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IOLsolutions for irregular astigmatism?
I have recently been searching for the best solution for treatment of a cataract in an eye with high irregular astigmatism.
I consulted three specialists and two of the three recommended not to have multi focus IOL's. (they were all happy to fit single focus IOL's)
This is because of the high degree of irregular astigmatism that is present on the cornea of my left eye. Some 22 years ago then aged 48,I suffered sub-acute attacks of high pressure in the anterior chamber of the left eye and a trabeculectomy(bleb) was carried out at the top of my eye. It's just above the cornea and is hidden by my eyelid. The operation worked well and is still keeping the pressure nice and low to around 15mmHg. Visual fields tests show no glaucoma degradation of the discs/optic nerve.My periferal vision is fine.
After about 10 years astigmatism started to deteriorate in the left eye and my current spectacle prescription is now +8.00(sph) -3.00(cyl) 70 (axis) +2.50D reading.
However the most recent specialist (number 3) found considerably more astigmatism of the irregular kind than the above prescription would indicate. Pentacam measurements show a range of 7.7D of irregular astigmatism in the centre portion of cornea.( I'm not sure what diameter this covers but about 3mm, a typical iris diameter in normal light conditions) He proposes only fitting a single vision IOL and then correct astigmatism with spectacles.
He says it's impossible to correct with a toric single vision IOL.
However the other two specialists are much more optimistic of being able to correct this amount to a reasonable degree.
This is something of a dilemma and a disappointing result for me.
I was hoping to be as independent of glasses as possible.
Specialist number 3 is my local one and he has impressed me the most with regard to his communication skills and explaining the situation and I believe that he an excellent surgeon.
I decided to go ahead with the right eye which was more in need of attention than the left with regard to the degree of cataract that has formed.
There was no problem to fit a toric IOL here as only small amount of irregular astigmatism.
This operation was carried out a week ago by specialist number 3 at a nearby private hospital. The Tecnis single focus ZCT with a power of +29D and 1.50D of toric astigmatic correction was used.
Post operation for the first few hours I was seeing double and the vision was very misty, but after 24 hours I was seeing extremely well in the distance and down to about 2 metres in quite good focus.
Images are bright and with good contrast much more so than in the un-operated left eye.
The iris aperture size returned to normal after 36 hours and it may be even slightly smaller than the left side now.
I am still experiencing a little flashing or twittering sensation out of the corner of my right eye every 10 seconds or so but I think this effect is diminishing
As a short term measure I have had a plano lens fitted in my glasses on the right to balance them up mechanically and give me some protection.
The imbalance between the eyes (aniosometropia) is bearable and not as bad as I had feared it might be. I guess the size of the retinal image is about 10-15% larger on the left than the right when wearing my glasses. I did try putting a prescription left lens as close as possible to my left eye and the image difference is greatly reduced. (So a contact left lens would be a potential solution on the left)
My left eye has always been the dominant one and continues to be so. The image size when looking bi-laterally takes on the size registered by the left eye. (the smaller image size on the right is suppressed) The effect of the right eye now is to increase overall brightness and contrast to the brain as well 3D which is a little different than before the operation.
The acuity of the left eye has always been better than the right and I think this is still the case. It's obviously not just a question of optics. One effect I had not considered before is the telescopic effect of wearing glasses for a long sighted person. I was wondering how this will affect my overall acuity when both eyes have been done.
As a temporary measure for reading and computer work I can manage quite well with +1.25 D plane lens in the right and retaining my varifocal lens on left side.
My plan now is to wait a few weeks and see how my right eye settles down and to see if there is any significant residual astigmatism. It will also be interesting to monitor the interocular pressure as this type of surgery can be good for glaucoma sufferers of the angle closure type. (the IOL is thinner than the natural lens of the eye so there is more room in the anterior chamber for the circulating aqueous humour)
In the mean time I need to find out more about correction of irregular astigmatism and whether there are any laser options.
Another option as mentioned is to use a contact lens on left eye.
