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John C Hagan III, MD, FACS, FAAO  
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Consider ALL the Options Before Your Cataract Surgery: Working Through What’s Best For You

Aug 10, 2013 - 72 comments
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Decisions before cataract surg



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Consider ALL the Options Before Your Cataract Surgery: Working Through What’s Best For You

John C. Hagan, MD, Fellow American Academy of Ophthalmology, Fellow American College of Surgeons.

Many decisions have to be made before having cataract surgery. The first is whether you need the surgery or not. Assuming you have made the decision to have surgery this is a discussion of the many options and choices you have.  THERE IS NO “BEST” TYPE OF PHACOEMULSIFICATION CATARACT SURGERY AND NO “BEST” INTRAOCULAR LENS. NO TARGETED POST SURGERY REFRACTIVE ERROR IS FOR EVERYONE. THESE DECISIONS WILL VARY FROM PERSON TO PERSON AND MUST BE INDIVIDUALIZED.  

We all have different visual needs.  Cataract surgery will be done earlier on a person needing perfect vision in all lighting circumstances, think airline pilots, truck drivers and heart surgeons. Surgery is done much later, if at all, on the very, very elderly, functioning combative or uncooperative dementia patients, those with terminal illnesses. In general cataract surgery is generally offered when a person is experiencing moderate or severe visual difficulties in activities they enjoy or need to do and the cataract is the sole or main cause.

Although the person is usually the one that makes the determination about how much of a problem his/her vision is in some cases surgery is strongly recommended by the ophthalmologist, optometrist or family.  Examples include inability to drive safely or legally; difficulty seeing the inside of the eye, major progressive physical or psychiatric disease, and if center of the cataract is getting “rock hard” (so called ‘brunescent or brown/black cataract) or could start to break up in the eye (so called ‘too ripe’).

Assuming cataract surgery is appropriate, the decisions that must be made include: which eye to operate on first, what type of IOL to insert, desired-targeted post-operative refractive error, how much glasses will need to be worn post operatively [NOTE: glasses are almost uniformly needed post operatively and are usually modern progressive bifocals]  SOME OF THE TIME a small % of people after cataract surgery can function without glasses or with inexpensive over the counter reading glasses.  Equally important is the choice of surgeon-ophthalmologist (Eye MD: a physician Doctor of Medicine or Doctor of Osteopathy that has been to medical school, medical-surgical residency and in many cases taken a special surgical fellowship.  Ophthalmologists provide a complete range of medical and surgical services.  Eye MDs must be distinguished from non-physician optometrists (OD) and opticians).

This discussion is not meant to be encyclopedic nor to give you “the answer.” As stated previous “the correct” answer will be different for different people. Informative is based on the most common questions posted on the American Academy of Ophthalmology MedHelp Eye Forums.

