Cataract surgery poor outcome

[Alleninohio]

Hi. I had cataract surgery in April 2021 on my right eye with Eyhance monofocal non-toric IOL and LRI.
Before the surgery RX was -3.50 -1.25  132, I could see 20/20 with glasses before cataracts onset.
After surgery RX is +0.75  -1.00   105. The surgeon was targeting plano for sphere and zero astigmatism.
I paid extra for Femtosecond laser and ORA to get A+ results, but I am mildly depressed about the results.
Uncorrected, my right eye is 20/40 distance, very blurry intermediate. With correction (glasses, scleral contacts, regular contacts) it's only 20/30.
I was referred to a neuro-ophthalmologist who said I have healthy retina, macula and optic nerve.
I had YAG treatment in December for PCO, no improvement from that.
Is it common to miss the targets for sphere and cylinder by this much during cataract surgery?
Thanks,
Allen

[Spoo_]

I'm not a medical professional of any kind, but I would speculate if your pupil gets very small during bright days, the central 1-2mm EDOF part of the Eyhance which has -0.5D power shift in the center of the visual axis takes over and your distance vision will become compromised. In lower light conditions your pupil dilates and more power from the neutral periphery of the lens allows you to see distance more clearly. I would imagine the Vivity (or any edof) has a similar property if your pupil gets small enough. I'm not sure what the critical size threshold for the pupil is where this becomes a significant issue.

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

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

The problem is you don't see 20/20 WITH GLASSES.  You need an explantion for that. If by LRI you mean limbal relaxing incisions then you may have irregular astigmatism. I would suggest you see a corneal refractive surgeon for corneal topography and get an explanation why you cannot see 20/20 with glasses.   As for your other question no surgeon however skilled and how much extra you pay can guarentee you will have no post operative refractive error (0.00) and see 20/20 at distance.

[Alleninohio]

Thank you Dr. Hagan. The Neuro Ophthalmologist said the problem must be the front of the eye. I was fitted with a scleral lens, but still only 20/30 with correction, so the cornea guy ruled out irregular astigmatism. When I use a pinhole in front of glasses, the vision becomes almost 20/20, but they can't get 20/20 with glasses alone, why could that be?
Could that just be the property of the J&J Eyhance IOL?
Thank you for your opinion.
Allen

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

Allen I do have a question. There is a recent post from a person with a cornea problem and he said that the scleral CTL fitter wants to charge him $7000 US and I think that outrageous. Do you mind sharing what you paid?

Go on line and read about what the pinhole does.  It is used to quickly check to see if reduced vision is due to disease or needing glasses. If the vision improves it almost always is refractive (glasses or if irregular astigmatism corneal): if vision doesn't improve it is usally disease. Where do you live. If in USA I might be able to direct you to a tertiary eye center that takes on difficult problems.

If it was the IOL the vision should NOT improve with pinhole. Our practice doesn't use that IOL so I have no personal experience with it.

Let me know

[Alleninohio]

Hi Dr. Hagan. My optometrist charged me an extra $35 to try a scleral contact lens after he could not correct me better than 20/30 with the regular refraction. I live in Columbus, Ohio.
Thanks,
Allen

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

You might try the cornea/refractive eye MD at Ohio State Dept of Ophthalmology. Or if not too far the Cinncinati Eye Institute

[Alleninohio]

Thanks for the referral, I just scheduled an appt with the OSU Ophthalmology. Do you have any plausible explanation why my operated eye with the IOL sees better sharpness and contrast in low light conditions (e.g. twilight or evening) vs. bright sunny weather or well lit rooms?

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

It would need to be related to pupil size.  There is also a post op IOL problem called positive dysphotopsia you can ask about. And to get the most from your 2nd opinion you want their  cornea/refractive surgeon expert

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

I did some more checking on cost of fitting scleral CTL and the highest price I found was $2500 which included all lens and office visits.