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I recently had cataract surgery on my left eye. What could have wrong?

I recently (one month ago) had cataract surgery on my left eye. I asked for distance vision. A 24.0 D IOL was implanted. My vision in that eye is now 20/100 (it was 20/50). Corrective glasses are -1.50 (it was +1.00 before surgery). Does this indicate that a 22.5 D IOL should have been implanted? I now have high contrast triple vision at distance in my left eye (I can read out at my finger tips). What could have gone wrong? I am very disappointed. I have cancelled the cataract surgery for my right eye since it is 20/50. How do I prevent the same thing from happening with my right eye?
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Avatar universal
Did the cataract surgeon know that you were planning to have IOLs in both eyes?
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233488 tn?1310693103
No the IOL power has no bearing to what glasses RX was before surgery.  It is based on a formula that does not include pre-operative glasses RX. The important thing you have not posted:  1. what is your distance vision WITH GLASSES.  2. What is your near vision WITHOUT GLASSES.  If the rest of your eye is healthy and surgery done without complication your near vision should be good in the operated eye without glasses. POST that information and I can give you a better answer.
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I received a 24.0 D AcrySof IQ IOL implant in my left eye only. The surgeon knew that I was planning to have both eyes done. Surgery on the second eye was scheduled for 6 weeks after the first eye. Prior to surgery, someone other than the surgeon measured both of my eyes. They measured the left eye first and the right eye second. I asked for distance vision in both eyes. During the measurement, I was told to look at the red dot. Initially I focused intently on the red dot. But the measurement took so long that my eyes got tired and I relaxed my focus and continued to look at the dot but not focused on it (like a blank stare). Later I called the “on call” surgeon for the practice and asked if that would cause an error and she told me that there are many safeguards built into the measuring device to prevent errors and that I should not worry about it. What do you think? I think the measurement device was a Zeiss IOLMaster 500.

Before deciding to have cataract surgery, I specifically asked my optometrist if there was anything wrong with my eyes (other than the cataracts) that would cause a bad result from the cataract surgery. He said there was nothing wrong with my eyes other than the cataracts and that I should expect a good result from the operation. I have never had any other eye surgery.

When I wrote that “I now have high contrast triple vision at distance” I was being sarcastic (or was it ridicule?). What I meant is that colors are now brighter and more dense (no longer grayed out) but my vision is out of focus, and that the brighter colors are worthless without focus at distance. Bright colors do not help me pass the vision test for driving. I don’t care about brighter colors. New Jersey requires 20/50 vision. There are no flowers on the test.

My question about the wrong lens being implanted: A 24.0 D lens was implanted. The required eyeglasses after surgery to achieve 20/20 vision is -1.50. Does that indicate that a 22.5 lens should have been implanted? Or is that a totally different measuring system? In hindsight, knowing that a 24.0 D lens would require -1.50 RX for eyeglasses, what lens would you have implanted? (knowing that hindsight is 20/20 (pun intended))

The RX for my left eye after cataract surgery is: -1.50 sphere / +0.75 cylinder / 150 deg. Axis.
I have not received my new glasses yet. In the surgeons office that prescription seems to produce 20/20 vision or better. We will have to see if that occurs with real glasses in the real world. If my eyesight in my left eye can be corrected to 20/20 with glasses I will no longer be depressed. But I will still be unhappy. I will still want my right eye to be 20/30 or better without glasses. I want that for driving and for golf.

My questions are: What could have gone wrong with the cataract surgery on my left eye? Why is my vision for my left eye 20/100 now instead of 20/30 or better like 95% of people who have cataract surgery? Could it be that someone got my eyes mixed up and the lens for my right eye was put in my left eye? What can be learned by what happened to my left eye to help get a better result when I have my right eye done? What can be done to ensure I get 20/30 or better vision in my right eye after cataract surgery? At the very least I will have my right eye measured again.