1. Where there is a difference of more than 1.50 diopters between the eyes post operatively glasses are often difficult or impossible to adjust to. The condition is called "aneisometrophia".  Part of the problem is due to the difference in image size each eye has with the glasses on; this is called “aneisokonia”.  Seek out Eye Forum posts on this problem by JodieJ. She had this problem post operatively and she clearly outlines her struggle and eventual success.
2. With modern cataract surgery not only do we try and make the person see better but we want the best possible vision without glasses and the two eyes to "work together" comfortably.  Tests are done preoperatively to help pick the proper IOL power to leave a targeted post op refractive error. This is not an exact science and the margin of error is +/- 0.50 but INCREASES with high myopia (long eye) or high hyperopia (short eye), eyes with previous RK, lasik, injury or additional eye diseases.
3. Typically the targeted post op refraction is between 0.00 (not needing glasses for distances of 20 feet (6 meter) or more) and -3.00 which has great vision for tiny detail at reading distance 13-14 inches.  Any difference of greater than 1.50 diopter post op may have trouble with glasses (some people tolerate much larger numbers but you never know). The range of relatively clear vision without glasses on is called “depth of focus” and will vary from person to person based on things like pupil size and corneal structure.
4. Some people that are highly myopic or highly hyperopic that do not have cataracts elect to have the lens of the eye removed (same technique as cataract surgery) and an intra-ocular lens (IOL) put in to eliminate thick glasses and improve vision without glasses. It is called "clear lensectomy" or "clear lens cataract surgery” or “refractive lens exchange”. This is done to reduce the thickness of their glasses or make them much more glasses independent.  We are not discussing whether that is appropriate surgery. The IOL and refractive problems are the same as those having cataract surgery.
5. A refractive error that makes some people happy post cataract surgery and often enables them to function without glasses for many things is 0.00 in the dominant eye for distance and -1.25 or -1.50 for the "reading eye." In good lighting they often can read without glasses. With glasses (the RX would be 0.00 distance eye -1.50 near eye and reading add of +3.00 diopters and the type glasses a no line bifocal) The glasses would be worn when best binocular vision is needed e.g. driving especially at night, sporting events or sports participation (gives the best depth perception) and prolonged reading or computer use. (This is called mini-monovision with distance bias)  If a person wanted to shift the clearest vision to intermediate and near (example some accountants, engraver, graphic design artist) the numbers change: -1.25 intermediate vision and -2.75 or -3.00 for reading/near eye. The glasses RX would be -1.25 and -2.75 with +3.00 add in progressive bifocals.
6.   If the person having surgery has astigmatism (aspherical or not round cornea) then the glasses RX will need a "cylinder" lens (second and third part of RX indicated by “cylinder and axis).  The vision without glasses will be less clear due to uncorrected astigmatism.   Assuming our models listed in above example and 1.50 diopters of corneal astigmatism the mini-monofocal distance bias will be 0.00 +1.00 axis 180 and the intermediate/near bias eye will be -1.25 +1.00 axis 180 and a +3.00 add in no line bifocals. This is more blurry vision than 0.00 at distance or -1.25 for near/intermediate.
7. NOTE: glasses can be written in PLUS CYLINDERS OR MINUS CYLINDERS (you can tell which by whether the sign in front of the cylinder number is + (plus) or – (minus) The two formula look very different and prescriptions in plus cylinder cannot be compared with minus cylinder.  Think about your body weight: your weight numbers will look very different whether it is recorded as pounds or kilograms since 1 kg = 2.2 lbs.  A discussion of this subject and the formula for changing plus cylinder to minus cylinders or vice versa is available at   http://en.wikipedia.org/wiki/Eyeglass_prescription
8.  Correction of astigmatism at the time of cataract surgery is desirable.  There are different ways to accomplish this; some are simple while others complex. Some will not generate extra surgical or IOL fees but others will:  placement of incision along steep axis of cornea-make incision larger-use more steroid drops; surgical or laser corneal relaxing incisions; toric IOLs or toric mutifocal IOLs; rounding the cornea at time of surgery with brand new (2013) femtosecond laser; post operatively using  lasik surgery to remove residual astigmatism.
9. In cases where one eye has a cataract that is symptomatic and causing problems with important functions such as driving, reading, recognizing faces, glare avoidance, etc.  but the other eye has no cataract or a cataract that is small and not troublesome in people with large refractive errors special attention needs to be made to choice of IOL.   If targeting of the patient/surgeon desired refractive error post operatively generates a difference in the two eyes greater than 1.50 diopters, the person should know it may be difficult to wear glasses conformably and/or glasses (no line bifocals usually) plus a contact lens on the un-operated eye. Or  lasik or other post-operative refractive surgery may need to be done on the un-operated or operated eye to help them work together.
10. The problems outlined in #9 above may require surgery on the “other” eye to re-establish the ability of the eyes to work together with and without glasses. This can be true even if the cataract is small or even non-cataractous.  
11. So called “Premium” IOLs (toric, multi-focal and accommodating) are used to reduce dependence on glasses. For almost all people they do not eliminate glasses 100% of the time. Even people that consider themselves “not needing glasses after cataract surgery” often wear glasses for special purposes such as night driving and prolonged reading or computer use. Premium IOLs are more expensive, have a greater chance of complication (although in the hands of an experienced ophthalmic surgery the risk is small), and produce unwanted glare and scattered light (dysphotopsia) more than modern aspheric monofocal IOLs.  
12. It is also fair to say that some ophthalmology and optometry offices exert effort to encourage people to “upgrade’ from monofocal IOLs to “premium” IOLs. In sales this is not called “upgrading” but “upselling”. Also it’s important to know that some optometrists receive part of the surgical payment for cataract/IOL surgery, this is known as “co-management”.  Premium IOLs are not better than monofocal IOLs; they are not designed to make everyone 100% glasses independent all the time. Most ophthalmologists and optometrists do present a fair discussion of each type of IOL and let an informed patient make the choice that suits them best.
13. While cataract/IOL surgery is the most common type of surgery done on adults and has a very low complication rate it is not risk free NO SURGERY IS RISK FREE; THAT’S WHY YOU READ (or have read to you) AND SIGN A SURGICAL CONSENT FORM THAT INFORMS YOU OF THE DIAGNOSIS, YOUR OPTIONS AND POSSIBLE RISKS AND COMPLICATIONS. These risks cannot be entirely eliminated. No surgery is entirely “routine and risk free”   Think about driving an automobile. Driving is “routine” to most of us. Yet everyday there are people injured or killed in automobiles. We continue to drive because, with care, the risk is relatively low. Think of cataract surgery the same way.
14. In most all cases cataract surgery is elective. You can take your time and make these important decisions. There is nothing wrong with seeking a second opinion from a different ophthalmic surgeon. You can also access the many helpful discussions on these topics at the two AAO Medhelp Eye Forums by using the search feature or looking in the archives.

15. This information is not meant to give you specific recommendations. This posting is for information purposes only. You should rely on your own multi-source research and discussions with your ophthalmologist, optometrist and personal physician.







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by suezq56, Aug 12, 2013
Thank you very much for a clear and concise article.  It's very helpful.

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by caregiver222, Aug 12, 2013
An excellent article. Thank you.

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by ill13632, Aug 12, 2013
I'm very myopic, nearsighted, if I have lasik surgery will I possibly go blind or have retinal detachment?  Thanks very much!

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by radar7, Aug 18, 2013
I had a cataract operation done on my left eye as night driving was becoming a bit of a problem.  Developed negative dysphotopsia which I feel is more of a bother to me than the cataract that I had.  The consent form that I signed and the literature I was given to read pre-op never mentioned this problem at all. I find this very disappointing. I wish more doctors give patients the pros and cons of cataract surgery as you have done in this excellent article.

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by jerseygirl1046, Aug 20, 2013
My husband had retinal detachment surgery 8 months ago.  He has double vision now, what can he do?  Thank You for anything you can suggest, I am concerned about his driving.  He is 67 years old.

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by John C Hagan III, MD, FACS, FAAOBlank, Aug 20, 2013
Go to the community eye forum, use the search feature and archives and read about double vision and cataractd surgery. Go to www.geteyesmart.org and find a Eye MD ophthalmologist near you that specializes in strabismus/pediatric eye surgery.   Go see him/her for 2nd opinion.

JCH MD

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by zwar, Aug 21, 2013
Dear sir,
              I am 28 years old and having floughter problem in my right eye that make my job more complex while working in office on PC and one major think spot comes in front of my vision that moves after many tries to move eye from right to left then it disappear for sometime but appears again. I feel little bit heavy eye bearing some wait.so please let me know what should i do?

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by kpbf, Sep 02, 2013
by kpbf

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by kpbf, Sep 02, 2013
by kpbf, Sept. 2nd, 2013

Dear Dr. Hagan,
I recently had a tecnis Model ZMB00 Diopter +21.0 D +4D multifocal lens put into my right eye on Aug. 8th and then in my left eye on Aug. 22nd.  On my day after appointments, the doctor said I had 20/20 vision in both eyes.

