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Planning for cataract surgeries with myopia and macular pucker

I have been diagnosed with moderate cataract cloudiness in both eyes
and I am trying to determine the best options
as far as IOL choices for likely surgery down the road.
I have read many posts on this forum and they are very helpful.
Everyone, of course, has their own situation and priorities.

My situation: I am a 72 year old male, fairly myopic my whole life (latest RX: -9 OS -11.5 OD).
Last year I developed a macular pucker in my right (dominant) eye and had a vitrectomy and epiretinal membrane peel surgery.
So far, this hasn't improved the distorted vision (20/50) in my right eye, but hopefully has stopped the progression.
My left eye has a PVD (floater), along with the moderate lens clouding, but is still 20/20.
As far as future cataract surgery, my cataract MD is suggesting targeting moderate near vision for the IOL's since I am myopic, but not rushing into surgery again, since I am still 20/20 in my LE.
Without glasses, my vision focuses a couple inches from my nose, which is handy for small work, but I can't read or use a computer without glasses, unlike other myopics on this forum.
I do drive and hike, so I'm tempted to look at plano vision for the IOL's instead, and continuing to use glasses for computer and reading. Either way, I'll lose my "microscopic vision", which I'm not happy about, but it seems inevitable with cataract surgery.
My optometrist is working with me to trial different options with contacts. First, I have tried a monovision option with distance in my good, but non-dominant left eye, and -1.75 for reading in my distorted (dominant) right eye.
I found that my brain kind of adjusted, but my pucker made it impossible to read at all from the right eye, so this did not work.
Basically, I find that I have to use my left 20/20 eye for any detail, with the right eye just filling in some binocular vision.
Because of this, I am inclined to get matching far vision IOLs, and continue with glasses for reading.
I'm getting matching far vision contacts to try this out next.
But reading vision, with glasses for distance, seems to be suggested on this forum and by my cataract surgeon.
My right eye distortion in my dominant eye seems to limit my normal options for IOLs.
What have others done in my situation and would it be inadvisable to shoot for plano as a myopic person with basically only one good eye?
And, will cataract surgery improve my vision at all in my right (macular pucker) eye?
Or, will this just help with image brightness and size between the eyes?
Finally, how can I "trial" near vision contacts, using glasses for far vision.
(Drugstore cheaters are only +diopters, aren't they?)

Thanks for any advice and feedback.
2 Responses
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233488 tn?1310693103
FIRST READ THIS CAREFULLY THEN COME BACK AND FINISH THE POST: 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

I would not rush into cataract surgery on your RE because of your pathologic high myopia and the problems in your LE  you are at much higher risk when cataract surgery is indicated (retinal detachement, macular edema, ERM).   My experience is that myopic patients that are used to reading or doing computer work without glasses all there life are extremely unhappy when they lose their near vision without glasses.  If some insists I demand they get a second opinion and that they undrstand that they would need one pair of glasses for reading, another for computer/shopping and likely a third for watching TV (5-16 feet away).  Only your retina surgeon can tell you how much your vision in the LE might be helped by cataract/IOL surgery. It depends on what the macular OCT tests shows. Rarely does an eye see a perfect 10/20 after this type of surgery.  
Helpful - 1
Dr. Hagan, thank you for your input on this decision. Yes, I started by reading your link awhile back before posting and it was very informative and helpful, especially for those who have not had prior retinal (ERM) surgery.

I'm taking my time deciding on cataract surgery. In my case, I don't do ANYTHING without glasses anyway (reading, computer, or outside). So I'm very used to using glasses at all times. I understand that those myopics who can read without glasses would be disappointed after cataract surgery to need them. However, this is not really an issue for me, so why not aim closer to far vision IOLs?

I just had my 8 month followup to my PPV-ERM surgery done last fall. My surgeon thought things are progressing well in the RE, but the cataracts seem to be advancing in both eyes, especially the RE, which had the ERM surgery, and I'm starting to see the effects in my "good" LE also. Meanwhile, the surgery did not seem to help my RE macular distortion (yet), despite being "successful" removing the pucker. My LE has no distortion, but I'm losing depth of field and the refraction in both eyes has started to wander in the last few months from my prescription. I understand this is probably due to the cataracts.

