ReStor IOL and Astigmatism

[Susan12345]

I have written before about my ReStor woes and trying to decide whether to take the  risk of having them explanted and replaced with monofocals.  I am still trying to figure out one of the things the doctor I consulted said.  I had astigmatic keratotomy done with my cataract surgery, but still have significant astigmatism in my right eye.  I thought my surgeon had not been able to correct my astigmatism totally, but the latest surgeon said in fact I no longer have astigmatism via corneal exam, though clearly do on refractive testing.  I still don't understand how that's possible.  The doctor said something about maybe it's in the lens, but wouldn't elaborate further.  If someone has lens related rather than corneal astigmatism, is this something that I might have had with my natural lens before surgery, something caused by a defective IOL, or something that has to do with my  eye's reaction to any IOL?    Susan12345

[Forum-OD-MP]

there are 5 surfaces that light hits as it makes its way through the human eye.  front side of the cornea. backside of the cornea, front side of the lens, backside of the lens and retina.  if any one of those surfaces is not spherical, or if the culmination of the addition of all those surfaces is not spherical, we call that "astigmatism".  most astigmatism is corneal, which barring degenerative corneal diseases like keratoconus...corneal astigmatism does not change over time.  you dont "get more" corneal astigmatism or "lose" corneal astigmatism w/o surgical procedures.

lenticular astigmatism implies that one or both of the surfaces of the lens/implant are not spherical.  its not as common, but comes up in cases of cataract and cataract extraction.  

"If someone has lens related rather than corneal astigmatism, is this something that I might have had with my natural lens before surgery, something caused by a defective IOL, or something that has to do with my eye's reaction to any IOL?"

literally all of those are possible, although "defective implant" would certainly be a statistical anomaly...

[JodieJ]

Susan, your question is so intriguing that I'd like to propose a possibility you haven't considered.  I don't think that any of the alternatives you mentioned are correct.  Cataract surgery removes any existing lenticular astigmatism, so your natural lens can't possibly be the source of the problem.  And your eye's reaction to an IOL can't cause lenticular astigmatism.  The possibility that your ReStor lens is defective seems too remote to take seriously.

If you truly have no corneal astigmatism (as your last doctor stated), I'm guessing that the results of your refractive testing (showing 1.75D of astigmatism) are erroneous.  Possibly a subtle deviation from the correct IOL position (decentration?tilt? both?) is having a weird, negative effect on your vision, making it difficult (if not impossible) for you to accurately determine which of two choices is better when your vision is tested.  (What is your BCVA with that astigmatism correction?)   This hypothesis might also explain why your ReStor lenses have been driving you crazy and making your life so miserable.

Regardless of the source of the problem, I think that explanting your ReStors and replacing them with monofocal lenses would be a good idea.  But I'm just an amateur in the field of eye care.  Perhaps Dr. EIZenhower can shed some light on your question.

[JodieJ]

Just a few more thoughts...  I'm guessing that the nature of the subtle distortion you're getting due to a minor displacement of your right lens sort of resembles astigmatism blur (but it's not!), which might explain the results of your refractive testing.  But based on info you've provided on previous threads, I think that both of your ReStors are displaced due to minor decentration and/or tilt.  This could account for your severe near vision problems with both eyes.

If my hypothesis were right you'd need additional surgery, either to correctly re-position the ReStors or to explant and replace them.

[Susan12345]

Jodie, your comment makes sense, but 3 doctors have told me my ReStors are positioned correctly.  Though of course the doctor who put them in certainly wouldn't admit it if he'd done them wrong, so I shouldn't count him.   Blue 92 wrote that he went to a doctor who immediately could tell that his IOL"s were positioned incorrectly when the other doctors had said that they were ok.  I wish I knew what type of tests that doctor used, it's hard to believe that that one doctor knows something that no other doctor can figure out.   Susan12345

[K-D]

Susan, could you be more specific about the problem with your Restor?  I understand that they are a horrible problem for you, and the fear you have in having them exchanged.  I can certainly relate to that.  I was just wondering what exactly your vision is like.  Do you have clear vision at any distance?  Does it constantly change? What is your best sight? Near, in between or far? Susan, you sound so miserable with them, that at some point, maybe just try exchanging one eye. Believe me, my heart goes out to you. I am very disappointed with my multifocal too, but not to the point of risking exchange, because when I am outside, I am fine, except for reading. Problem is that I live in a house. And then the horrible blur.  An going to try Dr. Eiz's kind suggestion.  Susan, the one thing that I can tell you is that vision keeps changing with a multifocal.  Maybe things will still get better for you.  I know that the psychidelic world that I thought I was trapped into forever, is after 9 months, almost completely gone.  So, depending upon you vision problems, maybe time will correct some of them. Sure hope so.  Best wishes.