Unfortunately, I did not do enough research before the surgery and now I am very worried that I made a mistake especially after reading your information above.  My right eye had a severe cataract but my left eye had a small one starting.  I said I would love to not have to use glasses and she said I was a perfect candidate for the multifocal lense. The doctor did not discuss my needs or the option of the distance only lense. She also said it would be much better if I had the second eye done quickly.  I should have waited to see how the first eye responded.  It has been 2 weeks and my reading vision is somewhat doubled or shadowed.  I can read the small print but due to it not being clear my eyes feel very strained.  My intermediate vision is poor.  My distance vision is good.  I test children and use the computer for my job therefore this is a serious problem.  I have ghosting and halos during the day which I have not read of anyone else having and severe halos, star bursting, and glare at night that is painful.  I can't even drive.  I live out in the country and have elderly parents.  

My doctor's appt. is this week.  I read an article by Dr. Rosenfeld outlining seven steps to take when caring for unhappy patients.  He said definitely do not have the YAG laser capsulotomy done if you think you may want the lens explanted.  He suggested residual refractive error, residual astigmatism, ocular surface disease, poor IOL centralization, and maculopathy as well as the posterior capsular opacification which involves the YAG laser.  What do you suggest?  Do you feel any of these suggestions will help? Should I avoid any others if I may want my lens explanted.

Can I have the lenses explanted and have distance lenses put in?  How soon would I have to have them done to avoid scar tissue?  What are the risks?  Will the distance lenses cause the severe halos and star bursts that I am experiencing?

Do you know of any eye specialists that do explants in or around Louisiana?  If not, who and where would you recommend?

Thanks so much for your help,
I have been so worried that I may not be able to drive at night!!!
Pam

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by John C Hagan III, MD, FACS, FAAOBlank, Sep 02, 2013
See what your surgeon says. Then get an independent 2nd opinion. LSU has a great ophthalmology department.

JCH MD

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by John C Hagan III, MD, FACS, FAAOBlank, Sep 02, 2013
This is faculty at LSU:



  

LSU Eye Center  





Clinical Faculty

Marie  D.  Acierno, M.D. - Neuro-Ophthalmology
Bruce A. Barron, M.D. - Cornea Service
Donald  R.  Bergsma, M.D. - Comprehensive Ophthalmology
Maria D. Bernal, M.D. - Cornea and Uveitis
Christine Connolly, M.D. - Comprehensive Ophthalmology
Ira  B.  Fuller, M.D. - Retina Service
Yen Ngo, M.D. - Glaucoma
P. Sean O'Sullivan, M.D. - Retina Service
Maria Reinoso, M.D. - Retina Service
Jayne S. Weiss, M.D. - Cornea, Cataract and Refractive Surgery
  
Dr, Jayne S. Weiss MD is the best match for you Pam.

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by kpbf, Sep 03, 2013

Thanks so much!
You are a wonderful person to take time out of your busy schedule to help us!
I had a wonderful quality of life and just want it back.

Sincerely,
Pam

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by dubois564, Sep 15, 2013
Dear Dr. Hagan,

Could you kindly recommend an ophtalmologist in Boston area who is specialized in high myopia and cataract?  

Thank you in advance.

Best regards,

D

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by John C Hagan III, MD, FACS, FAAOBlank, Sep 15, 2013
I do not know anyone personally there but Mass Eye & Ear is as good as they get.
JCH MD

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by AnnSalem, Sep 22, 2013
Dr. Hagan,
I very much wish I had read your article prior to my cataract surgery three months prior.  I had a Restore IOL implant with laser technology and anesthesia applied on a sponge in the eyelid.  My ophthalmologist was pleased with the healing progress, even though my vision still required quite a bit of correction with glasses.  My major concern is that I have experienced a pain in my eye since the few days after the weekly regimen of drops were discontinued.  I can best describe this as a nerve type pain on the cranial nerves on the right orbital side of my eye, and recently pain under the eye towards the bridge of my nose.  I have returned four times to the doctor who prescribed another week of Prednisolone.  This did not work.  The only thing that changes is the intensity of the pain from hour to hour.  Some days, I look at a clock to know when I can take the next pain reliever.  I have tried Excedrin, Ibuprofen, hydrocodone in one episode, ice pack, etc.  On my last visit, the ophthalmologist indicated he had never seen this and didn't know what to recommend.  At my suggestion, he ordered an MRI although he does not suspect this will show any answers.  Subsequently, I went to my internist who tried Celebrex for an anti-inflammatory and Afrin to take off any pressure under the eye.  This is only an experiment, as he expects I have nerve damage.  Next week, he wants to try Neurontin.  The Celebrix/Afrin is not helping.  I have been very patient thinking this was post op inflammation, but now I am fairly frightened that I have permanent nerve damage.  This level of pain is not tolerable long term.  Can you please advise me of appropriate next steps.  Are there cases of anesthesia causing nerve damage?  Any direction you can provide would be most appreciated.

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by John C Hagan III, MD, FACS, FAAOBlank, Sep 22, 2013
No none of the typical complications of cataract surgery include prolonged pain. Painful nerve damage persisting for long periods of time are unknown after cataract surgery. You would need to look for another cause (sinus disease, facial pain syndromes, cluster headaches, etc

JCH MD

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by Cataractjeweler01, Oct 23, 2013
Dr. Hagen,

I am a 37 year old jeweler who had a cataract in one eye. My Dr. Shoemaker in Sarasota fl, told my that the tecnis multi-focal lens was best to see close up. But now that I had it done I can not see the detail in which I could. But when tested by the card they give me to read I do much better. Even though I could not see out of my left eye will before now it seems it is disrupting both eyes when looking close up detail. I was offered to do a mon-focal lens instead. He suggested near vision and loss distance.  What do you think?

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by John C Hagan III, MD, FACS, FAAOBlank, Oct 23, 2013
The two eyes often fight one another with only one done that is called rivalry. You can try your work with a bifocal lens over the operative eye or even a jeweler's loupe.

I would suggest you get independent 2nd and 3rd opinion about your options. I suspect most will involve glasses some or most time  and/or surgery on the second eye if it has a cataract and you need more power for near vision in that eye.