You should know that the eye surgeon I chose has had 28 years of experience doing eye surgery and has done more cataract surgeries than 96% of his peers and has never had a malpractice lawsuit against him and I am not interested in changing that. I have full confidence in his abilities and I am convinced that he cares. His only shortcoming that I have now learned is that he is not a good communicator.
My near vision in the operative (left) eye without glasses is in focus out at my fingertips +/- 3 inches. Good for using the computer, for reading the instrument panel on my car when driving, for grooming myself, for preparing and eating food, for reading over some ones shoulder, for reading the check across the table. So it is not a total disaster. But this does not help me driving or playing golf which is what I wanted. At distance I have double and even triple vision depending on the light. In fact I have stopped driving at night because I don't feel safe.
1. Read this carefully  LINK  http://www.medhelp.org/user_journals/show/1648102/Consider-ALL-the-Options-Before-Your-Cataract-Surgery-Working-Through-Whats-Best-For-You
2. The result of the surgery is BEST CORRECTED VISION which in your case is 20/20    Moreover when you don't have glasses on chances are your operated eye sees better at near than the unoperated eye.
3. As the article says picking IOL power is not an exact science  
4. Get used to wearing glasses.
5. On the second eye if you still want to manage the test you can without glasses  you may need to consider a toric IOL and a distance sought for (but not guarenteed) refractive error of 0.00 to -0.25
I got my glasses. What a nightmare. My left (operative) eye correction is -1.50 and my right eye is +1.0. The double vision caused by the glasses is unusable, unsafe, and unacceptable. I was not able to safely back out of my parking space. I almost hit 3 cars and a woman. I immediately went back into the office and had the right lens removed from my glasses. My glasses are now -1.50 left eye and zero (uncorrected) right eye. With them I am able to drive safely with no double vision. I can get used to wearing glasses but not with double vision. I am waiting now for a new zero lens for the glasses for my right eye. I am hoping that I will not have double vision with this lens in the glasses.

My surgeon said that he targets 0.00 to +0.50 when selecting a lens. He says that my problem is that the lens  did not position itself as expected in the lens cavity. Does it seem possible that that could cause so much difference to produce -1.50? Do you think contact lenses would eliminate my double vision? My current situation is not acceptable.
Hope you read the posted linked article. Anytime there is more than 1 to 1.5 diopters difference between the two eyes more people cannot adjust and have eye strain, headaches, double vision. the difference between your two eyes is 2.50 diopters. I don't think that contact lens will help. If you are happy with the vision in your LE with your new glasses and the "zero' lens in the RE, and color is better in the LE and reading vision without glasses in the LE is better than the right then you might just go ahead and have cataract surgery on the RE maybe setting a target of 0.00 to -0.50     Your vision without glasses would be called 'mini-monovision distance bias"
And there is the problem. I want to have cataract surgery on my right eye to get 0.00 to -0.50. I realize that it is my best solution. I know that it wont be long before my right eye is worse than 20/50. But, how do I make sure I get 0.00 to -0.50 and not +2.00? I cannot take the chance of getting +2.00. My eye surgeon said he targeted 0.00 to +0.50 for my left eye. I got -1.50!   (What could explain that much error?) Your last comment suggests that 0.00 to -0.50 is an easy thing to achieve as if it is a no brainer. My right eye is my last eye. I do not get a do-over. I read your article. I know there are no guarantees. But how do I reduce the possibility of error to almost zero?
There are several things you can do.  First the standard error for IOL power is plus/minus  0.50 diopters   So your surgeon missed the mark by about a diopter.   If the IOL is not in the regular position and has moved forward of where it should usually set that could make your eye more myopic.   If you are really that bent out of shape about have a -1.50 eye that see's 20/20 with glasses and reads well without glasses at intermediate/near then I would suggest getting a second opinion from a cornea/refractive surgeon.   You could have LASIK or SMILE procedure on  LE  that could convert -1.50 to zero or -0.50     OR you could see another cataract/IOL surgery for a completely independent set of measurements on your RE to compare with your surgeon's readings. The numbers and calculations of IOL power should agree. If it doesn't then they would need to be repeated until both surgeon get' the same numbers.   To go back to your comment. What your surgeon told you is NOT that the IOL calculations were incorrect its that the IOL is not sitting in the position that was used in the calculations. You would need to discuss with the surgeon what about his/her surgical technique might be altered on the second eye to try and be sure IOL sits in the usual position.
Thank you for your help. I really appreciate your candid input. I am learning things from you that no one locally has told me.

When I first considered cataract surgery, I had difficulty deciding between two eyes with distance vision, or one eye distance and one eye reading like you mention in item #5 of your article. A friend of mine had that done and he is very happy with it. My other friends all got 2 distance eyes and they are very happy. They all got 20/25 unassisted vision or better. It seemed like a no-brainer for me to have cataract surgery and also have the benefits that they have. I decided on two distance eyes, but I think I can also be happy with one intermediate eye and one distance eye.

I am not really bent out of shape over the -1.50D of my LE. I can accept that and it is probably the smart thing to do to leave it alone now and not take the risks associated with trying to change it (even though I am a perfectionist). What I am unhappy with is the double vision resulting from using glasses with the combination of -1.50D LE and +1.00D RE (although, no double vision with -1.50D LE and Plano RE glasses) and what this has done to my golf game. I can’t even hit the ball with glasses on because when I look down through the lower left corner of the lens of the glasses, the ball seems to be in a different spot than it actually is. And without glasses on, I can’t see the ball in the air more than 100 yards away. It just disappears.

