Unilateral Cataract - Plano or Not?

[Visible]

hi, my mother, in her 60s, is scheduled for cataract surgery on monday.  a longstanding issue is whether to have her one cataract eye corrected to distance plano with the monofocal IOL or -2.0 diopter to reduce the anisometropia that follows.  both eyes are roughly -6.0 diopter and the other eye is relatively clear.

i believe the surgeon would prefer plano for himself but in a case where the other eye may not otherwise develop an opaque cataract for a while, it seems that the imbalance of one plano eye might be too great to suffer?

if given that she will need glasses for at least the one eye, and perhaps both for reading, might a -2.0 diopter correction be a good choice?

i realize there is no clear cut answer, but i would like to hear more voices or experience to help with the decision.  a search on the web turns up less than handful of mentions of this issue and no discussion at all. thanks.

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

Hello Visible, You are a quick study. Let me clarify. If your mother has never used mono-vision before, as a generalization she is not a good candidate for it.

Second. In my sugical practice I have never put an IOL in the eye to leave a person - 6.00. Speaking theoritically, I would aim for -1.00 to -2.00 on the first eye. EDUCATE the person strongly that their eyes will not work together after the operation and assuming the person is very happy with the first eye, the second eye has some slight degree of cataract on the second eye, would tell the person they likely will want or need to have the second eye operated on 4-6 weeks after the first eye ("when you're extremely happy with the result of your surgery") on the second eye I would give the patient the choice of "a little better at distance or a little better at near".

If the patient was very young and didn't have a cataract on the second eye I would recommend LASIK on that eye.

Your mom sounds like she's in good hands. This situation comes up all the time. The important thing is to discuss the problems before surgery.

JCH III MD

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

Thanks for the thanks. Hope all goes well.

JCH III MD

[Visible]

Thanks for the clarification.  I understand the surgeon's side of the story better now.  Your aim is to get the best vision for the patient.  Both eyes are part of the plan.

I'll report back in a few weeks, and thanks for taking your time to educate to patients not your own.

[Visible]

Thanks for the thoughtful replies.

We are indeed cutting it close.  Cataract surgery options are a multidimensional can of worms if a layperson chooses to look.

It seems that a 4 diopter difference would be too great, 2 diopters seems to be an acceptable difference?  So replace the lense with a -4.00 diopter IOL then a -2.00 diopter IOL for the other eye, if and when the time comes?

I assumed that when our doctor said "0" that he really meant -0.5 or some other margin of safety.  He's at a major eye institution... but I will check to make sure what he means by it.

Dr Hagan's discussion of monovision -- is that meant to be a parenthetical suggestion of an option choice my mother might consider or to say that unequal lense powers and the use of contacts opens the door to monovision?  If I'm mistaken, would someone please connect the dots for me?  (The doctor never mentioned it; my mom has never regularly worn contacts; and i feel it might require too much effort or experience to get just right.)

About the "relative clarity" of the fellow eye -- my understanding of your remarks is that although fellow eye is not indicated with cataract, the opacity of that lense due to aging will be much evident in contrast to the IOL vision, and that she would welcome followup lense replacement.  This would be true even if she it just got a matching IOL and didn't suffer problems caused by anisometropia.

I'll try to get all parties on the same page tomorrow; if not tomorrow, then Monday morning pre-op.

For someone not too concerned with being rid of glasses for a distance (far), a matching IOL of -6.00 seems to be the conservative choice?

Thanks.

[JodieJ]

I think that having one eye -6D and the other -2D would be too great a differnce to have comfortable vision with glasses.  Unless your mother were able to wear a contact lens, I don't think that this would work.  Maybe Dr. Hagan as an opinion about this.

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

Hello Visible,  You're cutting it close (pun intended) so to speak. Surgery on Monday and still your not made up your mind!

Plano in the operated eye and -6.0 in the unoperated eye, in my experience, won't work at all. Too much difference to be comfortable, too much to correct even with glasses or contact lens.

As many posts here will attest it's not an exact science trying to leave an eye "zero or plano" at distance. Depending on a number of factors she could be left under or over corrected. We don't like to leave eyes farsighted after surgery. Then there is no distance (far, mid, near) that's clear without glasses. If the eye is a little nearsighted then without glasses mid vision (shaving, make-up, computer, shopping) is often clear.

If you monther has never tried monovision (with contact lens or with natural unequal refractive errors) its important to know many people don't like it (you don't see as well because only one eye is used for distance and the other for near, mid range is often out of focus and depth perception is reduced, glasses are often not well tolerated and it can be expensive to "fix").  A few people love it especially those that have used mono-vision with contacts for decades.

All things considered shooting for a post operative refractive error of -1.00 to -2.00 would allow for more safety room.

I'm not sure what you mean by the other eye being "relatively" clear.  In a very young patient one option would be to do LASIK on the non-cataractous eye to balance the two off.

In her 60's with some clouding of the lens its likely that there is a cataract only just not as big.

In most cases patients having modern cataract surgery are usually so pleased with the experience that they can't wait to have the second eye done (this trouble forum is not a place that happy cataract patients go to post).  What I'm saying is that it is likely the OTHER eye will bother her a lot more after the first is fixed and a good result obtained. In that case she will be much more inclined to have the second eye done sooner as opposed to later.

You should try and discuss this again with the surgeon tomorrow and be sure everyone understands the the target refraction is and the problems of monovision and aneisometrophia (large unequal refractive errors).

Good luck. It's wonderful we have such choices. Such has not been the case 20 years ago.

JCH III MD Eye Physician and Surgeon

[Visible]

unfortunately, there's no edit function.  here's my hopefully one and last rewrite of the original query:

hi, my mother, in her 60s, is scheduled for cataract surgery on monday.  a longstanding issue is whether to have her one cataract eye corrected to distance plano with the monofocal IOL or made to match with the myopic of the fellow eye to reduce the anisometropia that follows.  both eyes are roughly -6.0 diopter, with mild astigmatism, and the fellow eye is relatively clear, so it may not need surgery for a few years.  (the unilateral cataract is not trauma induced that we know of.)

the surgeon prefers plano for himself but acknowledges that with anisometropia the patient would find vision so much better through the corrected plano eye, that the patient would soon opt for surgery on the other eye.  (i believe the doctor motivated by a personal preference of clear vision or symmetry over commercial interest.  he's not the procedure pushy kind.)  my mom would rather not have the fellow eye operated sooner than otherwise necessary just to match the first.

a second ophthalmologist she consulted recommended a -2.0 diopter correction, as a compromise step towards perfect far vision?

what's the experience of having one plano corrected eye and a -6.0 diopter uncorrected eye?  is wearing eye glasses for this combination (one lense cosmetic?) less comfortable an experience than to have both eyes matched?  what about with one eye corrected to -2.0 diopter?

i realize there is no clear cut answer, but i would like to hear more voices or experience to help with the decision.  a search on the web turns up less than handful of mentions of this issue and no meainingful discussion at all. thanks.