Another factor that has been suggested is that my droopy eyelids may be playing a part in relieving some of the astigmatism by a shielding effect (similar to a pin hole effect)
Any comments much appreciated
(picture attached showing left eye and trabeculectomy)
I consulted three specialists and two of the three recommended not to have multi focus IOL's. (they were all happy to fit single focus IOL's)
This is because of the high degree of irregular astigmatism that is present on the cornea of my left eye. Some 22 years ago then aged 48,I suffered sub-acute attacks of high pressure in the anterior chamber of the left eye and a trabeculectomy(bleb) was carried out at the top of my eye. It's just above the cornea and is hidden by my eyelid. The operation worked well and is still keeping the pressure nice and low to around 15mmHg. Visual fields tests show no glaucoma degradation of the discs/optic nerve.My periferal vision is fine.
After about 10 years astigmatism started to deteriorate in the left eye and my current spectacle prescription is now +8.00(sph) -3.00(cyl) 70 (axis) +2.50D reading.
However the most recent specialist (number 3) found considerably more astigmatism of the irregular kind than the above prescription would indicate. Pentacam measurements show a range of 7.7D of irregular astigmatism in the centre portion of cornea.( I'm not sure what diameter this covers but about 3mm, a typical iris diameter in normal light conditions) He proposes only fitting a single vision IOL and then correct astigmatism with spectacles.
He says it's impossible to correct with a toric single vision IOL.
However the other two specialists are much more optimistic of being able to correct this amount to a reasonable degree.
This is something of a dilemma and a disappointing result for me.
I was hoping to be as independent of glasses as possible.
Specialist number 3 is my local one and he has impressed me the most with regard to his communication skills and explaining the situation and I believe that he an excellent surgeon.
I decided to go ahead with the right eye which was more in need of attention than the left with regard to the degree of cataract that has formed.
There was no problem to fit a toric IOL here as only small amount of irregular astigmatism.
This operation was carried out a week ago by specialist number 3 at a nearby private hospital. The Tecnis single focus ZCT with a power of +29D and 1.50D of toric astigmatic correction was used.
Post operation for the first few hours I was seeing double and the vision was very misty, but after 24 hours I was seeing extremely well in the distance and down to about 2 metres in quite good focus.
Images are bright and with good contrast much more so than in the un-operated left eye.
The iris aperture size returned to normal after 36 hours and it may be even slightly smaller than the left side now.
I am still experiencing a little flashing or twittering sensation out of the corner of my right eye every 10 seconds or so but I think this effect is diminishing
As a short term measure I have had a plano lens fitted in my glasses on the right to balance them up mechanically and give me some protection.
The imbalance between the eyes (aniosometropia) is bearable and not as bad as I had feared it might be. I guess the size of the retinal image is about 10-15% larger on the left than the right when wearing my glasses. I did try putting a prescription left lens as close as possible to my left eye and the image difference is greatly reduced. (So a contact left lens would be a potential solution on the left)
My left eye has always been the dominant one and continues to be so. The image size when looking bi-laterally takes on the size registered by the left eye. (the smaller image size on the right is suppressed) The effect of the right eye now is to increase overall brightness and contrast to the brain as well 3D which is a little different than before the operation.
The acuity of the left eye has always been better than the right and I think this is still the case. It's obviously not just a question of optics. One effect I had not considered before is the telescopic effect of wearing glasses for a long sighted person. I was wondering how this will affect my overall acuity when both eyes have been done.
As a temporary measure for reading and computer work I can manage quite well with +1.25 D plane lens in the right and retaining my varifocal lens on left side.
My plan now is to wait a few weeks and see how my right eye settles down and to see if there is any significant residual astigmatism. It will also be interesting to monitor the interocular pressure as this type of surgery can be good for glaucoma sufferers of the angle closure type. (the IOL is thinner than the natural lens of the eye so there is more room in the anterior chamber for the circulating aqueous humour)
In the mean time I need to find out more about correction of irregular astigmatism and whether there are any laser options.
Another option as mentioned is to use a contact lens on left eye.
Another factor that has been suggested is that my droopy eyelids may be playing a part in relieving some of the astigmatism by a shielding effect (similar to a pin hole effect)
Any comments much appreciated
(picture attached showing left eye and trabeculectomy)
Best Answer
1 Comments
Dear Mr Hagan,
Many thanks for your valued comments on the above subject.
Yes I am indeed from the UK.
It is comforting to know that having had a mono focal toric aspheric lens implanted in my right eye last week that now three out of four specialists think it is the most appropriate choice in my case.