I just got a second opinion from the ophthalmologist (“she”) that operated on 2 of my friends and achieved 20/25 or better vision for them. She had only very good things to say about the skill and caring of the ophthalmologist (“he”) that did my surgery. She targets 0.00D to -0.50D when selecting an IOL. (Thinking back, that may have been what my surgeon said also. I remember clearly the 0.50 but may have remembered the sign wrong since I did not understand the meaning of the sign at the time.) She recommends a 22.5D IOL for my RE (I don’t know what D IOL my surgeon has chosen). She said she would have chosen a 23.0D IOL for my LE based on my eye dimensions now (hindsight). She said my LE is completely healed with no inflamation and the IOL is centered and recommends I leave it alone. Interestingly, she says my vision is -1.00D LE and Plano RE (not -1.50D LE and +1.00D RE) with astigmatism in both eyes (I learned it depends on whether you use + or - cylinder). The RE is 20/50 and cannot be improved with glasses because of the cataract.

I have decided that I will have cataract surgery on my RE and that I will use the same surgeon that did my LE. After all, we did have a “successful” result for the first surgery. All we have to do is agree on the D rating of the IOL. When I do it is to be decided.

Is it possible for the eye to change dimensions (elongate) due to the cataract surgery? The ACD for my LE is 4.24 mm. The ACD for my RE is 2.85 mm.
Cataract surgery will almost always change the ACD = anterior chamber depth, normally making it wider (bigger number). This is what I would suggest you do.     1.  Agree what you want from the second eye.  RE.    If you want distance vision then most surgeons will target 0.00 to -0.50    Going exactly for 0.00  introduces the possibility of leaving the eye farsighted and that is undesirable as no distance is clear without glasses.   2. I THINK THIS IS CRITICAL.     Ask your surgeon and the surgeon you consulted to compare their  measurements on your eye to be sure they agree.  Main parameters are axial length of eye, ACD, radius of curviture of the cornea.     IF THEY DON"T AGREE then ask both to repeat the testing till you have two sets of independent readings that agree.     Once you have two idential sets of numbers you need to know what IOL your surgeon plans to use. Each IOL has what is called an "A" constant.    There are also different formula that are used to make the calculations.  Once the data from the two sets are idential, and each surgeon knows the A constant for the IOL to be used in the eye is have them run their calculations separately.  You should have an IOL power that is almost idential to leave you say -0.25 or 0.50.   It should not be too expensive for them to do this,  you can ask for a paper printout and look yourself. That way you go into surgery knowing both your surgeons would use the same power IOL.
So then, if the ACD for my LE was about 2.85 mm before the operation (like my RE is) (or even less) and it elongated to 4.24 mm (as it is now) because of the operation, would that explain the -1.50D result of the operation? Is it possible for it to elongate that much? Could the ACD ever shorten? I need to find out what the ACD was for my LE before surgery.
Is the expected elongation of the eye included in the calculation of the D for the IOL? The second opinion ophthalmologist (“she”) said that she might even suggest a 22.0D IOL (instead of 22.5D Alcon SN60WF IOL [“A” const: 119.00] with predicted -0.09D vision after surgery that is her baseline recommendation) for my RE thinking that my RE might elongate significantly. This seems dangerous because if the eye does not elongate I would be stuck with +D vision and no clear vision at any distance and the possibility of double vision with glasses. What do you think?

At this point I've offered all the advice I'm going to.   Final word see if you can get both surgeons to agree on IOL power for the desired post operative refractive error.
Thank you for your help.
Best of luck and good fortune to you
For anyone who may be following this conversation. About my comments dated Sept. 25. Delete everything except the parenthetical expression about the recommended IOL from my second opinion Doctor. I misunderstood.

I went to my left eye surgeon for a follow up exam. He recommended a 23.5 D IOL for my right eye. This is significantly different than the 22.5 D IOL that my second opinion Doctor (she) recommends. He uses a Zeiss IOLMASTER 700 and she uses a Zeiss IOLMASTER 500. They use different predictive software. I didn't know this when I chose the second opinion Doctor, but the two Doctors know each other and operate next to each other at Wills Eye. I gave them permission to discuss my situation.  I hope this doesn't negate the purpose of a second opinion.

She is a much better communicator than he is. She has given me much more information than he has. She has actually called me twice since my office visit to discuss my situation.
Thanks for follow up. Best of luck.
I now feel certain that I know what went wrong.