JCH MD

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by Sparty1984, Nov 01, 2013
I'm 52 and scheduled to have cataract surgery soon, my right eye was measured at -17 dioptors with just under 2 dioptors of astigmatism ( this eye has a scleral buckle due to detachment 12 years ago). Left eye i believe was -14 dioptors with around 1.25 dioptors of astigmatism. I'm having the lensx procedure and was told that I would need a -3 lens but they only come in powers down to -6, this will be a acrysof toric lens for a target of -2 dioptors of myopia.  The left eye will have a non toric acrysof with the astigmatism corrected by the laser with target of Plano.  My doctors thinks this mono vision should work well and if I'm not satisfied we could tweak the residual myopia with prk later.  My question does this seem reasonable or should the lens selection for the right be a lower number that could get closer to Plano.  I'm just curios to other opinions on this.

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by John C Hagan III, MD, FACS, FAAOBlank, Nov 04, 2013
LE post op uncorrected refractive error of -3.00 and RE of 0.00  would be full mono-vision and is discussed in my blog article. It works for some people not for others.

JCH MD

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by Sparty1984, Nov 04, 2013
Thanks , should I consider a lowered powered non toric lens for the right eye and worry as much about the astigmatism?

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by Sfwolfe, Dec 04, 2013
Wonderful,informative article.  Thanks so much!

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by David274, Dec 05, 2013
After reading about increased incidence of complications with multifocal lens, I am rethinking having ReStor lens.  There seems to be less information regarding post-op experience with Toric monofocal lens.  I have astigmatism with -7,0 D and -7.5 D with glaucoma and cataracts in both eyes.  I am leaning toward Toric   The physician recommends cataract surgery on both eyes within one week interval.    Can you comment on Toric lens, and surgery interval?   Shouldn't I wait at least two to three weeks between eye surgery?

Thanks for providing a forum for discussion
David

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by John C Hagan III, MD, FACS, FAAOBlank, Dec 05, 2013
We use toric monofocal IOLS in our practice with much success. They are more predictable for correcting astigmatism than corneal incisions.  We do not operate on the second eye until the eye has healed and the patient is very happy with the result on the first eye;  generally we do surgery about 5-6 weeks apart.
JCH MD

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by fletch361, Jan 02, 2014
I am 52 years old and require cataract surgery on both eyes as a result of having vitrectomy surgeries on both eyes for macular holes (right eye 15 months ago -- left eye 6 months ago).  I am very nearsighted -8.0  in right and -7.0 in left per contact lenses prescription.  The holes closed successfully in the surgeries.  I have slight distortion out of center of right eye but overall can see pretty clearly with my contacts -- until cataracts started to form.  I am considering the Crystalens implants vs. standard lens to eliminate the need to wear contacts/glasses to see and hopefully may just need readers.  I am a computer analyst and on a computer 10 hours a day so need my near vision.  Do you have any advice on Crystalens?  The cataract specialist I am seeing does do laser cataract surgery as well and will correct slight astigmatism in my left eye.  In my online research I see very few success stories and more complaints making me skeptical; however most only post complaints.  Thank you.  Nancy

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by John C Hagan III, MD, FACS, FAAOBlank, Jan 02, 2014
Refractive and accommodate IOLs like Crystalens are NOT a good choice for someone with macular disease like you have (macular hole repair).  

JCH MD

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by John C Hagan III, MD, FACS, FAAOBlank, Jan 29, 2014
Just returned from a surgical conference in which the results of the femtosecond laser were presented and they were extremely impressive especially when coupled with intraoperative wavefront aberrometry and astigmantism correction at the time of cataract surgery. Anticipate more and more surgeons will be offering this technology which is NOT covered by most insurance plans resulting in out of pocket expenses increase.

JCH MD

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by penken, Feb 08, 2014
Dr. Hagan,
I cannot thank you enough for taking time to inform so many of us dealing with unusual vision issues.  I will be having a second cataract surgery soon, but I m going to postpone and let one eye heal. My surgeon seems to be rushing me to choose a prescription for my right eye. I am having difficulty deciding on the best option.  I m glad to hear of the successes of the femtosecond laser.  I will have an astigmatism corrected and an IOL put in after cataract is removed. Just wish I didn't need reading glasses but so thankful to see as I was a -19 in the L eye and now have 20/30 vision.  I could not qualify for the Toric lens due to high myopia.  I posted  my entire complicated vision story on another thread earlier  today.  I also have strabismus. Here is my story...
I am happy to have found this blog. I am a 53 year old female, highly myopic.   Glasses at age 2. Which  now is thankfully is correctable with contact lenses. -19.50 in R eye and -19 in left. I also have intermittent strabismus. I did 40 weeks of vision therapy a  year  ago. I am now able to tell when my right eye is on.  I had   2 strabismus  surgeries at ages 6  & 8. Right ye turns in if it isn't on and left eye turns in when R eye is on sometimes. This being said, I have developed cataracts and I was seeing double in L eye due to cataract.  I had successful cataract surgery last week and I am thrilled to see very well in the distance range, but I am disappointed with having to wear reading glasses. I had a standard IOL put in left eye, mild astigmatism.  The glare from lights  and headlights has I improved since cataract was removed, but  some long glare is still apparent along with some halos still remaining.
I am scheduled to have the R eye done at the end of the month. I have changed my mind twice on whether to have a lens put in for near or far vision.  I met with my long time eye doc to get an opinion.  My R eye has a  moderate astigmatism which he will work on with laser to correct.  
I am concerned that my eyes will not team and I will have constant eye turning in if I choose to have near vision in right  eye. I need another opinion and was hoping you coukd give me sone advice.  Thank you for your time.  Sorry for such a long post. I am so thrilled with the technology that has changed my life, just want to make the best decision.  
If I wanted a 2nd opinion here in the Jacksonville Fl area could you recommend someone? I am happy with my eye group of specialists, I just wish they were more forthcoming with information.  Thanks again.  Penny

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by John C Hagan III, MD, FACS, FAAOBlank, Feb 08, 2014
Glad you enjoy the article. I cannot give you an "opinion"  As indicated there are different answers for different people. If you and your surgeon really can't decide see another surgeon for a second opinion.
JCHMD

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by Terry132, Feb 21, 2014
I had cataract surgery on  left eye about 8 yrs ago with a lens implant - no idea what kind of lens. No problems with that eye since then. Cataract in right eye grew large until vision became blurry (especially if I covered the treated eye). Ophthalmologist said right eye cataract was large and recommended removal & astigmatic lens implant. Had surgery two days ago. After surgery doctor told me that 1) she decided against astigmatic implant and tried 'regular' lens; 2) eye tissue wouldn't hold 'regular' lens during surgery so she withdrew the lens. 3) she said eye was too stressed to insert lens 4) am now without cataract and without lens 5) she says to wait for about 3 or 4 weeks and then insert another 'regular' lens on the outside of the tissue (rather than the inside) 6) meanwhile, I am unable to work -- mostly I work at computer and am very uncomfortable. I am miserable and have 2nd post-operative checkup tomorrow.