What I am saying here is that the choice of IOL for the right eye is based on the type of IOL I will require for the left side when I get around to having this done be it a toric or not.
The irregular astigmatism I have on the left cornea is definitely a result of the trabeculectomy although it didn't show up for a number of years after the operation. I omitted to say in my report that I also had a periferal irodectomy operation in left eye some 10 years earlier when I was 38. This was for sub acute attacks of glaucoma.I had the right eye done too as it's a bi-lateral disease. However I have never had a problem with raised inter ocular pressure on right eye in this respect.Though perhaps the irodectomy is still doing it's job on the right eye.It certainly wasn't sufficient on the left hence the trabeculectomy.
I am very conscious of the risk of de-stabilizing the trabeculectomy on the left eye. Another reason not to rush into the second operation.
I seem to have lost the picture of left eye I posted on this site yesterday-not sure what I did. I was unable to answer directly to you on the page,so clicked on your name to send this message.
I'll keep you posted on how my right eye progresses and how I tolerate the imbalance between the two eyes.
(8.00Dsph -3.00Dcyl) which is quite a lot!
Best regards
Many thanks for your valued comments on the above subject.
Yes I am indeed from the UK.
It is comforting to know that having had a mono focal toric aspheric lens implanted in my right eye last week that now three out of four specialists think it is the most appropriate choice in my case.
What I am saying here is that the choice of IOL for the right eye is based on the type of IOL I will require for the left side when I get around to having this done be it a toric or not.
The irregular astigmatism I have on the left cornea is definitely a result of the trabeculectomy although it didn't show up for a number of years after the operation. I omitted to say in my report that I also had a periferal irodectomy operation in left eye some 10 years earlier when I was 38. This was for sub acute attacks of glaucoma.I had the right eye done too as it's a bi-lateral disease. However I have never had a problem with raised inter ocular pressure on right eye in this respect.Though perhaps the irodectomy is still doing it's job on the right eye.It certainly wasn't sufficient on the left hence the trabeculectomy.
I am very conscious of the risk of de-stabilizing the trabeculectomy on the left eye. Another reason not to rush into the second operation.
I seem to have lost the picture of left eye I posted on this site yesterday-not sure what I did. I was unable to answer directly to you on the page,so clicked on your name to send this message.
I'll keep you posted on how my right eye progresses and how I tolerate the imbalance between the two eyes.
(8.00Dsph -3.00Dcyl) which is quite a lot!
Best regards
Hopefully you are aware of this but angle closure glaucoma in all its variants acute, chronic, intermittent tends to run in families (and of course occurs almost exclusively in hyperopic/farsighted people). So it is critical that all your blood relatives know about your acute glaucoma problem and have their own eyes checked regularly especially after age 40 by an Eye MD ophthalmologist whom they have told about your problem.
Their also is a higher incidence of OPEN angle glaucoma in eyes that have had LPI and/or acute/chronic/recurrent angle closure glaucoma
JCH MD
Their also is a higher incidence of OPEN angle glaucoma in eyes that have had LPI and/or acute/chronic/recurrent angle closure glaucoma
JCH MD
2 Comments
Thanks for that.
Yes,I am very well aware of glaucoma running in families.
The only reason I became aware of my first attack or sub acute of raised inter-ocular pressure was when I was aged 38.
I was driving home at night after a strenuous game of squash and became aware of concentric ring halos from the headlamps of oncoming cars.(only in the left eye) I immediately new something was wrong. My Father had had very similar experiences in his fifties.So I was on to the case very early and saw a glaucoma specialist within two days and shortly after periferal irodectomies were performed in both eyes.
My understanding is that acute attacks of glaucoma are due to the sudden high pressure increase in the anterior chamber. This causes a temporary absorption of the aqueous humour into the inside of the cornea causing it to become temporarily slightly opaque. After a few hours rest the problem goes away and the patient thinks there is nothing to worry about. In my experience this is the time to seek urgent expert advice!
In those days the operation was carried out surgically with a kind of hooked scalpel and involved staying in hospital for about 5 days. Today it's a quick procedure with laser and home.
It's amazing how technology has transformed eye care in the last 30 years or so.
.
