After toric iol implant in left eye, lines of text have stair step effect.

[Joel847]

It has been only three days since the surgery to implant a toric monofocal lens with distance vision but it seems like a failure already. My pupils are now undilated and what I see is blurriness at all distances with the closer objects being less blurry than the distant objects. Also there is a strange stairstep effect. A line of text appears to be divided into thirds, At the end of the first third the text jumps up half a character height higher for the next third and then jumps again at the 2/3 distance. The characters themselves increase slightly in size at the beginning or each section. The keys on a computer keyboard appear to curve upward with the keys on the right appearing larger than those on the left. This is added astigmatism that I don't think I had. At the following day follow up exam at the doctors office I was unable to read any characters from the eye charts except for a 5 inch tall letter E place directly in front of my nose. In the follow up exam the doctor stated after examining my eye, that the iol was correctly positioned. He wanted to proceed with surgery on the other eye which I refused. Currently I can read titles on the spines of books but the letters are blurry. Distant objects are blurry. Is there such a thing as an iol manufacturing defect ? Does anyone recognize this set of problems ? I have another appointment scheduled for next week. What should I do ?

[JohnHaganMD]

See post yesterday 131Steve.

[JohnHaganMD]

Cataract surgery requires a healing process. For most people its about 3-6 weeks before vision stabilizes.   Someone posted an almost identical complaint yesterday and they were 4 days post op. As long as your surgeon says there is no problem accept her/his word.  With multifocal the healing is even longer.

[Joel847]

Thanks for your response. It does help.

[JohnHaganMD]

My wife was not happy with her surgery 4 days post op. Now she is soooooo pleased

[Joel847]

It has been just about two weeks since the insertion of the toric iol. I am now waiting for a pair of glasses to correct the altered vision in my left eye.
My left eye vision is the same  as described in my original message.
Before the surgery my left eye glasses prescription was:
Sphere: +2.50, cylinder: +0.50 axis 120.
After the surgery my left eye glasses prescription is now:
Sphere: -3.00, cylinder: +4.00 axis 110.

I am thinking that the two prescriptions should not be so radically different ?
My surgeon mentioned fixing this with "cuts in the cornea" in three month from now which I think refers to radial keratotomy. Given the numbers will that be likely to succeed ?
How do you decide that the wrong iol was inserted ?

Best Regards,

Joel847

[JohnHaganMD]

If your wrote your glasses RX correctly:   You have a problem here and you may want to seek an independent second opinion:   1. Prior to surgery you only had 0.50 diopters of astigmatism.  Most surgeons would NOT use a toric IOL for that small of amount.   2. Post op you have 4 diopters of astigmatism.   That is hard to explain unless the wrong power IOL was inserted into your eyes. You should have a card with the maker and power of the IOL.  It should say the cylinder power is about 0.50 or 0.75 diopter. If it says 3 or 4 diopters big problem.  Moreover you have more cylinder than rotating an IOL would take care of.  I suggest second opinion. This is BIG problem,  efforts to "fix" are not generally charged to the patient.

[Joel847]

The card has Diopter +24.0 SE 6D CYL.
There was some explanation offered which was there was a problem with the shape of my eyeball being elongated "like a football". The implication was that my natural lens had a lot of astigmatism correction in it so it would have to be replaced with an astigmatism correcting toric iol. The eye by itself minus the natural lens, if the measurement of the eye was correct, would be contributing -6D. CYL.  which would be counterbalanced by the +6D CYL from the toric lens. When I looked up astigmatism correction, there were references to the cornea but not to the eyeball shape. Due to the resultant excess of +4 CYL I am inclined to not believe the explanation. I put in a call to set up a second opinion.

[JohnHaganMD]

Most astigmatism arises from the cornea. You can have lens astigmatism (Lenticular astigmatism) but it is rarely anywhere near 6 diopters.   Such unusual results should have warranted a second set of measurements done at a second testing to be sure they agree with the first.  So there was a 4 diopter error.   I think you are headed for an IOL exchange.  The calculations will be difficult to make with that IOL in the eye. Important you seek out surgeons experienced with dealing with unusual post operative problems. Probably needs to be cornea/refractive/cataract specialist.

[Joel847]

Thanks for this clarifying information.

[JohnHaganMD]

Good luck.  Very difficult situation

[Joel847]

I need your advice again. I was unable to get the original doctor to admit that there was a big problem. He wanted to correct the problem with Lasik which I didn't believe was correct based on your previous remarks.  I found a top expert in removing IOLs but something seems off here too. I brought with a copy of my medical records from the original doctor but he purposely left out all his measurements and calculations related to the original implant which annoyed the new doctor who is part of a group of doctors.  so far I have interacted with three of them. When I asked whether another doctor in the group if they were able to retrieve the missing data during a second visit there was no answer. However, many new measurements have been taken. There was trouble measuring my retina similar to the trouble measuring my eye that occurred with the original doctor. They have detected a rotation error  which may account for the fact that squares look like parallelograms to me. There has been talk of rotating the toric iol but not of removing it which I find puzzling because of the massive cylinder error. I have now been diagnosed with Salzmann Nodular Degeneration in the same eye which shows up as a darkened lower rim in the retina (cornea ?) mapping picture. I am scheduled for a superficial keratotomy which I was warned is quite painful. I have no symptoms from this nodular condition that I can detect either visual or sensory. The nodules only come into play when my pupils are dilated because they are on the periphery of the cornea. The idea is to have the outer rim of the cornea grow back in a more clear state to get a better measurement. They are going to use a laser to do this which Medicare may not pay for and I can't get them to tell me the out of pocket cost which is worrisome. The Medicare payment would be around $900 but I could get a bill for $9000. I tried to get an answer to the question of "Will this be classified as medically necessary by Medicare" from the staff but got the answer: "We will submit it to Medicare and see what happens". Also I have been assured that unlike Lasik surgery there is very little chance of chronic pain resulting from this surgery because it does not cut as deeply into the "Stroma". I wonder. I would like your input on this chronic pain likelihood question. I also wonder if this keratotomy is even necessary if they already know the angle that the iol needs to be rotated, why not just do that ? I asked the surgeon who will do the keratotomy if an iol with 6 diopters of cylinder was implanted and was 4 diopters in excess would it not make sense that an iol with 2  diopters of cylinder would have been the right amount of cylinder ? I was told that it would be nice if that were true but the situation is more complicated due to other variables.  I question that. There are no other variables. Everything else such as the retina and cornea are constants. Maybe they plan on using Lasik after rotating the iol which I won't allow due to fear of chronic pain. I classify dry eye as a type of pain. I better mention that to them. I would allow the lens to be swapped. I may have to be more assertive but I don't want to bruise any egos since I am depending on them. I bruised the original doctors ego by declining to do both eyes a week apart stating that I wanted to see the results in the first eye and he was not happy and look what happened. Why would the edge values of the mapping be important enough to justify the risk of this superficial keratotomy ?  

[JohnHaganMD]

You must understand that you have a very complicated problem even for the physicians that can examine your eye and make scientific measurements. I cannot make any further advice to you.  US Medicare does not 'pre-authorize" procedures but if you have a Medicare tie-in they will normally tell you in advance if they will pay or not as 'medically necessary"  if they agree Medicare rarely ever goes against that.  You are owed ALL your old records especially the pre operative measurements done before surgery called "A-Scan and keratometry" and the IOL calculations used. I would insist on them even if you have to go over and demand them in the office or have your lawyer send them a demand letter.  I will not be making any further comments. I wish you well but I've taken this as far as I can, these are the rules of MedHelp.org