[Susan12345]

My biggest complaint about the ReStors is a kind of fluttering sensation, difficulty focusing with reading (newspapers are worst) and under bright lights, especially fluorescent lights like in a supermarket.  My distance vision on a cloudy day is good, I can read the computer fine (with my reading glasses).  My vision does seeem to keep varying, every doctor I have seen has gotten different results. And the fluttering with reading can be so much worse some days than others.    I can't stand not being able to see things close, so inside I wear my reading glasses most of the time (except when watching TV),  outside bifocals.  ( I can read for a short time with my bifocals, which is better than before surgery, but then I was nearsighted and could just take my glasses off to read, now I have to find my reading glasses, which is why I usually just leave them on inside). My eyes are very dry, especially in the morning, that of course is not the fault of the ReStors, but I assume of the astigmatism repair.  Halos aren't a problem, I can definitely see a circular pattern around lights at nights but it doesn't particularly bother me.   It would be easier to make a decision about surgery if it were terrible all the time, but it's not and I'm just so terrified about making things worse.  Susan12345

[Susan12345]

Jodie, in the Mono or Multifocal thread you said that my doctor's statement that any time you went into an eye for surgery you had a one in a thousand risk of complications casuing blindness in that eye was **** ****.   What kind of statistics have you read?   I've been trying to find actual statistics but every site I can find on cataract surgery is very vague.  And of course there's virtually nothing writtten about explants.  Susan12345

[JodieJ]

What is your best corrected vision for distance and near?  Your statement that your vision keeps changing when tested lends further support to the hypothesis that your distortion and blur is related to the misplacement of your lenses.  (In addition to the fact that you can't have lenticular astigmatism with an implant.)

I think that even skilled and experienced surgeons aren't accustomed to the degree of precision required by the multifocals.  Apparently, even tiny deviations from the correct placement can cause horrible problems with vision.  In another thread, blue92 posted that the source of his/her vision problems were finally diagnosed by wavefront analysis and slit lamp digital photos.  But few surgeons are doing these tests when patients return with complaints, and the lenses seem to be correctly placed.  (Maybe some patients are even dismissed as being "overly demanding perfectionists.")

I've read that blindness post-surgery is related to infection.  I suppose that happens more often in third world countries.  It might also be related to noncompliance with using prescribed antibiotic eye drops and failure to keep post-surgery followup appointments.  I've read that noncompliance is highest among  the elderly, some of whom might lack the dexterity to apply the drops correctly.  But Susan, this certainly wouldn't apply to you.  Nothing is ever guaranteed, but didn't your last doctor say that he could explant your lenses safely?

[Susan12345]

Different eye exams have listed me as anywhere from 20/20 in both eyes to 20/40 in the right and 20/30 in the left.  The prescription I had a month after my 2nd surgery was OD: +0.75-1.00x032  OS: +0.50-0.75x007 Add +2.50 OU.   Four months after surgery (with a different optometrist) it was OD; +1.00-1.75x047 OS: +0.50DS Add +2.50 OU.   Though according to my surgeon my vision is perfect, even the reading problem is just because I hold stuff too close, the fluttering, which incredibly he didn't even mention in his notes, was just because I was tired.  Yeah, I'm definitely pegged in my records as an anxious neurotic.  Even the note written by an optometrist several years before I had surgery, when I was 1st informed I had cataracts AND signs of drusen (early signs of macular degeneration) wrote incredibly, pt. seems overly concerned as to why she has these problems at an early age (in my 50's).  Overly concerned?!!!!!!   Do most people react "Oh, no big deal!"   Of course it's no big deal to the doctors, but it sure is to us!.  