I think I should get second opinion about how to continue to get right eye fixed.  Right now it is much worse than before surgery. What do you suggest? Can you give me any further information about this failure to be able to insert lens in eye?  Can the eye function reasonably well without a lens implant? I am 65.

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by OneEyedJill, May 23, 2014
OMG !!  Thank you, Dr. Hagan.  I have never read such comprehensive material about the many considerations involved in cataract surgery.    I think many of us worry that we won't receive such individualized treatment.  My mother, who had Alzheimers, refused cataract surgery from fear and distrust.  In the  late 1980s, she  went blind, and died with what I can only describe as a look of terror that I was legally helpless to prevent.  They say knowledge empowers, but  it doesn't necessarily remove the fear of making the wrong choices.   Still, it is  always better to know the choices and consideratons,  than to later wish I'd known  (-:

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by Fraidycat13, Jun 11, 2014
Dr. Hagan,  Interesting article. I have cataracts in both eyes and trying to decide if permaclear is the right choice. I read articles where people had crystalens or restore lens and had many problems with the crystalens. What is the difference between all 3, pro or con on them? What would you recommend to your patient?  Thank you.

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by John C Hagan III, MD, FACS, FAAOBlank, Jun 11, 2014
Read the article again you'll learn even more.  Our practice uses Crystalens. Personally I would never consider a ReStor IOL in my eye.  Since I am all about precise optics, good night vision and have worn glasses for 50 years I would not personally choose any multifocal IOL and would go with monofocal asphric IOLs like the Technis our practice uses.. However some people hate glasses are willing to pay a lot more to use glasses a lot less and willing to put up with varying levels of dysphotopsia. There are ophthalmologists that have had cataract surgery on themselves and have had ReStor and Crystalens put in their eye.

JCH MD

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by CurlyButterfly, Jul 12, 2014
Dear Dr. John C Hagan III,
   Would you be willing to read my post I've put on medhelp and give me your input? I've been emailing back and forth with a lady who has had similar eyes as mine who has already had surgery for cataracts (which has been helpful). I wondered what your opinion might be. I've read a lot that you've written which has also been very helpful. Here is the medhelp link: http://www.medhelp.org/posts/Eye-Care/Cataracts--Toric-IOL-for-Astigmatism/show/2231723

Thank you for your time, it is TRULY appreciated! My surgery is scheduled for the end of this month. Bless you for doing this work here on medhelp.org.

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by skigirl23, Jul 16, 2014
Gosh, thanks for the great article. I am an artist who has been struggling with what to do so that I will not loose all intermediate vision.  I am also an athlete and love the idea of skiing without glasses---although I already own the goggles with the fan!!  I will reread this article until I get it--thanks.

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by learyeyed, Oct 04, 2014
Dr. Hagan,
  I am a 70 year old female. My only eye problems are cataracts ( both 2+), astigmatism ( both about .75), hyperopia, and I assume presbyopia. Cataract surgery scheduled in a couple of weeks, with a top-notch surgeon MD, in cataracts, lasik,corneal transplant, femtosecond laser cataract surgery, and etc. He will be using the femtosecond laser machine for my surgery.  I want the best clearest crisp uncorrected distance vision possible. I use binoculars for bird, and wildlife watching almost every day, and I can not wear my glasses when I do, because of essential tremors, not being able to hold my hands steady, I hurt my nose with my glasses on. Binoculars have rubber cups.  I would like to be able to see to drive at night, (haven't driven at night for past 3 years). Would like to see better in dim light. I would like to read things on grocery store shelves without glasses, and see at least 11 to 12 feet away for watching TV, and being able to read the on screen guide, when in bed at night without glasses. I would not mind wearing glasses for closeup reading or the computer. I am very active, do all sorts of projects, closeup, like sewing, and far away, like playing golf.  This is what I can dream for, but in the end just be thankful for some kind of vision.  Multifocals and crystalens are out.  With the research I have done, I narrowed it down to toric or monofocal. With the low astigmatism, overcorrection would be a concern, with the toric. My surgeon uses both the Staar and the Tecnis brand lenses. Here is my problem. He wants to use the Staar toric AA4203TL or TF. I don't know which. I wanted the Tecnis toric ZA9003, but he did not want that one.  I think the Staar is inferior to Tecnis because of it being silicone, and all of its other past problems which you are probably aware of without my listing them. One of my concerns is if I would have an eye problem where they would have to use silicone oil in my eye. I can not understand why, with a brilliant of a doctor as he seems to be, why he would choose such and inferior lens which the Staar toric seems to be.  I like the Tecnis with the features it has, and it is aspheric. At my age I don't know if the feature of it being aspheric would benefit me in the long run.  I talked with my surgeons nurse again, and she insists he made the best call with the Starr toric. This is my second surgeon I have been to. The first one wanted to implant torics also.  I am worried about being overcorrected for astigmatism, and getting an older style lens with too many faults, like the Staar. I have already paid this surgeon fully for the toric upgrade so the money is not the issue, and I don't want to go through the hassle of a third opinion.  Should I just go with his choice and hope and pray that everything turns out alright or what. Maybe you or someone who posts on here can enlighten me. Thanks much.

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by John C Hagan III, MD, FACS, FAAOBlank, Oct 04, 2014
There is no best IOL or all surgeons would use it. Just like there is no "best automobile".  All of the lens you mention are by reputable companies with good quality control.  You have set up so many qualifications and stipulations that you have almost guaranteed that no IOL and no surgeon could meet all your expectations.

