noticed it if it had been present then, because I was walking under and past streetlights for a good 15 minutes.

2) I'm nearsighted: -5.5 dioptres in my left eye before the op and -7.5 in my right eye before the op (but it had been about -5.0 in my right eye before the cataract had started - the cataract had caused it to climb alarmingly, and I'd had two changes of glasses in six months before getting the cataract surgery). Left eye, BTW, didn't have a cataract - I had them both done together so I could have them both fixed for distance and so be free of glasses. I'd had vitrectomies performed on both eyes and I knew a cataract in the left eye would probably soon follow the one in my right.

3) Power of the IOLs is -16.0 dioptres in the left eye and -16.5 dioptres in the right eye. Also, the surgeon said he'd try to reduce the -1.0 dioptre astigmatism in the right eye surgically - whether by LRI or merely by his placement of the lens insertion incision, I don't know.

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Avatar_m_tn
You did have a wrinkle in the posteior capsule which is quite common after surgery and does go away. You are a myope, have had vitrectomies and probably have a fairly long and large eye. THe shimmering is from the second eye surgery since you did not have it on the first and it will probably disappear as the bag tightens down the lens stablizes. Good luck.
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Avatar_m_tn
Thanks for that advice, eyecu.
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