post-rd surgery issues

[sb001]

Hello, I am new to this community and I have may post-surgery issues and would love to solicit the advice of members of this community, particulary JodieJ, as I have been very impressed with your knowledge, advice, and very generous giving of time to help others in this eye care community.  Here's my history - I have always been extremely myopic (about -12) in boths eyes and recently sustained a detachment in my left eye as a part of the PVD event.  I'm a 50 year old female.  I underwent 2 surgeries - the first was vitrectomy/laser/gas to reattach the retina.  A complication resulted in the removal of my natural lens.  Due to the formation of scar tissue less than a month later, a second surgery included a scleral buckle/laser/gas.  It is 9 months later now and I am very grateful that the retina has remained attached.  However, I am now about +2.5 in the surgery eye or so due to the lens removal and maybe 20/50 or so, so I am having major problems with the difference in the eyes - both when a wear my contact lens in my good eye and when I remove the lens and wear my eyeglasses in the evening.  I occlude the surgery eye lens of the eyeglasses.  The obvious answer would be to get a contact lens or implant in the surgery eye, but I have pretty severe self diagnosed (from reading forums like these) aniseikonia in the surgery (smaller image up to 50%) eye and some kind of seeming cental vision problem where the image I focus on is smaller - for example when I look at a person, their head is smaller than it should be in proportion to their body(at a certain distance).  I am curious to know if this is part of the aniseikonia that could be corrected to some extent.  The eye is also very dry and red still, sensitive to light, and the pupil is enlarged - I also have a blind spot at the bottom of the eye.  The eye outwardly bled for about 12 days following the 2nd surgery and looks pretty beat up, although my current opthalmologist seems to think that a contact lens could be tried in the future.  The surgeon won't say much but when pressed says no scar tissue, no macular issues, the blind spot may take a long time to go away, etc.  That's my story!  I assume I  will soon be finished with the surgeon and plan to see someone else, but have no idea who could help out with these issues. Does anyone have any recommendations as to who might be willing and able to think outside the box with my issues?  I am in the Washington DC area.  I am realistic with my expectations, and would be grateful for any relief at all.  I believe someone recommeded Ohio State University which uses software for help in treating aniseikonia.  Thank you so much!
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[sb001]

Wow Jodie, you seem to really have a good understanding of these issues - comes with personal experience and motivation I guess - I and I am sure others are extremely grateful for your sharing of your knowledge.  I haven't yet found an opthalmologist to work with, but I am sure hoping to!  (My previous comment must not have been clear).  I am hoping that one of the George Washington University folks will be interested in trying to help me out.  If I find someone I will certainly share the information.  Seems like an area where there is a real need and a fascinating topic and that someone would want to jump in - I"m very happy to hear that there is hope for improvement in the distortion over time.  I think that mine has improved some - I think it's hard to notice because the improvement may happen very slowly.  For that reason, I guess I"m a bit hesitant to move too quickly, especially with an implant.  Sounds like you are doing really well and that your efforts have paid off - good for you!  Thanks again for the encouraging info..

[JodieJ]

The distortion is caused by changes in the photoreceptor distribution in the macula.  With an ERM, there is wrinkling of the macula and traction toward the fovea (which can produce a larger image size).  After the ERM has been peeled and an OCT scan shows a smooth macula, the underlying photoreceptors may not return to a normal distribution.  But es98 take note:  In a personal communication Dr. Marta Ugarte of the UK told me that there can be improvements in the photoreceptor distribution (and a reduction in distortion) even 10 years after ERM surgery.

I'm really not knowledgeable about the causes of distortion in cases of RD.  There is reportedly a pull away from the fovea, which produces a smaller image size.

A combination of a contact and glasses lens can partially reduce the image size difference between the eyes, making binocular vision more comfortable for some people.  The discussion section of "Retinally Induced Aniseikonia" describes other potentially helpful options.

Based on my personal experience alone, I think that neuroadaptation also has a role.  Although my vision with my right (affected) eye is not exactly perfect (e.g., a vertical elongation of images at certain distances, straight lines become slightly wavy), I am almost never aware of these distortions.  Somehow, my brain has learned to ignore the distorted image when I use both eyes together.

I'm really glad to know that an ophthalmologist will be working with you, sb001.  Hopefully, this doctor will be interested enough to want to work with other patients who have retinal damage.  I suspect that experience will lead to expertise in this area.    

[sb001]

Wow, that's interesting - I am going to be more assertive at my next eye appt and ask more questions.  I have assumed that my retina is simply stretched and that's what is causing the wierd distortions that I am experiencing.  My circles actually appear wider and I've noticed that cars seem longer and lower to the ground - pretty crazy.  Yes, I am aphakic now - the gas apparently clouded the lens during the first surgery and the lens had to be removed.  The surgeon said he left a good structure and that it would be easy to slip in an implant.  I've been reluctant to think about that as my distortions become more visable if the refraction is corrected.  I'm interested to know if getting a plano lens implant would provide any benefit.  However, I"m now a bit encouraged that I may eventually get some relief if I can find an opthalmologist to work with me on the aniseikonia with the software mentioned by Jodie - some combination of contact lens or implant and glasses.  Thanks for your comment - it's really nice to hear from others with similar issues!  

