large pupils, cataract surgery,pilocarpine Restor 3

[miria]

I had cataract surgery Sept 09 with Restor #3; Improved distance vision (20/30 uncorrected) but poor intermediate vision and very poor near vision (can't read AT ALL uncorrected, don't see letter shapes, only squiggles, but can read with readers, at 3.25)>> I was very distressed by the near vision problems, as presurgery I didn't need glasses to read at all. MD says problem comes from large pupils which don't contract for near vision, and that same problem would have occurred with other multifocal brands, and even worse with monofocal, traditional lens. However,  a 2nd opinion MD said he stopped using Restor 3 as his patients reported similar problems with near vision, which is very different from my MD's diagnosis!

I  would appreciate  a doctor's response to his/her experience with large pupils and problems with cataract surgery. Is this a common problem? How has it been handled?
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The MD put me on pilocarpine in October at 4X daily, 1 % ,which greatly improved reading and intermediate, but I had adverse reaction after 2 days,  (tearing, redness, swollen lids, inflammation which lingered months). He wants me to try again, at 2x daily, but I am fearful and a 2nd opinion MD said pilocarpine can diminish distance by restricting pupils, which is exactly what I gained from the surgery and don't want to lose.

What are doctors' experiences with pilocarpine? Can it diminish distance vision with prolonged use?

The other eye has a significant cataract (20/400) but despite that, I CAN READ without glasses with that eye, and postponed surgery that had been scheduled. I use that eye to read and was told that reading glasses for both eyes wouldn't work for me because the eyes are too divergent

Can I stay with an uncorrected cataract indefinitely? I don't want to lose reading ability with both eyes and am fearful of the same thing happening with that eye as with the 1st surgery. As I said, the MD thinks I would have problems with all cataract surgery because of large pupils.

I am being evaluated for a YAG, on Monday, which was postponed because on the inflammation from the pilocarpine (it took months to go away!).

Please reply

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

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[JodieJ]

It seems that many of the surgeons implanting ReStors are not aware of the information you posted about pupil size and reading ability for ReStor vs. Tecnis multifocals.  This is truly unfortunate for the patients who receive an IOL which is wrong for them (and end up with painful inflammation from an attempt to correct a situation that never should have happened.)  There has to be a way to inform the surgeons who use these IOLs about all this.  

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

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[eyecu]

Not all multifocals are alike. The Restor lens does not provide good reading with large pupils in low light. The reading zone is in the middle or center of the lens which then blends over to distance after about 3.5mm. The Tecnis multifocal has a full diffractive pattern througout the whole optic which provides reading in all lighting condtiions and is pupil and illumination dependent.

You need to find a surgeon experienced with the Tecnis lens that understands its optical principles, your interests and hobbies etc. Pupil size is one thing that should always be measured prior to IOL selection.

If you proceed with a YAG in your Restor eye you are limiting your chances of a safer IOL exhange should you want to go down that trail.

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

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[JodieJ]

Since your ReStor provides distance vision only, essentially it IS a monofocal IOL.  If your vision can be corrected from 20/30 to 20/25 with a lens, then the power of your ReStor is slightly off.  A yag might help your distance vision a little.

You might consider getting a monofocal lens for your second eye before doing anything to your ReStor eye.  Then you can evaluate your vision with both eyes and decide between a yag or an explant.

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

I was only referring to Aphagan for pupil size. As you know this is used primarily for glaucoma treatment and if you are taking it for glaucoma then that is a bird of a different color and you should stay on it.

You have heard the old adage "you can see three different doctors and get 5 different opinions"   Often there is no "best" way but several different ways. Only your treating physician can tell you for sure and no way I would try and second guess from here.

The only thing that sounds bad to me is a second ReStor in the eye.  Since you have a surgeon you trust if he/she feels that a yag could help then strongly consider that. Know that it can raise IOP so have that monitored closely post treatment.

JC MD

[miria]

Thank you both for  continuing the dialogue
Dr.H- I am perplexed. Initially you mentioned trying Alphagan, instead of pilocarpine,  I have been taking alphagan for 2 weeks  (for high pressure from extended use of prednisolone due to inflammation fcaused by a reaction to high dosage of pilocarpine months ago, 4x daily). Alphagan: 2x daily, at  0.15%, but no effect on reading/near vision. Your 2nd post seems to indicate that I shouldn't try alphagan (higher dosage, more 2x per day?).???
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Dr. H---I have had several  other opinions already-- this has been going on since Sept!:

one doctor thought Restor lens too weak and should be explanted for a stronger version

Another doctor said his patients have had similar problems with Restor 3 and he no
longer uses it, thought I should have monofocal in other eye eventually,and live with everything as long as I can

Another MD recommended Restor in the other eye to have them work better in tandem., and said he didn't know why I had problems with near vision/reading!

