Vision problems after 6-months post-op of multifocal lenses

[CKLG]

To: Michael J Kutryb, MD
Dr. Kutryb, I have read your replies to other patients and found them very thorough.  I have ReZoom in my right eye & ReSTor in my left implanted last October (sole decision made by my eye surgeon).  I am having many disappointments and complications as you can read from my post above.  Since my eye surgeon is not friendly or helpful and it takes a long waiting period for setting up an appointment, would you be able to answer some of my questions & concerns:
1) I don't know why the ReZoom lens is not giving me the "claimed' intermediate vision.  
(2) I don't know why after 6-months post-op my distant vision is not as sharp & focussed as before (both lenses).
(3) I don't understand why as soon as I am indoor I am having spotty misty vision & seeing ghosting with my ReZoom lens.
(3) I don't understand why after 6 months my glare/halos doesn't diminish a bit
(4) I don't understand what causes the most annoying flickering light reflections in the right side of the ReZoom lens when I blink under certain angle of any artifical lights - even in a room when facing a window!  Is this a reflection of the lens itself?  Will it go away or is it permanent (which means I am doomed for life!!!)?
(5) I don't understand why having this flickering light reflections for a while (such as sitting in a bus with all the neon lights above) will give my eye pressure & discomfort (I would even use the word pain & side headache).
(6) I don't know why I am seeing floaters since February - is it because my eyes are strained, traumatized & I am too stressful?  
(7) I don't understand why I have developed capsular fibrosis so soon when my eyes were healthy and never had any problems except the initial stage of cataract before surgery.

My eye surgeon suggested I have my existing lenses explanted and replaced with the Tecnis monofocal lenses.  I am extremely nervous and afraid of the significant risks involved (and given my luck with the first surgery!).  He also suggested a YAG capsulotomy for my capsulor fibrosis if I choose not to have my lenses explanted.  But there are risks involved with this treatment, too, such as RETINA DETACHMENT, right? How long can the capsule bag hold a lens if it has a hole in it????

Sorry for this long email but I am very depressed and desperate with my eye condition.  Thanks for your patience and look forward to your reply.
CKLG

[SoftwareDeveloper]

re: "or is the wrong size"

The lens doesn't come in different sizes, it is one size fits all for an  IOL model at the moment. When the patch was removed, did you tell them about the issue, did they check to see if the lens was properly centered at that time? Usually as soon as they remove the patch they would check the placement of the lens and should have told you if they saw something wrong with it. Or did they have you take off the patch yourself and you haven't had a postop check yet after that?

I am guessing you'll have a postop at one week, but if you are concerned you could try to get in sooner, and they can confirm the placement of the lens. If it isn't centered (and movement in the initial postop period is possible even if not usual), the odds are good they can center it, so I wouldn't worry unless they discover some rare issue preventing that.

Unfortunately  as you presumably understand from this thread, even iwth a properly place lens, some people do have a problem seeing the edge of a lens. Most who do will learn to tune it out. If they can't, there are options they can consider, such as a piggy back lens or lens exchange, as you'll read about in the links above or if you search for information on negative dysphotopsias.

Did you have astigmatism that wasn't treated perhaps which might account for the blur? If the lens isn't properly placed that could account for the poor vision. Alternatively,  It sounds like you are saying all distances are blurry, or is there an intermediate range thats clear? I'm just speculating  perhaps they didn't hit the refraction target. (if you were left hyperopic then perhaps the distance peak for the lens  is too far out, and the near peak is repositioned at intermediate).  I don't know myself how often surgical issues like swelling might interfere the first few days and whether or not that indicates a problem the doctor needs to treat, perhaps an eye doc will chime in, but I'm guessing your doctor's staff could tell you if you don't get enough of an answer on here.

With the Symfony IOL my distance vision was good from the time the bandage came off, and the near came and went for a day or so but was fine by a couple of days after. I don't know if that is typical, but I get the impression most people have fairly decent vision within a couple of days, even if it takes longer with a multifocal sometimes for better quality near to come in.

[khick]

I just had cataract surgery and the Tecnis Multifocal 3.25 lens inplanted in my right eye a few days ago. Immediately after the patch was removed I was seeing the edge of the lens in my right peripheral vision. It is very bothersome to me and I am wondering if the lens has moved, wasn't placed properly, or is the wrong size? I don't think I will be able to live with this effect. Also a second question, how long should it take for my vision to clear in this eye after surgery? My vision up close and at distance remains blurry 3 days post op.