[es98]

The distortion you are seeing may simply be caused by wrinkling of your retina.  After a ERM peel, I myself have been left with some distortion similar to yours, but only on one side of my vision.  Circles are not circular, but rather oval.  A rectangle will appear pushed in on one side if I look at it from a certain distance and angle, but that shape will change as I get closer/farther away from the object.

Also, it's not clear whether you have had your lens replaced yet..  Are you simply apakic at this time?

[JodieJ]

Unfortunately, I didn't receive your message.  But I'm so glad that you have an opthalmologist who will work with you.  It might involve some trial and error, but I think that you'll be able to get some type of optical correction that will make your binocular vision more comfortable.

You are amazingly observant about the variations in your distortion.  Yes, it involves a central vision problem; the viewing angle changes with the distance of the image.

[sb001]

Thank you very much for your response!  My best corrected vision in the surgery eye is 20/50 I believe, although I cannot tolerate the +2.5 glasses that were prescribed for me because the distortion is strengthened as well as the visual acuity and I experience dizziness, headaches, and depth perception problems.  I asked my surgeon if my macula was affected and he said no, but I have a followup appointment in a few weeks and will press for more information.  I just tested myself on the Amsler grid and when looking at the dot, all lines are wavy but nothing disappears.  When I look at a square such as my computer monitor, there is an hourglassing effect - when I look at the top of the square, the top becomes narrower and the bottom appears wider, etc, etc. So the shape is constantly changing as look from top to bottom.  Thanks again for your comments...

[sb001]

Hi Jodie,

Thanks so much for the wonderful information.  I had seen references to Dr. de Wit's work probably from you!) but had not seen his paper - very interesting!  I think I'll definitely take this information to a new opthalmologist who is willing to work with the software.  I was trying to wait a few more months or so to make sure my eye has settled to it's final post-surgery outcome.  I've heard and read that sometimes the eye doesn't fully heal until 12-18 months following surgery.  I thought my "small head" phenomenon was more of a central vision problem (not sure if the scar tissue affected the macula), rather than aniseikonia - very enlightening to read your comment.  My image size difference gets worse in general the further out into the distance (where everything is smaller, not just the central vision) - I thought that was the definition of field dependent.  I"m happy to hear that you had a good outcome with your contact/glasses solution - are your glasses regular glasses or specially made lenses?   I did try to contact you directly as you are a bit of a "rock star" in this community, but I don't know if I sent the message correctly.  I believe I went to the Friends section and looked up your nickname and sent a message.  Oh well, I did hear from you and am so happy to get your response.  Thank you so much.  I would like to send updates when I do seek out treatment.  I think my first move will be to address the dry eye problem so that I can tolerate a contact lens - baby steps!  Thanks again Jodie!

[JodieJ]

If you haven't already done so, do check out Gerard de Wit's opticaldiagnostics website.  The "About Aniseikonia" section has a link for downloading Dr. de Wit's paper, "Retinally Induced Aniseikonia."  This is absolutely the best paper about your condition.  Pay particular attention to what seemed to help the patient who had experienced retinal detachment.

Unfortunately, I don't believe that Dr. de Wit is still doing online testing for aniseikonia.  However, he will give an eye care provider a free trial of his Aniseikonia Inspector test and provide consultation for prescription writing.  Your description of viewing a person with a head disproportionately smaller than his body at a certain distance is a rather elegant illustration of field dependent (retinally-induced) aniseikonia.  Although it's not possible to fully correct this type of distortion with contacts/glasses, in many cases an optical correction can make a huge difference in vision comfort.  (In my own case, the contact lens/glasses combination that Dr. de Wit recommended immediately eliminated my double vision and made my binocular vision more comfortable.)  Your test results would determine what type of correction might help you.

The College of Optometry at Ohio State University also does aniseikonia testing using an older version of the Aniseikonia Inspector.  I spoke on the phone with an optometrist there, who recommended that I try putting Scotch magic tape over the glasses lens of my affected eye.  This was not at all helpful for me, but it apparently does work well for some people.

I had no luck at all getting help from any of the local eye care providers (ophthalmologists and optometrists) whom I contacted.  Most of them wouldn't even see me when I told them that my problem was retinally-induced.  I hope that you have better luck.  I suggest that you try an optometrist who specializes in low vision--maybe someone associated with a college of optometry.  I'd be happy to answer any questions you have to the best of my ability.  Most of my knowledge and personal research concerns aniseikonia related to an epiretinal membrane.  I could put you in contact with someone with aniseikonia related to retinal detachment so that you could share experiences/resources.  If you're interested, send me your email address in a personal message.  

    

[Ray T Oyakawa, MD]

What is your best corrected vision in this eye?  Was the macula detached? Where was the scar tissue formation?  Did it involve the macula?  How is your amsler grid?

Using a contact lens will neutralize the refractive difference and the image size difference if it is due to an optical issue.  It will not if due to a retinal issue.

Dr. O.