You can always step back, postpone surgery and get a third opinion.

You might re-read my article again. If both eyes are set for distance 0.00 you will not be able to see a TV set at 12 feet away clearly because "distance" is 20 feet and further.

JCH MD

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by Melliforte, Dec 04, 2014
Dr. Hagan,

I am planning to have cataract surgery in 2015 and came across your helpful and detailed article about the many considerations that should go into decisions made with regard to IOL replacement. I am very interested in the Bausch + Lomb enVista lens that was FDA approved in 2012 and would like to discuss its suitability for me with a surgeon in my area (Atlanta, Georgia) who has experience with it. Have you heard of or worked with this lens enough to have an opinion about it? Do you or does anyone reading this know of a surgeon in Atlanta who has experience performing enVista lens implants?

Bausch + Lomb enVista IOL:
http://www.bausch.com/ecp/our-products/cataract-surgery/lens-systems/envista-iol#.VIEHZFfF9cs

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by John C Hagan III, MD, FACS, FAAOBlank, Dec 04, 2014
Melliforte:   I trained at Emory Dept of Ophthalmology which is world famous. I do not know private practitioners to recommend but I'm sure there are many.  B&L is a quality company. I do not have any experience with the enVista lens.  I have seen hundreds of patients with acrylic lens with glistenings but never had a single complaint so I think the "sizzle" of this lens is overstated.

JHagan MD


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by Canesee, Jan 20, 2015
Dear doctor
I am 54 years old and my eyes were perfect up until I was about 42. Over the last few years they have got worse and I now use 3.0 reading glasses. My long vision has faded but is still ok. I am booked in to have oculentis m plus lens fitted to my right eye this Friday. Now reading all this bad feed back am very worried. Would you recommend this to save me from my reading glasses?
Graham


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by John C Hagan III, MD, FACS, FAAOBlank, Jan 20, 2015
This discussion is only for people with cataracts and reduced vision not corrected with glasses.  Near vision getting worse as we age is normal and is called "Presbyopia"

JCH MD

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by PenelopeLane, Jan 20, 2015
I had cateract surgery 6 days ago.    In addition to cateracts, my eyes have VERY narrow angles, and have been a source of agonizing pain off and on for decades.  The surgeons say that the new lenses will prevent an iridotomy.  After the first surgery of last week, I am seeing light streaks from all lights at night since the 2nd day.  All set for other eye surgery in 4 weeks, also at Wilmer in Md.   My question is simple.  Do light streaks ever go away on their own while the eye heals?   The eye was set for distance 24.0. It is an AcrySof  MA50BM.  

The right eye will be set for near distance only.  

Thank you for your help!


PL

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by John C Hagan III, MD, FACS, FAAOBlank, Jan 20, 2015
Please do discuss with your surgeon, Wilmer at JH is among the best in the world. The MA50BM is a high quality monofocal IOL not associated with a high incidence of "dysphotopsia"  (search the word and read about, I have published studies on same).  In most people these streaks go away as swelling decreases and any residual refractive error is corrected with glasses.

In most cases with monofocal IOL gone by 2-3 weeks post surgery.  Permanent dysphotopsia much more likely in multifocal IOLs like ReStor

JCH MD

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by PenelopeLane, Jan 20, 2015
Thank you.

I understand Wilmer is a superb Hospital, but it takes weeks for them to respond, which is very frustrating.  I have researched the lens only yesterday, but found nothing that indicated how long it could take.  Knowing the facts keeps me calm . . .

I do not want more troubles with my eyes.  Decades of it has been debilitating, and frightening.


Thank you for your kindness, Dr. Hagan.   I feel better!

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by John C Hagan III, MD, FACS, FAAOBlank, Jan 20, 2015
Every reason to suspect you will do well. JCH MD

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by Mizmo412, Feb 10, 2015
Thank you so much for the write up above.  My situation is addressed in #9; non-dominant eye has cataract ready for surgery, dominant eye has cataract as well, but not deemed as significant for surgery yet.  I have very good distance vision, and require +1.5 for reading.

The Dr was pushing ReStor, but I'm not willing to deal with the halos/glare or reducing the sharpness of my distance vision.  I've been trying contacts to mimic monovision and seem to be able to tolerate it.  

Dr is recommending -1.75 or -2.0 anticipating further denigration of my vision.  However, neither worked for me with contact trial; I was unable to read the computer.  

How much additional denigration should I anticipate after implanting an IOL?  I'm 54; I've read that most of the change occurs during 40's & 50's.  My thought is to go with mini-monovision, with -1.5 in the non-dominant eye, which would give me near vision now though I may need readers for near vision in the future.  It also minimizes depth perception issues, which is somewhat of a concern, since I am a skier.

Is there any reason to consider Crystalens?  I initially eliminated after 2nd Dr told me they tend not to work over the long term, but haven't seen that issue validated in the research I've read.  What I have read is that Crystalens is good for intermediate and distance and most likely will require glasses for near vision.  If so, I don't see advantage over mini-monovision -- am I missing something?

Finally, could explain mini-monovision with distance bias in layman's terms?  If I understand correctly, distance glasses would essentially reverse the IOL and near glasses Rx would be for both eyes, with distance eye getting an addition 1.50.  I lost you at +3.00 for progressive bifocals.

Thanks in advance for your response.



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by John C Hagan III, MD, FACS, FAAOBlank, Feb 10, 2015
The loss of focus power with age called presbyopia stops when an IOL is put in the eye.   Mini-mono distance bias would be to leave your operated eye which has good vision at 20 ft or further (  glasses RX would be zero or as we say plano) and in your unoperated eye to put in an IOL to leave you about -1.25 or -1.50     With no glasses distance and mid vision (shopping, speedometer, etc) should be clear. For prolonged reading, very small print or prolonged computer use you would need glasses generally no line progressive     Mini-mono near bias is for myopic people that have always been able to read with out glasses and want to keep it that way.  Their target refraction would be about -1.50 and -2.50   they should be able to read well without glasses and likely use a computer. They would need glasses (again no line progressives for distance like drtiving) they are use to that and don't mind.