Dr. Hagan, are you saying that I might not be able to have cataract surgery AT ALL due to the previous PPV-ERM surgery in my RE? When you say there are increased risks of cataract surgery in this case, HOW risky and will I not get any benefit from getting cataract surgery. It seems that if I'm losing more and more vision from the lens clouding, and I can't get cataract surgury due to the prior retinal surgery, I'm in a real pickle.

I am not saying that you will not be able to have cataract surgery and the surgery itself should be no different than normal.  What I am saying is that in the eye that had the ERM surgery it may not have 20/20 vision and it may also have distortion. So the vision would be better because cataract gone but the back of the eye has problems.  You have pathologic high myopia and with or without cataract surgery you are at a higher risk of retinal detachment, glaucoma and myopic macular degeneration.   As I described in the different ways of correcting an eye if you and your surgeon for for distance  (plano   plano)  it is possible that your distance vision at 20 feet may be quite good but you would need glasses to see a TV  15-10 feet away, a computer screen 3 foot away and a book 18 inches away. In other worlds multifocial glasses most of the time.
Ok, that makes sense.

I'm not expecting miracles with cataract surgery on the eye that has the ERM surgery, but I do hope the overall vision gets a little sharper in that eye and I will be only be dealing with the macular distortion. My vision in both eyes seems to be looking more "smeary" overall (cataract?)

As far as the additional retinal issues you mentioned, yes, my doctors are monitoring both some mild glaucoma in the right eye (they did SLT) and they note the start of some "mild" AMD in both eyes on the latest OCT scan.

As far as what lens to target for cataract surgery, have you had *any* highly myopic patients like me that tried for near plano that were happy with their decision?

Yes a few BUT HUGE DIFFERENCE  they were having both eyes operated on so that their post op refractions are usuall  0.00 (plano) dominnt eye -1.00 non dominant eye. YOU on the otheer had would be plano 0.00 in the RE with the ERM and -11.50 in the LE that still sees 20/20   there would be a huge difference in image size and glasses would not work at all,  Even with a contact lens on LE and multifocal glasses you would probably have problems.    You have a very dificult situation to balance the eyes EVEN if the RE did not have an ERM.  
Good point.
I also have a similar cataract in the "good" LE (Rx -9.00), so am looking at IOLs in both eyes eventually.
For some reason, my RE went from -8.75 to -11.5 after ERM surgery. What would cause this?
With my dominant RE having distorted vision (20/50), I'm thinking that a monovision kind of target wouldn't work well for me (I tried with two contacts and couldn't even read text.)
I also have some astigmatism in both eyes, so will probably need toric IOLs.
If I went with near plano IOLs, would it be wise to shoot for, say, -1.00 in both eyes?
First the increase in myopia in your RE post vitrectomy is called "pseudomyopia" and is due to the membrane peel surgery causing cataract to grow faster a well known complication. Our practice does not put toric lens in patients with macular pathology like you have.  At this point I have to say I've gone about as far as i can go and the rest is up to you and your surgeon. Might do well to get a second opinion from a respected cataract surgeon on what refractive error to aim for.
Thanks, Dr. Hagan. I appreciate your input.
Maybe another patient has some experience/advice for my myopic situation on the forum...

If anyone does please post
Some followup thoughts from Dr. Hagan's posts...

- If the increased myopia in the vitrectomy RE is related to the cataract, it sounds like cataract surgery could fix this since the lens would be replaced, correct?

- If a toric IOL is not advisable for my puckered RE, perhaps multiple glasses for different activities post cataract surgeries are inevitable for me anyway, and targeting a mildly myopic IOL makes more sense over a plano target, since my astigmatism will have to be addressed via glasses with the IOLs.

Does this line of thinking make sense?
YES cataract surgery can take care of the cataract but not ERM>   Please look on my posts. Our practice was involved in the original research for the RxSight Light Adjustable Lens. This is the most advanced IOL I have ever seen and if available would be an excellent choice if the surgeon is experienced. it can be adjusted AFTER it is put in the eye.

Is this adjustable IOL normally used to fine-tune the Rx after surgery one time, or will Rx continue to wander in the future, despite the removal of the cataract?
Can it be adjusted for astig as well as the refraction?
(I'll search for RxSight in your posts.)

I realize the macular pucker distortion won't improve just due to a cataract surgery. But I'm hoping it will help the "pseudomyopia" that keeps increasing and  clear and sharpen some of the fuzzier peripheral vision since the PPV-ERM surgery.