I called the latest doctor's office to have my records sent,  so I'll see if he had done either of those tests.   He did a very throrough exam the 1st time and told me to get my last 6 years worth of eye records and return in a month.  That time he did a very brief exam and started to read my records, realized he didn't have time and said he'd called me after he'd read them.  He did call me the next day and talked to me for about 40 minutes, giving me his statistics, the one in 1000 etc.  Then he realized how long he'd talked and said that was all the time he had to give me.  I asked if I could E-mail him any more questions, but he said no, he didn't do that, if I had more questions to make another appointment.  Basically, it was,  I've given you the facts, call back if you want to take the risk.  So he didn't make it sound as risky as the 1st doctor, but definitely not a piece of cake either.

I guess if he didn't do those tests I need to find someone who does.  Though I'm really not clear how repositioning the IOL's would be significantly less dangerous than exchanging them.  You'd still have to open the capsule, with the risk of its rupturing.   Susan12345

[JodieJ]

It's really disgraceful that you paid good money for premium IOLs and ended up with your current vision.  And you're right--the optometrist's comment about your "over concern" about developing cataracts and signs of drusen at an early age is totally ludicrous.

Susan, would you really want to get your ReStor lens re-positioned (rather than explanted)?  If so, I suggest that you set up another appointment with your last doctor.  Tell him that you recently had a long talk with an optometrist from Indianapolis (maybe the brother of a close friend who was in town for the holidays) about your vision problems.  Explain that the optometrist has treated post-cataract surgery patients with symptoms very similar to the ones you're currently having.  Tell your doctor that the optometrist believes that your IOLs may be very slightly decentered and/or tilted.  Say that this needs to be verified by wavefront analysis and slit lamp digital photos.  Say that the optometrist suggested that your doctor contact Dr. Kevin Waltz, a cataract surgeon in Indianapolis, for detailed information about how to diagnosis and treat this problem.  (Believe me, if you're honest and say that you read about all this on an internet forum, it will not lead to the outcome you're looking for.)

Given all the frustration and anxiety you've experienced due to your ReStor problems, I think you might be happier explanting them and getting monofocal lenses.  You don't have any astigmatism anymore (per your current doctor), so if you targeted the focus of your new lenses for near/intermediate vision (like you want), you probably wouldn't need glasses at all when you're at home.  You'd only need glasses for distance vision.

[Susan12345]

Well, Blue's symptoms (ghosting, double vision, and poor intermediate  vision) were totally different from mine.   Hopefully, he'll write back and let us know the results of his surgery to reposition the IOL's.  But it makes no sense that this one doctor is the only one who knows about these tests.  I live in a city with a metropolitan population of about 2 million people, if these tests truly are valid there have to be doctors here
who know about them.  My doctor may even have done them, when I get his records, I'll see.  If nobody but this one doctor in Indiana has ever heard of them, I can't say I'd put much faith in them.   I suppose it doesn't really matter, if I decide to go through the risk of surgery it would probably make more sense to just have the ReStors explanted instead of a repositioning that might not work.  Though of course it would be nice to have ReStors that actually worked liked they're supposed to, it sounded so great, not to constantly be switching glasses, that why I sought out the doctor who did them in the 1st place.  But as "they' say,  things that sound too good to be true usually are.   Still, it wasn't like I went to some quack who advertises in the Sunday comics page, the doctor who put them in was supposed to be one of the best and I have no way of knowing if this new doctor is any better.   Susan12345

[JodieJ]

The doctor who implanted your ReStors was probably a good surgeon but relatively inexperienced with multifocals.  I'm sure that there are experienced docs in your area who have re-positioned multifocal lenses.  You might try posting your location, and hopefully one of the manufacturers' reps could recommend someone.  Or you could just get your ReStors explanted.  But you should probably do something in the next month or two.

[blue92]

Just to let you know that my surgery for recentering my right Rezoom IOL went very well. Dr. Waltz from Indianapolis did an excellent job with no complications. The surgery took approximately 6-7 minutes and my wife was even able to watch on a small screen outside the operating area. Even she noticed how the lens was displaced and how, after the surgery, it was centered. I had my post-op appointment today and everything (pressure, centering, inflammation) looked good. Because the procedure only involved making two small entry ports, the trauma to the eye was kept to a minimum hence the reduced amount of inflammation post-op.  As for my vision, I have no ghosting or double vision at this point, but because my pupils have been constricted (and will be for the next few days) to reduce any muscle movement that could shift the newly repositioned lens, I won't know the full effect of the newly positioned lens for another few days. I will keep you updated, but for now everything looks very very positive. We are flying back home to Massachusetts tonight.I will give you a more detailed follow up next week.

