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17484539 tn?1580565249

Is dry eye syndrome a counter-indication for toric lenses?

Hello, I wrote in February of my upcoming cataract surgery but since all elective surgeries in my state were  put on hold until just now. The cataract surgery is expected between June & September. So I am having my final measurement appointment today for eye#2 (LE). My RE is set for distance only (no astigmatism correction, glasses are a challenge) and a decision was made in February after contact lens try-ons, to choose the far vision option for the LE as well (dominant eye) WITH astigmatism correction.  I had an acceptable results with the contact lens try on.Now my doctor tells me there are two choices: 1) Toric and 2) regular (the kind Medicare pays for) with a laser option added for the astigmatism. Measurements to be taken today. My ophthalmologist told me last week during the first exam (with dilation) said that the astigmatism in left eye might not measure sufficient to choose the topic option. She also counted me to make sure & have my eyes well-hydrated for the exam today as I have dry eye syndrome & this can throw off the measurements. I read up on topic lenses and there DOES seem to be some room for error due to the dry eye syndrome I have. (She terms it Map Dot Fingerprint Dystropy).    If the measurements are off, then the lenses may not be placed correctly resulting in some degree of blurry vision and needing surgical correction afterwards). Would be interested in any  experience re toric lenses vs dry eye syndrome. Thank you in advance!
3 Responses
17484539 tn?1580565249
Sorry I meant TORIC lenses of course! (you see I really DO need that Cataract surgery!)
177275 tn?1511755244
Before you do anything read this article CAREFULLY:  https://www.medhelp.org/user_journals/show/1648102/Consider-ALL-the-Options-Before-Your-Cataract-Surgery-Working-Through-Whats-Best-For-You--2019-2020-Update

My biggest concern is that you are aiming to set both eyes for distance (20 ft or 6 m) so the far RX after surgery would ideally be 0.00   You would not see clearly at distances less than 20 ft.  So you would need glasses to see TV at 10-15 feet, be unable to read, use computer, shop.  So you would be wearing no line (progressive) multifocal glasses most or all of the time.  Granted you might be able to read with over the counter reading glasses but you would need a different pair for shopping and computer and only a custom lens for TV and intermediate.    I have many patients that consult me with surgery done elsewhere unhappy with this.  A better solution described in the article for most people would be mini-monofocal distance bias   that is -0.25 for dominant distance and -1.00 for non-dominant eye.  

The cornea problem you have is also called basement membrane disease.  It is common and often assymptmatic.  Generally it does not interfer with the pre-op tests for implant measurements.  I strongly suggest you discuss your targeted post op refractive error with your surgeon.
4 Comments
Dr Hagan I read your answer. Did you read my previous 2016 problem with getting a farsighted prescription for my other non dominant right eye? So the mini would have been ideal but since the RD us done I thonk I’m stuck! ?? Or am I ?
My astigmatism measurement ranged from  .5 to .9 diopters, 3 measurements
You have 38 posts and I con't have recall of everyone past history.     You can summarize what is important and i can review.  If you had a scleral buckle that will make determining IOL power a lot more difficult than your cornea problem
Sure, glad to!  I had cataract surgery on my right (non dominant eye) in 2016.  I ended up with far vision in the implant (great for driving but I'm a graphic artist) much to my unhappy surprise.  I have near vision in my left eye so glasses were a problem for extended reading.  85% of my life is computer work and reading, driving and other social activitiesis maybe 5%.  I also had and have a stable macular pucker in my right eye. I sought 3 additional opinions after that surgery because I was mise4able losing my near vision, but it took so much time to get appointments it was to late for a redo.  

Now that its time for my left eye cataract surgery I (we) have to decide what strength lens to put in the remaining eye which is the dominant one?  Near vision doesn't work. Did a contact try on in February with a colleague of doc.  We came out with a decision of making the left eye another far vision but with astigmatism correction which I was told will help me with reading.

But today at my doc visit I got a completely different answer (which was actually similar to your post this morning.) The doc told me if I go with the far vision in my left eye too so that RE & LE are same, I will never be able to read anything or see things fairly close like computer without glasses even WITH astigmatism correction.  I was able to clarify my need that this was NOT workable.  The way we left it was that the doc will talk to the lens guy she works with to reconsider what strength would work best, given I'm a graphic artist.  I had tried mono vision in Feb but with more near vision & it wasn't comfortable. Of course the idea solution woud have been intermediate strength in the RE (non-dominant, and far vision in Dominant LE. But it was reversed. question now is whether we considered all the in-between alternatives.  We are to speak again in a few days.

My surgery is scheduled for early July so we should have time to come to a good decision.  Doc has excellent rep & is trustworthy & flexible. We did decide that Toric is probably the better alternative  But not the strength. Any insights gratefully appreciated!  (Glad I don't do this often!)

Gratefully, Candice
I so appreciate your input so far and deep knowledge!