I also wish I could get an idea how dangerous cataract surgery really is following PPV-ERM surgery. (e,g, 50% chance of destroying that eye? 1% chance?)

I'd like to have some good questions for my cataract surgeon at my next (brief) visit with her.

The LAL can be adjusted 3 times over the post op 3 weeks. Then a light is used to "set" or "Fix" it and no further adjustments are possible. It does correct astigmatism. with small incision no stitch surgery after 3 weeks the RX is relatively fixed for most people.   Cataract/IOL surgery is not much more difficult or dangerous but the prognosis for vision more guarded
Avatar universal
I'm still weighing my options for IOL refractive target(s) for my situation with the macular distortion in the RE (PPV,EMP,mild OAG, early AMD); LE 20/30 with advancing cataract and PVD, but otherwise healthy so far.
I've learned more lately from reading (and especially from this forum).

I'd like to plan for cataract surgery in 5-6 months.

Meanwhile, I've looked at the LAL RxSight product and it looks intriguing. Unfortunately, there is no one in the four-corners area who is offering this, as it is new and it seems to need a larger staff and facility and more followup visits to fine tune the Rx.

My surgeon's comment about the LAL was that it was still too new.
And... she also told me that she was leaving the practice in a couple of months, so I guess they will refer me to another surgeon and I'll have to discuss my priorities with them and hear what lens choices they can offer.

I have recently read about the Technis Eyhance monofocal lens, which might allow me a little more depth of focus. I'd like to be able to see far distance and intermediate  distance (e.g. 10 ft), but can use glasses for computer and cellphone use. Is this possible without two good eyes and monovision?

I wonder if targeting something like -0.5 in both eyes, combined with Eyhance lenses (in both or one eye) would make sense? I have read that -.5 might not work for distance, though. Others say they've achieved distance and intermediate vision with the Eyhance targeting distance.

Has anyone had experience with Eyhance? What is your experience?
Helpful - 0
The Light Adjusted Lens (LAL) is not expertimental. One of the lead investigators when it was experimental was John Doane, MD of our Discover Vision Centers practice in Kansas City, MO.  Now that is approved our  surgeons are using it as the preferred premium IOL.  NOTE:  LAL is not covered completely by commercial insurance or Medicare and there is a significant out of pocket expense.   I don't know where '4 corners' is.  You can contact the company that makes LAL directly and their Customer Service can liekly provide you with the name of an experienced LAL surgeon within driving distance.
Thanks for responding, Dr. Hagan
I am in SW CO, so an 8-hour drive to Denver is the closest, according to the RxSight website.
How many followup visits does the LAL surgery typically take, and on what kind of schedule usually?
Are both eyes operated on at the same time, or one at a time, typically?
I will take your advice to contact RxSight to see if there are any other surgeons nearer that are considering offering this lens in the near future..
How long was the learning curve for your staff with the new equipment needed, etc.?
Maybe I'd be better to wait another year for this move...
Both eyes are never operated on at the same time. The patient is seen the day after surgery, and three subsequent visit over the next.  The learning curve is relatively short, much shorter than learing a new type of cataract surgery or 'premium IOLs like toric, multifocal, etc. This is from an ophthalmology publication:

Light Treatments

The RxLAL is FDA-approved for three or four light treatments over a one-to-two-week period 17 to 21 days after surgery.8 The RxLAL recipient is also required to limit his or her UV light exposure for the duration of the fine-tuning phase by wearing polarized UV-blocking glasses both indoors and outdoors to ensure the adjusted refraction isn’t affected by ambient UV light.

“It’s very important that patients wear their UV protective glasses, which come in both clear and sunglass options,” says Dr. Thompson. “We start the adjustments at three weeks postop. Typically it’s three adjustments, at least 48 hours apart, so you can pretty much do a full adjustment with a Monday, Wednesday, Friday schedule. Then there are two lock-ins in the following week, and it’s finished.”

Setting patient expectations is important for these adjustment visits—which some surgeons worry could be onerous—since these visits aren’t brief. At each exam, patients will undergo refraction and measurements before the adjustments and dilation for five visits. “You’re doing two- or three-hour visits, and you want to plan accordingly,” Dr. Thompson says. “At the same time, patients are getting the vision they want for the rest of their life with a procedure that doesn’t touch the cornea, and without the risks associated with LASIK or PRK. It’s amazing when you hit your true refractive endpoint.”

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