In my Father's case he took pilocarpine in both eyes for quite a long time before having irodectomies in both eyes. He then received very bad advice from the surgeon who said he was cured and didn't require further checkups. This was the worst possible advice because he subsequently developed chronic glaucoma as well and lost periferal vision before the problem was detected.He subsequently had a trabeculectomy in one of his eyes in his late seventies and an IOL was fitted in that eye he also ended up with the iris sticking to the lens capsule and the iris was very badly torn in the operation.(maybe Pilocarpine was slightly to blame)
All in all a very sad state of affairs for my poor old Dad. When he died age 84 his eyesight was in a very bad way with tunnel vision and very bad acuity.
I suppose I am the lucky one here, that's why I have developed a great interest in eye care and strive hard not to fall into the scenario of my Father.
I will continue to stress the importance of regular eye check ups to my two son's and their families.
Yes,I am very well aware of glaucoma running in families.
The only reason I became aware of my first attack or sub acute of raised inter-ocular pressure was when I was aged 38.
I was driving home at night after a strenuous game of squash and became aware of concentric ring halos from the headlamps of oncoming cars.(only in the left eye) I immediately new something was wrong. My Father had had very similar experiences in his fifties.So I was on to the case very early and saw a glaucoma specialist within two days and shortly after periferal irodectomies were performed in both eyes.
My understanding is that acute attacks of glaucoma are due to the sudden high pressure increase in the anterior chamber. This causes a temporary absorption of the aqueous humour into the inside of the cornea causing it to become temporarily slightly opaque. After a few hours rest the problem goes away and the patient thinks there is nothing to worry about. In my experience this is the time to seek urgent expert advice!
In those days the operation was carried out surgically with a kind of hooked scalpel and involved staying in hospital for about 5 days. Today it's a quick procedure with laser and home.
It's amazing how technology has transformed eye care in the last 30 years or so.
.
In my Father's case he took pilocarpine in both eyes for quite a long time before having irodectomies in both eyes. He then received very bad advice from the surgeon who said he was cured and didn't require further checkups. This was the worst possible advice because he subsequently developed chronic glaucoma as well and lost periferal vision before the problem was detected.He subsequently had a trabeculectomy in one of his eyes in his late seventies and an IOL was fitted in that eye he also ended up with the iris sticking to the lens capsule and the iris was very badly torn in the operation.(maybe Pilocarpine was slightly to blame)
All in all a very sad state of affairs for my poor old Dad. When he died age 84 his eyesight was in a very bad way with tunnel vision and very bad acuity.
I suppose I am the lucky one here, that's why I have developed a great interest in eye care and strive hard not to fall into the scenario of my Father.
I will continue to stress the importance of regular eye check ups to my two son's and their families.
I decided to post the last two items into a new page /thread-
"Sub acute attacks of Glaucoma" as this may be more appropriate than the subject of this thread.
"Sub acute attacks of Glaucoma" as this may be more appropriate than the subject of this thread.
Surface irregular astigmatism due to very superficial scarring or corneal epithelial disease such as basement membrane disorder is relatively easily treated and can be done in USA. Uses eximer laser to remove superficial cornea then put on bandage contact lens. One of most common causes of irregular astigmatism is people who have had RK surgery. It can be helped but because the scars extend 90% through the cornea cannot be eliminated. Keratoconus is a common cause and cannot be treated with laser. I suspect irregular astigmatism due to a glaucoma trabeculectomy would not be able to be treated in US or elsewhere since the corneal warping comes from the large incision at the limbus Superiorly.
I think he buried the lede and that the major question after those details is: "In the mean time I need to find out more about correction of irregular astigmatism and whether there are any laser options. ". I haven't had reason to explore the various laser surgery options in detail, just in passing I'm aware the laser systems continually make advances in analyzing corneal topography and planning how to treat it, but I don't know the current state of the art and its limits. His profile indicates he is in the UK (the mention of a trifocal as an option gave a clue he is outside the US) so he'd likely have access to newer tech than we have.
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I would avoid any type of multifocal or accommodating IOL in an eye with irregular astigmatism. The safest and least likely to cause troublesome ghosting, dysphotopsia, flare, glare, etc would be a high quality aspheric monofocal IOL. If the surgeon thinks a toric might be acceptable you might consider that. Know that aligning a toric IOL in the proper axis is much more difficult with irregular astigmatism and a trabeculectomy bleb. Know also that there is some risk of the bleb failing during the healing process and your glaucoma could get worse not better.