The surgeon (who is not my doctor now) said everything was due to the opaque capsule and all would be resolved with the YAG> I distrusted his advice, he dismissed my concerns (said other people have worse problems, such as blindness) and I eventually changed MDs. Current MD is very well-regarded in NY, other doctors send difficult cases to him from neighboring states etc, and he actually does a lot of explants for incorrectly fitted/aligned lenses, etc.


You can see how all this confuses me, different diagnoses and recommendations,

Jodi- I was cautioned that the YAG will not ameliorate near vision(except for the surgeon, whom I no longer see),and don't expect that, but am told that the YAG should improve  distance. ALL the doctors I have seen (about 5 by now!) see an opaque capsule affecting distance vision, I'm scheduled for an evaulation for the YAG Monday, depending on inflammation residuals, pressure, findings, etc. I have to be very clear about what to do!

Since I can read with readers from the drugstore with the eye with Restor 3, would it be safer to live with the Restor,,and eventually get a monofocal with the other eye that still has a cataract at 20/400?.

I understand Jodi saying that would need glasses for  distance if the monofocal were set for near vision--but I have improved distance now  (20/30 uncorrected) and I assume the YAG would improve it further. If I do get a monofocal (which my doctor does NOT think is right for me, as I explained, because he sees problems with monofocals, large pupils and near vision), what would I do about intermediate vision?  I am not familiar with mini-monovision lenses. How might that help me?

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

Alphagan P only is available as 0.1 and 0.15% and 0.2 as a generic but I would not use them at all.

Jodie J has given you excellent advice. I would never have another ReSTor put in my eye.  Big pupils are less of a problem with monofocal especially since people plan on wearing glasses. Accommodating IOLs like Crystalens are less reliant on pupil size.

Normally the pupil size is measured prior to surgery and ReStor and the really bad ReZoom are not used with big pupils

I would suggest you get two other opinions. Your call but if I were in that situation I would opt for a monofocal IOL and plan on wearing glasses some time.

JCH MD

[JodieJ]

Your surgeon may (or may not) be correct in stating that you would have problems with any multifocal lens (e.g., ReStor, ReZoom, Tecnis multifocal) because of your large pupils.  With a monofocal IOL set for distance vision, you would indeed have blurry near and intermediate vision WITHOUT GLASSES.  WITH PROGRESSIVE GLASSES YOU WOULD HAVE EXCELLENT VISION AT ALL DISTANCES REGARDLESS OF YOUR PUPIL SIZE.  (If your monofocal IOL were set for near vision you could read without glasses, but you would need glasses for distance vision.)

You have posted elsewhere that your distance vision in your ReStor eye is 20/30 correctable to 20/25.  I suspect that the power of your ReStor lens is incorrect, making you mildly farsighted and adding to your near/intermediate vision woes.

Please do NOT proceed with a yag; it will not help your near vision.  Use the "search" feature to read the posts by londonbridge, who had problems similar to yours with ReStor.

Since you're used to being able read without glasses, you might not be thrilled with 2 monofocal IOLs set for distance vision (even though you'd have excellent near vision with glasses.)  You'd probably be happier with mini-monovision with monofocal IOLs.  (Use search feature for more info.)  In any case, definitely consider having an experienced surgeon explant the ReStor.  Do NOT get a second ReStor--double trouble.  And lose the pilo and the Alphagan.

[miria]

Thank you for your response about pilocarpine.  (I am not "younger"--64!). When you say the pupil may not dilate  normally-- does that mean that it could reduce distance vision?
Re your recommendation for trying Alphagan--I have been taking Alphagan P 2x daily (0.15%) for the last few weeks, since Jan 18, as  prednisilone created elevated eye pressure (47!). (I took  prednisolone for a few months, since Nov.,  to reduce the inflammation from the adverse reaction to pilocarpine 4x daily for 2 days), There has been no effect on improving near/reading vision from the Alphagan (pressure has stabilized at normal range).  

However, might a higher % and a more times per day be helpful, (and more risk-free than pilocarpine)?

.  Also, any comment on large pupils and the effect of cataract surgery? My MD feels my large pupils are responsible for my difficulty with near vision, that my pupils don't  contract for near vision, says that I would have  had problems  with any multifocal brand, not just Restor, but that I would have had even more difficulty with monofocals. He wrote in his report "near and intermediate acuity OD would have been worse if a monofocal implant had been placed."  

Jodie had written that she has successful monofocal implants with large pupils, and wondered if I had misunderstood the MD.

Any comments on large pupils and difficulties I am experiencing? I am concerned about what to do for the other eye with the cataract. My MD wants to implant another Restor, yet a 2nd opinion recommended a monofocal. Confused.

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

Pilocarpine is often hard to tolerate especially in higher concentrations and younger people. Moreover the stronger concentrations 1% or more carry some risk of retinal detachment and after being on pilo for a long time the pupuil often will not dilate normal.

You can try Alphagan P

A cataract can be left in the eye too long and get very hard which incrases the risk of surgery or too ripe which can cause severe pain and pressure and makes removing an emergency and a high risk operation.

JCH MD