O
177275 tn?1511755244
Okay. Your RE non-dominant has good distance vision without glasses (20 ft or further) the refractive error is likely close to 0.00 if you see well without glasses.   The dominant for distance and non-dominant for near is a guideline and I have many patients quite happy with it reversed.   You obviously are an intelligent woman who is putting a lot of thought in this.  For most people aiming for -1.00 on the  LE would work well.    Assuming you hit the target and the toric corrects your astigmatism your post operative glasses RX would be RE 0.00 LE -1.00 with a +3.00 add in multifocal no line lens.  Without glasses your vision would likely be acceptable from about 3 feet to 20 ft and more.  The exact distance of clear vision at intermediate cannot be exactly determined since it depends on your pupil size and how mobile it is.
8 Comments
Dr H, thanks for your quick response for which I'm grateful. Yes isn't this far better to tackle this now than to be left with an unexpected result like I had with RE! The first time I read about Mini-Monovision was your reply yesterday & I've just spent the last 2 hours reading up on it. A couple questions:  I'm assuming your suggestion the same as mono vision but less difference between the strengths?  I did try mono vision in February (contact lens trial)though I think the distance between the two strengths was much larger. I can check that. I do have one question: what means your phrase "with a +3.00 add in multifocal no line lens." I've never (so far) been able to adjust to progressives, but is progressive more desirable for close tasks?Right now I have two different glasses with 3 strengths:  1) distance and 2) bifocal combo computer(intermediate) and reading (near). I'm retired but that combo got me through a  pt library  job  where a combo of fine print & computer was necessary.  So I think I understand your response except that one line about the 3.00 add (which is obviously the adaptation to near & intermediate).  I guess all that is workable with the right lens implants. Many thanks (that goes without saying!)  Gratefully yours, Candice
To see the best you possibly can see at all possible distances with one pair of glasses you would need progressives lineless.  That being said some people cannot adjust.  About 10% of people wear bifocals (invented Ben Franklin 1700's) or  trifocals (invented 1800's Harrison).   Also the special purpose glasses like you have will have a larger optical zone because has fewer prescriptions.   So you apparently are in the 10% non-adjusters.
Good morning again.  My long awaited cataract surgery is finally scheduled for JULY 13. I did have a surprise on my doc appt last month.  I thought a decision had been made for a -1.00 correction on the LE which would give me mono-vision, only to be told by the main doctor who works with the optometrist that she has me scheduled for  FAR vision correction in both eyes.  I told her that would NOT be a satisfactory result, due to the fact I want to at least have some near vision.  I pointed to my iPhone held at arms length and said "I need to be able to see this without glasses."  I think my message then came across. The doc then said she would communicate with her optometrist again.

The optometrist measurements taken in Feb DID adjust for a -1.25 correction in LE and recently I was given a "double check"  appointment with him tomorrow.   He is going to try a -1.00 correction contact lens try on this time.  I don't understand the disconnect with the main surgeon thinking I would get far vision in the 2nd eye too and I hope my communications have been clear.  And hopefully they remember I'm a graphic artist and 90% of my time is spent with computer or reading or fairly near objects. Hopefully they will both be in the office tomorrow and can speak together during my appt and allign  their communications.

I extremely appreciate the insights I've learned here, Dr. H.
There was an article in the eye surgery literature recently. I don't have time to research. It said for "distance" or "Far" vision (20 ft/6m) or further that  1. the post results are more accurate 2. the patients are happier targeting -0.50 than 0.00     You might be able to come up with that article with literature search. But for your 'far' eye aiming for -0.50 might be a good choice.   That eye would not be able to read or likely see computer clearly without glasses.
Good news!  Well I am 4 days out from my cataract surgery on the LE. Just as a review I had my first surgery on my RE 4 years ago, got great far vision but lost my near vision which was v. distressing and was terrified of this LE cataract surgery  because I didn't want to completely lose my near vision.  I am very grateful to you Dr. Hagan  for your advice NOTto get two eyes far vision because I would have been very distressed to not even be able to see my computer without putting on my glasses.  I had a last minute inspiration to explain my goal to my doctor and said: " I do not want to put on glasses to see my iPhone!"  That seemed to clarify everything! I am very happy because   I ended up with what I think is a vision range of 3 to 20 feet pretty clear in my left eye with some astigmatism correction.  (more will be needed later with glasses). And it seems to work okay with the other (far vision) RE. I will write again when I am more healed and everything settles down but must tell you how deeply thankful i am, having chosen this option!  In fact...thrilled!  Thank you deeply.
Candice. We love happy endings here. Thank you for taking the time to post.  As I have said many times seeing clearly at 20 feet or further but blurry anything nearer rarely, if ever, makes for a happy campter. Best of luck.  JHagan MD
Hello, I am now 5 weeks out from my surgery and still pleased with the outcome.  It is not perfect, my far vision improved drastically and my intermediate range stayed the same but I can still see 3 to 20 feet pretty clearly without glasses and have no trouble around the house, watching tv and regular chores.  I can read and answer messages on my iPhone even at 1 or 2 foot away if I happen to forget my glasses and in a pinch read many menus.

The odd thing is that I did end up with plano in both eyes, and yet the doctor told me that she and her colleague the optometrist were absolutely positive I had the kind of astigmatism which could be corrected during the surgery so that my intermediate vision would be acceptable and I could also have far vision..  

And they were right.  As my eye healed further in weeks 2 through 5, my intermediate vision stayed ok but I began to see farther and farther away as well. I was astounded. But how this is possible is a mystery to me. As a happy bonus I have never been able to see this  far away since I was 21 years old and as long as it doesn't interfere with my intermediate vision I am a happy (and relieved) camper.

Another bonus is that my new temporary glasses are for the first time in years comfortable  as the eyes work more closely together.  

I will report back if anything changes, but do wish to express my gratitude again and I did promise to write when the dust had settled!  I am so glad I was able to be so clear with my docs and this forum gave me the confidence and facts to do that.
well done and thanks for sharing your experience.  We love happy endings.
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