Our practices uses Crystalens and when done by a skilled experienced surgeon it is the best of all the multifocal/accommodating IOLs in my opinion. We also have people that have had a monofocal IOL successfully set for distance like you that have a Crystalens in the other eye and they can use computer and read without glasses.  Again to use both eyes need progressive bifocals.

The thing that makes this difficult: there is no best IOL there are lots of good ones, there is no single answer for every person and what makes one person extremely happy another might consider a poor result and be very unhappy

JCH MD



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by Joanlimsaw, Mar 15, 2015
Dr Hagan

I have bilateral cataracts and have been advised to remove them.
Since at a young age I've been rather myopic and at present -9.25 and -10.5
I also have astigmatism but not sure how much
Plus glaucoma in both eyes, the left eye having lost about 20% sight.

My doctor suggests that I have intraoccular lens in my dominant eye for far vision and in the less dominant eye for closer/ reading vision as I have been using contact lenses following this principle.
But now I am having the lenses implanted into my eye and would dearly like your opinion on it.
Thanks




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by John C Hagan III, MD, FACS, FAAOBlank, Mar 15, 2015
If you are use to "mono-vision" (discussed in my article) then you might opt for what is called "full mono-vision"  i.e. distance eye Plano (zero power) to -0.25 and for reading -2.75   however there would still be some distances you would still need glasses to see (intermediate vision ) and of course you would only be using one eye for distance and one for near to your acuity and depth perception will be reduced since these require both eyes being used together.

Most myopic patients are use to glasses and do not object to wearing them post operatively and are generally happier with the mini-monovision with near bias or mini-monovision with distance bias.  You might inquire about your astigmatism and if over 1 diopter discuss toric IOL

JCH MD

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by Joanlimsaw, Mar 16, 2015
Dr Hagen

Is it advisable for a bilateral cataract patient who has bilateral glaucoma and has lost,about 20% sight in one eye to have premium multifocal iols?
Also some degree of bilateral astigmatism and highly myopic

Thank you

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by John C Hagan III, MD, FACS, FAAOBlank, Mar 16, 2015
A toric lens would not be a problem but multifocal and accommodating IOLs are something I advise my glaucoma patients against.

JCHMD

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by abrahamic, Mar 17, 2015
Dr. Hagan,

I'm a 30-year old man with big cataracts in the non-dominant right eye. I scheduled for cataract surgery in 7 weeks, but upon seeking a second opinion, I was diagnosed with Uveitis, high cup/disc ratio (I'm not sure how serious this is) in the cataractous right eye, and possibly some signs of Fuch's Corneal Dystrophy in the non-cataractous left eye.

1- Do I have to reschedule my cataract to avoid any complications? (2nd Dr suggested extensive checkup to find out the cuase of Uveitis which may have cuased the cataracts)

3-When I develop presbyopia in my dominant right left eye in 10-15 years, how will that affect the near/intermediate correction I intend to choose with the IOL in the non-dominant eye? (I currently wear 1.25 near correction in the left eye, and my distance is just fine for driving 20/30)

Thank you for taking the time to address our questions.

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by John C Hagan III, MD, FACS, FAAOBlank, Mar 17, 2015
1. Since cataract surgery is elective and uveitis is a special problem I would suggest having the uveitis evaluated before the surgery. It make a difference in which medications and how long they are used before/after your surgery.
2. Assuming the dominant LE does not develop a cataract after presbyopia you will likely need to wear progressive bifocals to use the two eyes together.

JCH MD

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by Joanlimsaw, Mar 25, 2015
Hello Dr Hagan

Does intermediate vision mean the distance referring to an arm's length from the eye?
As I'm considering aspheric iols for long vision in one eye and close/reading vision in the other eye, you stated in your reply that I may need glasses to see in intermediate vision. Are you referring needing glasses to read on the computer screen for example or is it that everything within this distanc of area will be blurred?

Thank you


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by Joanlimsaw, Mar 25, 2015
Hello Dr Hagan

Does intermediate vision mean the distance referring to an arm's length from the eye?
As I'm considering aspheric iols for long vision in one eye and close/reading vision in the other eye, you stated in your reply that I may need glasses to see in intermediate vision. Are you referring needing glasses to read on the computer screen for example or is it that everything within this distanc of area will be blurred?

Thank you


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by John C Hagan III, MD, FACS, FAAOBlank, Mar 25, 2015
It is an admittedly inexact term but roughly 3 to 15 feet, would encompass computer, shopping and watching TV in small to medium size rooms.
JCHMD

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by Joanlimsaw, Apr 03, 2015
Dear Dr Hagan

I am going to have my 1st cataract operation within the next few days.
Can you please tell me if an implanted iol needs to be removed and replaced, would it be complicated and difficult with risk of eye damage?
Thank you for your prompt answer always

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by John C Hagan III, MD, FACS, FAAOBlank, Apr 03, 2015
It is extremely rare to have to remove or replace a intraocular lens.  Probably less than 1 in 1000. And not difficult to replace  if necessary.
JCH. MD.

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by Joanlimsaw, Apr 07, 2015
Dr Hagan

I have just had an aspheric mono iol implanted in the right eye for long distance 6 hours ago
In that eye the image slants somewhat to the right and is not horizontal. Is it too soon to worry? Must I give more time for the eye to adjust?


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by John C Hagan III, MD, FACS, FAAOBlank, Apr 07, 2015
The MedHelp legal staff has advised us not to answer questions asked about surgery or in the immediate post operative period so you will need to ask your surgeon that.
Best of Luck.
JCH MD

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by Joanlimsaw, Apr 07, 2015

Thank you Dr Hagan.
I do understand your stand point.
However I do want to thank you for your help every step of the way to my iol implant.

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by SLMitchell, Apr 13, 2015
First of all, thank-you so much for all your invaluable information! I have cataracts in both eyes, worst in my non-dominant right eye.  I have been myopic since a teenager.  I have to have something done soon; however, I have been researching this issue and iols for many months and am still immobilized by a lack of decision re: which iol to have, whether to have laser-assisted surgery, etc.  I will come up with the additional money for the premium lenses if they are worth it! I thought the nanoflex lens sounded great, but cannot find current information regarding its track-record. Also, is there some "miracle" lens about to be approved that would be worth waiting for?  Thanks for any input you might offer.

