Post Cateract IOL Enlarged Pupil & Eyelid Weakness

[paul042]

4 weeks ago I had cateract surgery in my right eye and had an IOL implant. At 46 years old I was classified as young for the issue to come up.  Although none of the typical reasons for early development seemed to apply, we decided to go ahead with the surgery.  My presecreptio was -9.5 going into the surgery and the doc aimed for plano. As it turns out the technician mis-measured my eye and the vision ended up at -2.5.  They say this was the largest 'miss' they have had in over 6 years. As a result, I still need to wear a contact in my right eye since the -2.5 is not clear enough for long-term vision and since my left prescription is -8.0 and glasses are not an option.  In addition to also developing a 'magnified' effect in my right eye for close vision, the pupil size in my right eye is now significantly larger than my left, and the eyelid does not open as much as it used to.  I am no longer on any post-op drops.  Although I understand the operation had risks, I definately did not expect such a noticable change in the appearance of the eye, and am concerned that the pupil difference and eyelid weakness may be permanent. All in all at this point the surgery has been a big disappointment.  I have my one month post-op with the surgeon later this week.  Has anyone experienced such symptoms after surgery and what have been the long-term results?

[paul042]

Thanks for your reply.  You have been very helpful.

[2ndsight]

my surgery was around 10 days before yours. I would say it's gotten a lot better over the last 2-3 weeks, but sometimes it comes back. Try experimenting with different reading glasses, bifocals, I found some inexpensive ones online. It helped me to go out and jog and do other physical things and realize my mind was also "magnifying" the differences. One of the techs in my surgeon's office said some people adjust, others end up having the other eye done to have better balance.

[paul042]

Thanks for the comments.  I spoke with my Optomitrist today, and she said virtually the same thing.  She thought it would get better over time as the brain readjusts to the magnified effect in the right eye.  Also though maybe readers would help.  
How long did it take you before you stopped noticing a big difference?  The imbalance in my depth perception is driving me nuts!

[2ndsight]

because you are wearing a -7.50 contact lens in one eye and the other eye is corrected to -1.00 with the IOL, your two eyes are not the same refractively I think is what it is called, Dr Hagan could explain this more accurately.

I had something like this because I wear a -6.50 lens in my unoperated eye but it only seems to affect things at certain close distances, maybe 4-6 feet. I have gotten used to it to a great extent and hardly notice it now but when it would bother me I would put on a pair of 1.25 bifocals or the progressive reading glasses I now have. Dr Hagan told me in a post I wrote about it that I could also try taking the contact lens prescription down and be more nearsighted in the contact lens eye and it might help, you could try asking your doctor. I think this is partly why people are told they should get surgery in both eyes but like you my left eye sees 20/20 with the contact lens.

[paul042]

It's been 7 weeks now since surgury in right eye.  Pupil difference has lessoned somewhat, so I'm hopeful it will continue to even out over time.  Another issue that has continued though is one that I'm hoping you have some experience with and could offer advice.  I continue to work with my optimitrist on this as well.  Specifically, prior to surgery both eyes were >-7.75.  When the cateract was removed from my right eye we hoped for plano with the IOL, initial post surgery was measured at -2.5, but after a month I ended up at -1.0.  Not too bad, and I am wearing a thin contact lens to correct the right eye, and was re-prescribed a -7.50 in my left.  The issue is that my right eye (one with IOL), although pretty clear now, continues to 'magnify' things and they appear larger than out of my left. I'd thought perhaps it would adjust over time, but the imbalance continues to causes me to feel somewhat disorented and dizzy.  The odd thing is that individually both eyes are clear.  However, when both eyes are open they don't seem to be working together that well.  Based on your experience, is this something that will work itself out over time, or should I be asking my optimitrist/surgeon for alternative approaches?  Thanks for the insight.  

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

Just do a Google search of "ptosis and cataract surgery" and "dilated pupil and cataract surgery"

One study on droopy eyelid I remember was by Paul Arnold MD and appeared in the Journal of the American Cataract and Refractive Surgery Society.

JCH III MD

[paul042]

Thanks again for your thoughts.  I'll wait it out for awhile and see how things go.  I'll post back in a month or two to (hopefully) close the loop and offer hope for others who may find themselves in a similar situation.
Only odd thing thing is that my surgeoun seemed baffled by both the pupil difference and the eyelid weakness.  Given that he has done thousands of these operations that made me nervous that this was not something that was common at all.  Based on your experience it sounds like you have seen it many times before, so I appreciate your advice.