[Jmadison]

Susan said:

"But it makes no sense that this one doctor is the only one who knows about these tests."

Dr. Waltz has multifocal implants himself according to a journal article (the Array lens from Advanced Medical Optics).

[JodieJ]

Blue92, thank you for the valuable information you've posted and best wishes for your recovery.  Please continue to keep us posted.

Susan, I did a little online research about infection related to cataract surgery.  Based on data collected from Bascom Palmer between '84 and '94, less than one in ten thousand patients developed an infection (i.e., endophthalmitis) following cataract surgery.  In the very small group who did experience infection post-surgery, visual outcome was good with prompt antibiotic treatment.  The risk of vision loss was greatest in patients who delayed treatment.  No exact figure given, but I'd estimate that blindness occurred in less than one in fifty thousand patients.

[Susan12345]

I live in Seattle, if anyone has info on how to find the best doctor.  The trouble is, multifocals are relatively new, and so probably every doctor is relatively inexperienced.  I just wish I'd known that the implant process was so much more complicated BEFORE I had my surgery.  I was terrified of eye surgery period, but certainly nothing my doctor said suggested that multifocals were more difficult, technically,  to implant than monofocals.  I asked a lot of questions, but unfortunately not the right ones.  Of course, he still thinks he did a great job and I'm just a whiner.  At least the doctor I was referred to thought my complaints were valid, but he certainly had no suggestions about repositioning the IOL's,  just explanting them, and the one in a thousand blindness for any eye surgery was his statistic, whether general or based on his personal experience I don't know.  He did say there's no rush, after the first couple of months, which are long past, waiting doesn't increase the risk any further.   Susan12345

[Susan12345]

Blue, did the doctor who put your Rezooms in use sutures?  My doctor did use sutures with my ReStors, which you'd think would make them less likely to slip out of place.  He took both sutures out at the same time, which was 8 weeks after my left eye surgery and 3 weeks after my right eye, maybe that's why I've had more problems with my right.  But lots of doctors don't use sutures at all for cataract surgery. Of course, maybe the IOL's were put in the wrong place to begin with.  But surely they must have some kind of guide marker or something so they aren't just slipped in randomly!   Susan12345

[Occupant]

I don't know how much or if of any help this will be to you, but I am writing this to point out that even with normal eyeglasses the problems that may occur are sometimes difficult to identify. My wife had new bifocals made and couldn't stand to wear then because of blurry vision. She went back several times to have them re-adjusted, the only difference to your case being that the optometrist believed her when she said, she had a problem. He rechecked the prescription and the lenses, everything seeemed to be in order. After several adjustments (in your case that would be surgeries), they decided, to send them back to the manufacturer. They came back, they are fine, but no information is available as to what went wrong with them in the first place. The optometrist stated, that the manufacturer wouldn't tell him. This is not to say, that I believe, that there is something wrong with your lenses - at those prices, there better not be.

[JodieJ]

Apparently there is more than one possible method to determine whether IOLs are correctly positioned.  I just came across an article in Ophthalmology Times (11/15/06, Cheryl Guttman) that uses anterior segment OCT to calculate IOL tilt and decentration.  (I've had OCT many times at my retinal surgeon's office, but I don't think that many cataract surgeons use or have access to this equipment.)  OCT is reported to be more accurate than the "Scheimpflug videophotography system" for calculating IOL tilt and decentration in some cases.  My impression is that IOLs are rarely perfectly positioned but are usually pretty close.  I also think that they may change position slightly as the eye heals.  Based on blue92's posts, probably some method for calculating IOL decentration and tilt needs to be done when there are unexplained vision problems with multifocals.  Hopefully, this will become standard practice as docs become more experienced with the multifocals.  But I suspect that many surgeons have been implanting multifocals for less than a year or two, and they are still on the learning curve as far as the fine points.

