imbalance after cataract surgery

[karp989]

I had a cataract removed left eye with the acrysof IQ monofocal on  my left eye. My eye prescription before cataract surgery was -.75x-3.500x020(od)
                                                                       -4x-1.25x010     (os)

after cataract surgery                                   -4.25 +3.75x110(od) plus prescription
                                                                         +.50+.75x090    (os) plus prescription

I don't have cataracts on my right eye, so there seems to be an imbalance driving me crazy. I didn't have an imbalance before the surgery. I also have keratoconous, so prk/ lasik is not an option. Can you tell me the diopeter difference of two eyes post up cataract surgery? According to surgeon it is 2.25 which he said my eyes should be able to handle but they're not. For some reason i ended up farsighted on left eye instead of plano. Any suggestions as tho what should i do?

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

It's a really big difference in the two. THe smaller image would likely come in the RE.  The difference in refractive error is called aneisometrophia and the difference in size is aneisokonia

JCH MD

[karp989]

Can you recheck my RX again, i might have written it a little off before please.
right -075-.350x016(right eye)
         +125-100x170 (left eye)... Add 2 only (OS).... i dont have double vision or anything, only thing is a little weird with image size difference, but biggest symptom to me is depth perception. Do you think that the progressive lens on left eye should help with this, as the optometrist told me this might help. Surgeon also suggested that the diopeter difference isn't too great to cause major problems.. Assuming the prescription i recently got from my optometrist listed above..
thanks

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

Over the years I would say that approach has been successful perhaps 30% of the time, it takes a very skilled contact lens fitter, a very determined patient, a lot of time and money and a lot of luck for that to work.

Why don't you make an appointment at the UCLA or USC eye centers with their cornea/refractive surgery experts for a second opinion.

That's pretty much all I have to say. We have a masterful cornea/refractive surgeon in our practice, John Doane MD and I now just ship these problems to him and almost always a happy patient returns to me having benefited from state of the art laser/cornea refractive surgery.


JCH MD

[karp989]

glasses on top of the contact lens in this particular eye..

[karp989]

Thank you Jon C Hagan for your options. I'm thankful that patients have a place like this to take out their concerns. I was thinking about one thing +.50+.75x090    (os) . Since replacing the iol monofocal lens is a great risk. Just in my head do you think that by putting a -4 lens in order to induce myopia and then glasses that correct the small amount of astigmatism would be of help. that way there wouldn't be such a difference between the two eyes. what i'm trying to say is to purposely leave the eye myopic with contact lenses and then trying to alleviate this problems with glasses, making the prescriptions with less of a difference(diopeter) between the two eyes.

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

You are wrong, I did recognize the difference between the two. I'm making the assumption that before the sugery you were tolerating those strong glasses.  I'm not going to go through the math but to determine the difference before and after surgery you first convert both to the same format either plus cylinder or minus cylinder. Then you determine the spherical equivalent of each RX before and after surgery. Then you determine the difference in the spherical equivalents before and after surgery.  When you do this the difference between the two eyes before surgery was about 2 diopters and now its about 4.5 diopters.

In any case the options I outlined are the same, however you are ruling out cataract surgery.  You can put up with it or try rigid/toric contacts and glasses. Or when I have such a problem I refer my patients to our corneal surgeon who does the highly advanced anterior lamellar corneal procedures for K-conus. Only a small number of cornea surgeons have the experience and expertise to do this to avoid the much more drastic corneal transplant surgery.

JCH MD

[karp989]

I'm a 23 year old male. my vision in right eye is about the same 20/30. Only differene is that it is in plus prescription. Keratoconous hasn't changed much right eye. You probably got confused, because the prescriptions before and after are written in different format. Only prescription changed was my left eye. I dont need a a cataract removed right eye, since im young and still dont need it on right eye. corneal transplant isn't necessary yet, since my right eye still has good vision.

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

For having Kconus you have had a great result on the LE assuming with that RX you see well. Your problem is the Kconus on the RE has gotten a lot worse. (if you wrote out the RX correct you have -.75 before and -4.25 sphere after)

In any case post op you have aneisometrophia or unequal refractive error. Most people would NOT adjust to the RX.

It is very rare not to have at least small/incipient/microscopic cataracts in the fellow eye. These are what I see as your options:

1. Try a rigid contact lens and glasses on the RE (low success rate)
2. Have a cataract IOL done on the RE to restor balance.
3. Refer you to an advanced corneal refractive surgeon who is trained to do some of the anterior lamellar K-conus surgery that obviates having to do a full thickness penetrating keratoplasty (corneal transplant)
4. I would suggest you get a second opinion from a corneal/refractive surgeon. You might ask your surgeon to refer you to the most respected cornea surgeon he knows.

JCH MD