Before the cataract surgery (which was done on 8/13/18), I went to Dr. H on 07/31/2018 to have my eyes measured. His assistant measured both of my eyes using a Zeiss IOLMaster 700. The measurement of the curvatures K1 and K2 of the cornea of my left eye resulted in the spherical equivalent (SE) (the average of K1 and K2) of my left eye to be 42.31D. The axial length (AL) was measured to be 23.22 mm and the anterior chamber depth (ACD) was 2.46 mm. Based on those measurements (and possibly others), the selection of the 24.0D IOL predicted +0.03D to -0.40D (per 4 different formula) final vision after surgery. Which should have resulted in 20/30 visual acuity or better.

However, according to Dr. H, the actual result with the 24.0D IOL is about -1.12D vision in my left eye. I now have about 20/80 to 20/100 visual acuity in my left eye. So I went to another Ophthalmologist for a second opinion.

I went to Dr. M on 09/21/2018 for a second opinion. Her assistant measured both of my eyes using a Zeiss IOLMaster 500. The SE was 43.49D, the AL was 23.07 mm and the ACD was 4.24 mm for my left eye. The predicted vision for a 24.00D IOL was -0.93D. This is close to the -1.12D actual.

In summary, the measurements for my left eye were:

Dr. H’s assistant:
07/31/2018: SE = 42.31D, AL = 23.22 mm, ACD = 2.46 mm. (Before surgery)

Dr. M’s assistant:
09/21/2018: SE = 43.49D, AL = 23.07 mm, ACD = 4.24 mm. (After surgery)

This is what went wrong! The error is in the 07/31/2018 measurement of the SE by Dr. H’s assistant.
The difference of 43.49D minus 42.31D is 1.18D. Almost exactly the error in my vision. The research that I have done says that an error in the SE measurement results in an equal error in the final vision.

This explains what went wrong but does not explain how or why it went wrong.

On a later followup visit for my left eye on 10/25/2018, Dr. H had his assistant (not the same assistant as the first time) measure my right eye again. His assistant did not measure my left eye again.

The measurements for my right eye were:

Dr. H’s assistant(s):
07/31/2018: SE = 42.73D, AL = 23.30 mm, ACD = 2.75 mm.
10/25/2018: SE = 43.17D, AL = 23.29 mm, ACD = 2.79 mm.

Dr. M’s assistant:
09/21/2018: SE = 43.33D, AL = 23.22 mm, ACD = 2.85 mm.

Notice that there is a significant difference between the two SE measurements made by Dr. H’s assistant(s). It would seem that the measuring device was not functioning properly, it was not calibrated properly, or it wasn’t operated correctly on 07/31/2018. What else could have went wrong?

Is it possible for the curvature of the cornea (SE) to change that much naturally over a short time? Could the cataract surgery cause the curvature of the cornea to change that much? Can eye drops change the curvature of the cornea? I ask this question because during the 07/31/2018 measurements, two different eye drops were administered because I couldn’t keep my eyes open continuously long enough because my eyes were burning.

When selecting the IOL for my right eye, I will ignore the measurements made on 07/31/2018. The predicted result for the SRK/T formula is almost exactly the same for the other two measurements. So I still need to chose between a 22.5D (-0.09D to -0.12D predicted final vision) and a 23.0D (-0.44D to -0.47D) IOL for my right eye. Which is the wisest choice considering any margin of error?

I suggest that anyone planning to get cataract surgery get a second opinion BEFORE the surgery.
First I want to point out that Dr. H does not mean Dr. Hagan.   Second it would be a huge waste of time and energy to get two opinions on every cataract surgery and have two different sets of measurements from two different offices. In cases where there has been a surprise with the first operation in very long/very short eyes it might be appropriate.    Second the formula only give an estimate of the post operative uncorrected refractive error.   It says absolutely nothing about the post operative visual acuity.  If an eye with macular degeneration has a post operative refractive error of 0.00 the best vision may be 20/80 due to the internal eye disease.   If you eye is normal and you have a -1.25 lens in front of your LE you should see 20/20  if you don't something else is wrong with your eye.   Also your vision for reading in good light should be ab out 20/25.    
I apologize to Dr. Hagan. The Dr. H in my Feb 25 post is not Dr. Hagan. I made a poor choice.

I do have 20/20 vision in my left eye with prescription glasses. The 20/80 is without glasses.