[JodieJ]

I just have one more suggestion--then I promise to quit overwhelming you with way too much information.  In a previous post on this thread, you mentioned that your optometrist saw early signs of drusen. (I don't think this is at all related to your current ReStor problems.  And from what I've read, a few small drusen are normal after age 40, and they can disappear spontaneously.)  I still think it might be a good idea to have this evaluated by a retinal specialist, if you haven't already done so.  Because of the loss of contrast sensitivity, multifocal lenses wouldn't be the greatest if you were to develop retinal problems in the future (which, of course, might never happen).  I'm thinking, though, that getting input from a retinal specialist might help you make a better decision about your ReStors (explant vs. re-position vs. nothing).  And it would really be great if you could find a doctor who was willing to take the time to address your concerns in depth.

[Susan12345]

The referral doctor did say that retinal problems can cause problems with multifocals and a technician in his office did a lengthy macular degeneration test with one of the many mystery machines eye doctors have.  I've mailed in the form to get copies of my records,  so hopefully I'll see soon exactly what tests were done. But the doctor who did my surgery KNEW I had drusen before  I ever had my surgery.  If he had given me the slightest indication that I was a high risk candidate I would NEVER had the surgery.  It makes me angry.  He's a big wig corneal specialist, not a retinal specialist, but he would have to know if that would cause problems.  

I go back and forth in my mind, but when It comes right down to it, I just can't see myself going in for more surgery.  I'm just too afraid.    Susan12345

[JodieJ]

I don't believe that drusen is a contraindication for multifocals.  But multifocals are so new that doctors are still in the process of figuring out exactly what the contraindications are.

The last surgeon you consulted seems to be very competent.  After reviewing all of your records, he should be in a position to make recommendations to you.  I wish you the best, regardless of your decision.

[K-D]

Seems like we are in the same situation. I too am too fearful to have an explant. However, I do believe that doctors are just now learning all the possible problems with multifocal lenses that they did not know when we had our surgery.  Unfortunately, we are very early on in the multifocal implants.
Susan, since it will not matter any longer if we wait for an explant, since we are 3 months past surgery, this is what I am trying to do to reduce my anxiety.  I try an focus on the pluses.  Yes, I hate the inside blurr and aberrations. But I would hate not being able to see buttons on an elevator. or microwave, or keyboard.  Yes, I know that our priorities are not the same.  But try to concentrate on one plus from the Restor until you decide on explants.  And I read that they are developing instrunments that make explants safer. Hang in there.  Things keep improving.  Who know what will available in just a few years. I am guessing that someday to explant will be very simple and safe.

[blue92]

As you know, I had my surgery last week. The results so far are encouraging. The eye is still healing, but I already see progress. In good light conditions my vision is very good at all ranges, close, intermediate and distance. At low light conditions, the intermediate vision is still a work in progress.

Everyone is different and in my case, the slight decentering has caused a lot of aberrations (ie. ghosting, double vision, halos and glare). I had very much given up driving at night. Fortunately, I no longer have the debilitating glare and multiple halos. I have one halo around lights and, because it's a multifocal lens, it will always be there. Before this surgery I had such lousy vision that I'm supersensitive to everything. Having seen some changes already, I'm going to relax and let the brain and mother nature take its course.   K-D, like you, I had useless indoor intermediate vision.

In any event, the reason I feel comfortable and positive is that the option of explanting the lenses is still there if I choose to do so. After having the repositioning surgery, I have full confidence that if I choose to explant my lenses, Dr. Waltz has the technique, tools and knowledge to do so.

The plan now is to wait for the healing and adjustment and decide what to do next. Remember, I have lived for almost a year with decentered lenses (.7 mm on the right eye). By the way, the lenses did not move. They were placed as such from the beginning.

As for explanting your lenses, it is really up to the skill of the surgeon and if you find an experienced doctor, you should be fine.  I was a good candidate because of my age (52 yrs old) and in excellent health.  If you wish to contact me, my email address is ***@****.  I'll give my telephone number if you contact me for additional details. Bottom line is, I know how stressful it is to think that you have to live with this problem. Finding alternatives have made my situation much more bearable. I'm hoping to stay with multifocals but if, at the end of the day, I don't adapt, I'll switch to monofocal lenses.   Good Luck.