[paul042]

Thanks for your first hand insight.  It is good to hear that perhaps things will take care of themselves in time, and I'm glad your situation seems to have worked itself out. It's been 4 weeks now, but I'll try to be patient and see how it goes.  I hope everything goes well for you.  

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

Yes I would recommend waiting it out. My surgical experience is >11,000 cataract/IOLs.  Dilated pupil post op and droopy lid (ptosis) are both very common. Any literature search will pull of 100s of published papers on the subject.

Both are much less common now than in the large incision, intracapsular surgery of the early and middle 70's.

You might ask your surgeon if retrobulbar or peribulbar "injection" anesthesia was used as dilated pupil ismore common after that type of anesthesia than so called "needle-less" topical anesthesia (please note that not all cases can be done under topical). Also incidence is higher with elevated pressure in the eye post operative.

Ptosis is much less common due to faster operations and gentler lid holder-openers (speculums) and no longer using superior rectus bridle sutures.

I would not consider any surgeryon the lid until you are 4-6 months post op and I would hold out hope that the pupil will improve also.

JCH III MD

[2ndsight]

Dear Paul, you are not alone in these issues. I had a Crystalens implant in my right eye 6 weeks ago and still have some disparity between my two eyelids, also my pupils were not identical for awhile either, the operated eye was first larger, then smaller, now they have gotten more equal. I came out of the surgery with good distance vision but my astigmatism which was very minor is worse now so I am getting reading glasses with astigmatism correction (extra money which I had not planned on spending) SO do not despair none of this is an exact science.

[paul042]

Dr Hagan; I had my one month follow-up today, and the surgeon said he was not sure why my pupil would now be larger in the operated eye.  He said the drops I am on (Omnipred) do not cause pupil dilation. He noted that they did not stretch the pupil during the surgery, but it was dilated.  He also had no answer as to why the eyelid now does not open quite as far as the left eye either.  Given that they did not stretch the pupil and it is not caused by the drops, would you still recommend 'waiting it out' to see if these issues correct over time (and for how long) or is there some other path you would follow?
Thank you for your sound advice!

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

-

[paul042]

Thanks.  Since my left eye is fine I have no need to do anything to that eye hopefully for many many years. I'll wait 2-3 months as you suggest and then see how things are at that time.  Hopefully the eyelid returns to normal and the IOL irritation goes away.  Then, if the only issue that remains at that time is the pupil size we'll figure out if anything can be done then, or if it is just an annoyance that cannot be adjusted.  Given the not so great outcome (at least so far) of the IOL implant in my right eye I do not want to do anything with my left unless/until it becomes absolutely necessary.

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

Its possible that you might be using drops that will dilate the pupil some (especially if they have  red top).  If the pupil doesn't dilate well at surgery techniques or instruments have to be used to dilate it as the cataract is taken out through the pupil. Sometimes the pupil remains stretched and is permanently larger than the other. However afterr the second eye is done they usually are about the same size. The problem usually is only worrisome if the pupil does not constrict or is massively larger than normal.

JCH IIMD

[paul042]

Thanks for the comments.  I'm glad to hear that there may be improvement down the road with the eyelid, so I'll wait and see.  What are your thoughts about the right (operated) pupil size now being larger than the left?  Is this something that generally works itself out too are do you think that will be more of a long lasting effect?  
Thanks very much for your informed response.  It has been difficult to get a clear response from my surgeon, so your insight is very helpful.

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

Prediciting post op IOL problems is not an exact science as may discussions here and a search of the internet will confirm. Moreover the forumlas are much less accuate for very short eyes or very long eyes as yours is. So a -.2.50 does not mean that you were measured wrong.

Don't despair just yet. As your surgeon but some drooping of the eyelid is normal with surgery (may be due to the steroids or a protective effect) and usually has cleared 2-3 months after surgery.

You would expect a magnified  view for reading as you are now less myopic. Myopic glasses or contacts make things look smaller.

If you do not have your contacts or glasses on then your operated eye will have better vision than the left eye and reading vision should be quite good.

If you were Plano at distance (no need for glasses) your eyes would not work together, glasses would likely not work and you would still need glasses AND contacts.

I have many similiar patients that ASKED to be left about -2.50 after surgery to read without glasses.

The right eye can be made less myopic and moved to PLANO  if you want with lasik down the road.

Hang in there. I think you'll be much happier in a month or two.

JCH III MD