I ask Dr. Hagan and anyone else with knowledge of the subject.
Is my last post technically correct?
Does it make sense to someone with knowledge of the subject?
I plan to send this information to both my ophthalmologists.
What is your glasses RX on the LE?  Your vision is 20/80 at distance without and 20/20 with glasses.   If you are myopic you should have good near vision without glasses.  What is your present glasses RX on the RE and you vision with this RX?

Also you can't compare readings BEFORE and AFTER cataract surgery. SO if you want to compare apples to apples you need the two doctors offices both before or both after not one before and the other after.  Surgery changes them. That is why these two are so different: Notice how much larger ACD (anterior chamber depth) changes. That is because the IOL is much thinner than the cataractous lens and the iris moves posterior.

Dr. H’s assistant:
07/31/2018: SE = 42.31D, AL = 23.22 mm, ACD = 2.46 mm. (Before surgery)

Dr. M’s assistant:
09/21/2018: SE = 43.49D, AL = 23.07 mm, ACD = 4.24 mm. (After surgery
I had the 22.5D  lens implanted in my right eye. My final visual acuity in my right eye is about 20/30.

I now have about 20/80 vision in my left eye and 20/30 vision in my right eye.
This is not as bad as it sounds since my left eye is focused exactly at the distance of my dashboard when I drive and my right eye is focused down the road so I can drive in the daytime without glasses or with my favorite non-prescription polarized sunglasses. I do not legally have to wear glasses to drive but I do at night time because it is so much clearer. I don't want to hurt anybody (or my car).

That is the good news. The bad news is that I cannot wear prescription glasses when I play golf because if I do the ball appears to be slightly in the wrong location when I try to hit it so I cannot hit it accurately. But without my prescription glasses on, I have very poor depth perception so after I hit the ball I can see the direction it goes but I cannot tell how far it went. But it will not stop me from playing golf.

But the really bad news is that I have been left with severe dry eyes (both eyes) because of the cataract surgery. Lubricating eye drop including prescription eye drops (Xiidra) provide only very short periods of comfort. This is now my overwhelming problem. Focus problems can be corrected with prescription glasses but nothing helps my dry eyes. It interferes with every part of my life. This is absolute torture.
I would suggest you get all your records together and go to a world class tertiary eye center. The prototype is the Wilmer Eye Institute of Johns Hopkins University.  
20852966 tn?1541695947
I am having the exact same issue as you have described herein. If you find out what is wrong, going on or even notice improvement over time, please let me know. That is, if you don't mind taking the time to email me at ***@****. I would so very much appreciate your help.
Helpful - 0
Get a second opinion from a different eye MD surgeon or if you have only had one eye done know that they often don't work together until both are fixed and you have NEW GLASSES>
I personally think that the problem is with the lens. My vision without glasses is as bad, if not worse than it was before the surgery. Why must they put a corrective lens in, in the first place? Why not a clear lens and let the glasses do the work? That is just what I expected. I was told nothing about the lens having a power. Nor has anyone else that I know of who has had cataract surgery. This should be divulged in the very beginning.
Also with the cataract, I couldn't read the guide but I could see the picture just fine with a haze. Now with that eye, it's blurry.
Consider a second opinion since you are so unhappy.  Implants (IOLs) are the standard of care and put in ALWAYS anyplace in the world when a cataract is removed even in the poorest countries.   IOLs were developed about 1972-78.    Before IOLs were developed (First by British surgeon Peter Choyce)  the eye had not lens (aphakic)  the glasses that have to be used after that type of surgery are nothing like the glasses you are used to wearing. They were super thick, maginified everything about 30% and had a circular blind spot in the perepheral vision (ring scotoma)   They would not work with a fellow eye that had not had the human lens removed. Moreover when the entire lens is removed and no IOL put in the risk of retinal detachment is about 1-5% whereas with IOL it's about one in 3,000-5,000.    
Thanks Dr Hagan, my regular eye doctor has explained that to me in detail and I understand. She also said that the formula used to get the right diopter for the lens is based on measurements. It can be off and a second surgery is not out of the question. I don't doubt that the measurements could be off due to the fact that I have severe nystagmus.
Severe nystagmus will make the measurements less reliable and most people with severe nystagmus do not have normal vision even before the cataract develops.
No, I know that far too well. I've worn glasses since I was about 6 months old. Back in those days they even tried painting lenses with only a a small circle to see through, to try and strengthen the muscles.
Best of luck to you
@Brokeneckgkr, note that an IOL with a corrective power was likely used to provide some degree of parity with your non-operative eye.  That was divulged to me by my cataract surgeon well beforehand,  after I informed him that I was having the surgery on my LE only since my RE was not in need of it at the time and remains so today.  Both of my eyes by the way are myopic.
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