[CBCT]

Yes, I know.  My replacement lenses are in the sulcus.  Another reason to avoid YAG when considering an exchange is the fact that every surgery, whether by blade or laser, increases the risk of retinal tear.  Been there, done that too.

[SoftwareDeveloper]

re: "Dr. Sam Masket in LA"

Yup, he was the author of one of the articles I linked to above:
http://crstoday.com/2014/05/solving-the-problem-of-negative-dysphotopsia
Dr. Holladay was also mentioned prominently in some articles on the topic (and on many other cataract surgery related topics) and is in Texas, but seems to have retired from clinical practice:
http://www.hicsoap.com/biography.php

Yes, it is best to avoid a YAG if possible. The only reason to consider it would be   if a surgeon considers there to be high enough odds it will resolve the problem that its worth the risk. Obviously sometimes they do decide its worth the risk, given they comment on using a YAG as a treatment option. I gather that usually (though I don't know if its always the case) the main issue with a lens exchange after a YAG is they usually can't implant a replacement lens in the capsular bag, but need to place it outside the bag in the sulcus. Most lenses are designed for placement in the bag, so that limits the options for a replacement lens choice.

[CBCT]

If you are considering a lens exchange, don't have a YAG.  It seriously complicates further surgery.
BTW, Sam Masket in LA is an expert on Positive Dysphotopsia.

[SoftwareDeveloper]

I am assuming these flashing arcs have been there all along, rather than being a new symptom? (a new symptom might indicate something like retinal detachment, though its odd that'd be in both eyes). They refer to a visual glitche like this generically as a dysphotopsia. While they are more common with multifocal IOLs, they do happen with monofocal IOLs also. For instance some relate to reflections off the edge of a lens, which has nothing to do with whether the lens is a multifocal (but might potentially be helped with a different edge design).

Fortunately most go away with time, so unfortunately that means they prefer you to wait before treatment to avoid the risks of a new surgery.

There are approaches other than lens swaps that they consider, like a YAG procedure or adding a 2nd  piggyback lens:

http://www.eyeworld.org/article-understanding-positive-dysphotopsia
"With both positive and negative dysphotopsia, Nd:YAG removal of the nasal capsule overlying the IOL may be helpful, and secondary piggyback silicone IOLs with rounded edges in most cases will eliminate the symptoms."

As a clip further below notes, it is also possible that drops to either constrict or dilate the eye (depending on the cause of the issue) might provide some temporary reduction of the problem.

The cause of the dysphotopisa (if it can be determined) may impact what treatment option is best (or what lens replacement lens, or piggy back lens, to consider). Your description doesn't match exactly the usual keywords they use (it may be a combination of them), here is an old overview article:

http://www.reviewofophthalmology.com/content/d/features/i/1320/c/25409/

You don't mention when these symptoms occur (e.g. all the time, only in bright light, only at night, when looking far, close, etc) and the description doesn't quite match the usual phrases used. This article mentions one I hadn't heard of, a "Maddox rod effect", which I see elsewhere described as a line of glare (though I hadn't looked into exactly what they mean that looks like, or whether it   it flashes to match your "flashing arc" or is persistent, just throwing out something to research):

http://crstoday.com/2014/05/solving-the-problem-of-negative-dysphotopsia
"Dysphotopsias represent subjective and undesired optical images that are associated with uncomplicated cataract surgery. In essence, positive and negative dysphotopsias (PD and ND) are unanticipated photic consequences. Patients describe PD as streaks and arcs of light, central light flashes, and starbursts. They describe ND as a temporal dark shadow similar to the effect of wearing horse blinders.
Additionally, patients may notice a Maddox rod effect  (with point sources of light) from striae in the posterior capsule; this undesired optical phenomenon is not specific to any IOL and may be managed by a laser capsulotomy, as necessary....

ND is not as well understood as PD. Interestingly, PD symptoms may improve with pharmacologic pupillary constriction, but the opposite is true for ND, which almost invariably improves with pupillary dilation. "

This was where I saw it described as a line of glare:

http://webeye.ophth.uiowa.edu/eyeforum/cases/191-maddox-rod-effect.htm
"The patient describes a line of glare, which is causing a Maddox rod effect, and corresponds to the fold in the posterior capsule in the right eye.  "