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by John C Hagan III, MD, FACS, FAAOBlank, Apr 15, 2015
Since you are myopic you are use to wearing glasses and seeing clearly up close without glasses.  So spending the extra money for an accommodating or multifocal IOL would likely not be worth it for you and these lens are more prone to cause glare (dysphotopsia). If you have astigmatism a toric IOL is worth considering.  Cataract IOL is highly successful and at present very few patient spend the extra money for laser assisted surgery. However the technology while it adds some benefits is not really necessary if money is a problem.  At present 99% of our patients do not opt for femtosecond laser.

There will always be new IOLs coming out none are going to be breakthrough.  If you need the surgery don't put it off. I saw 4 patients yesterday for their last post cataract/IOL surgery visit and they were all ecstatically happy.

JCH MD

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by Joanlimsaw, Apr 18, 2015
Dear Dr Hagan

It's been 11 days since I had an aspheric iol implanted in my right eye.
I received good clear sight all along until yesterday night watching television that the images were not sharp  anymore until this morning
As instructed by my doctor I have Tobradex drops 5 times daily since after the cataract operation
What can cause this and is it temporary?

Thank you

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by Joanlimsaw, Apr 18, 2015
Regarding above letter I forgot to mention that since yesterday morning I have a sore throat so could be an impending cold/ virus infection

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by John C Hagan III, MD, FACS, FAAOBlank, Apr 18, 2015
Sorry have to repeat:

The MedHelp legal staff has advised us not to answer questions asked about surgery or in the immediate post operative period so you will need to ask your surgeon that. All major changes should be reported. Minor day to day fluctuations are not unusual.
Best of Luck.
JCH MD


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by mizdara, Apr 20, 2015
Dr. Hagan, ten years ago I had cataract surgery for my right eye and received an implant for distance vision. Now I have been advised that I required a laser correction. In addition, it is now time to remove the cataract in my left eye. It was recommended to me to get a lens for close vision in that eye and thus eliminate the need for glasses. Two questions: Which proceedure should be done first and because I am a jeweler, should I consider the recommended lens or just get another lens for distance and use reading glasses plus jeweler's optics? I want the easiest and most effective solution.

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by John C Hagan III, MD, FACS, FAAOBlank, Apr 20, 2015
Likely the procedure you need on your RE is a yag laser capsulotomy. If that is the case it is generally done first.  Sometimes the other eye bothers you less and sometimes more when the RE sees better. I suggest you re-read my article and get a second opinion about lens choices.  As a jeweler you need the best possible vision out of both eyes to allow yo to work.  The recommendation you have been given to have one eye for distance and one for near and not need glasses is not really the case.   That is called full mono-vision and is discussed in my article.  If you choose that option you will be doing your jeweler work with one eye, your driving with the other eye, you lose depth perception, don't see as well, there will be distances you can't see well and full mono-vision glasses are often difficult to adjust to and wear.

JCH MD

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by Joanlimsaw, Apr 30, 2015
Dear Dr Hagan

Can you tell me how serious is the possibility of vision loss for post op cataracts patients with glaucoma?
How high an IOP before it poses to be a danger and is vision loss reversible once the IOP is down to normal controlled level again?

Thank you

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by John C Hagan III, MD, FACS, FAAOBlank, Apr 30, 2015
For the great majority of glaucoma patients cataract surgery does not impose increased risk and extremely often the intraocular pressure goes down several points. Cataract surgery is now thought of as a treatment for glaucoma. For patients not well controlled or on several eye drops new types of glaucoma operations called MIGS procedures are often done at the same time.

In both normal and glaucoma patients there is sometimes a spike of IOP after surgery especially if the surgery was complicated but generally can be controlled with eye drops.

So bottom line cataract surgery is usually good for glaucoma and is being done earlier in glaucoma patients than non glaucoma patients.

JCH MD

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by sharmex, May 17, 2015
Dear Dr Hagen :
I am an active 79 year old  Internist from Hickory NC  .I have bilateral cataracts,I could not pass the Driver test at the local DMV, I was sent to an Otholmologist who  gave me Diamox and combigan and few days later wated me to come back. My IOP was 40 initially in the R eyer inputou and 18 in the Left. A few  days later he recheked the pressure in the R eye it was 12, he scheduled me cataract removal surgery.
I went and after 40 min. i came out of sugery,my wife was told he could not put an IOL as there was no tissue to hold it,he told me later the posterior bag collapsed and he put four stiches to hold it. I am blind in in oe eye now!
Thanks for your input
Govind sharma, MD

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by John C Hagan III, MD, FACS, FAAOBlank, May 17, 2015
Dr. Sharma: In a situation like this generally I would recommend going to the finest tertiary eye care center that you can get to and from on a regular basis. Examples might be Duke, U of NC, Vanderbilt or Emory. I would do this ASAP. Likely your local ophthalmologist would be more than happy to have the help of an internationally known department of ophthalmology.
Your most important eye is the unoperated eye and everything needs to be done to be sure that it will not have an attack of glaucoma as the R eye did.  The fact that you failed your drivers license and had cataracts suggests you have not had your eyes examined regularly by an ophthalmologist as these problems with cataracts typically develop over years.
Another question is why did your RE have an IOP of 40.  Was it angle closure glaucoma due to the cataract. This is highly possible especially if you are hyperopic (farsighted). That puts your LE at high risk of having the same problem and hence the need for a world class group of ophthalmologists.
It is likely that your RE will not end of blind but you may need the services of a retina surgeon to be sure there is no retained lens nucleus or cortex, a glaucoma specialist to control the IOP in the RE and examine the LE to be sure it could not suffer the same fate.  After the operative eye has quiet down, inflammation controlled, IOP controlled the Eye will need either fitting with a aphakic contact lens or you would need a posterior chamber IOL sewed into the eye by a ophthalmologist that specializes in cataract surgery complications.
I would urge you to move quickly on this situation. This is why we have referral centers like Duke, UNC, Emory, Vanderbilt and others. Best of luck.
JHaganMD


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