Vision unclear after ICL surgery

[Jag737]

Goodmorning

On december 15th 2017, I had bilateral ICL implantation, for the correction of my myopia and asstigmatism. One day after surgery I had almost perfect vision in my right eye, but not in my left eye. Today, 10 days after surgery I still see blurry with my left eye (at all distances). In addition, my left eye feels relatively dry.

The strange thing is that when I bend my head forward (while looking straight ahead) the vision becomes clear in my left eye.

Does someone has a possible explanation for this ?


My prescription was:

right eye: -3.75D and -.75 D asstigmatism.
left eye: -3.75D and -1 D asstigmatism. In this eye I received a toric lens.

The lens used was the newest ICL: EVO+ICL    Version 5, with enhanced optic and aquaport. (surgery in europe)

(My eye doctor is not available between christmas and newyear. I will get in touch with him next year about this)

[JohnHaganMD]

When you move your head such as you described you change the shape of the eye and thus the residual glasses RX. Since your vision is blurry distance and near I suspect it has to do with the astigmatism part of your correction.  The ICL may be "off axis"  

[Jag737]

Doctor Hagan, thank you for replying.

Since my eye doctor is on christmas holiday this week I consulted with my optician to check if I indeed have a residual RX in my left eye. This seemed to be the case:

+0.5 D  -0.75 D at 18 degrees

What does this actually mean ? Is this just an off axis asstigmatism correction of my ICL ? In that case a simple rotation of the ICL may give me proper vision ?

Or is the entire lens (sphere + toric) fit wrong ?

(My left ICL : -3.75 D -1 D at 120 degrees)


I will get in touch with my eye doctor next week to discuss this.... But a heads-up would be appreciated if you have an opinion about this, doctor Hagan.


Thank you.

[Jag737]

correction:

My left ICL: -3.75 D -1D at 90 degrees

[JohnHaganMD]

Please don't use the word "simple" if it were simple you would not have this problem in the first place and its a known problem with any toric optical device (contact lens, glasses, IOL, ICL)  If your ICL was 'on axis" you would have no residual astigmatism as you had 1 diopter before surgery and the ICL has 1 D of correction.   Did the optician tell you what your vision was with this correction in front of your eye (eg 20/20 or metric 6/6/?)

[Jag737]

You're right: if it was simple this mismatch would not have happened.

The optician noted the following:

Without correction it was 20/25. With correction 20/16.

Although 20/25 is a huge improvement from baseline, details are still somehow blurry.

[JohnHaganMD]

So between now and when you see your surgeon concentrate on these, your own words "a huge improvement"   A thin pair of glasses with a RX like the optician found gets you better than 20/20, you are used to wearing glasses. Don't sacrifice acceptable in the quest of perfect.   Everytime the eye is opened there is risk of infection, bleeding, ending up worse than before the second procedure.

[Jag737]

Those are wise words.

I already wondered if the pros would outweigh the cons in this case, justifying a second intervention.

Thank you for your feedback, doctor Hagan.

[JohnHaganMD]

You are welcome and best of luck to you Jag

[Jag737]

Hello again dr. Hagan


Today I had the 1 month follow-up check, after having my ICL surgery.

As suspected, I have some residual asstigmatism in my left eye, which is causing some blur:

+0,5 D  -0,5D at 15 degrees

My vision is 20/25 uncorrected, and 20/16 corrected.

For my profession, as a commercial pilot, I do need 20/20 vision (corrected or uncorrected). The reason I had ICL surgery is to be independant of glasses in the cockpit.

My eye doctor proposed to do a single 'Limbal Relaxing Incision' to get rid of the asstigmatism. It should be a small procedure with very few drawbacks.

What are your thoughts about having (or not having) a LRI in my case ?

I hope to hear your pros/cons , if possible.

Thank you in advance.


Jag

[JohnHaganMD]

I don't think it's fair to say that LRI is a a procedure with few drawbacks and I would suggest you get a second opinion before you go down that road.  LRI is a manual cut that is not precise and it leaves a scar on the cornea.  Once the cornea is cut it no longer becomes possible to predict how rotation the ICL will effect vision. You are used to wearing glasses and your vision is much better now than before your surgery why not just wear glasses. If they fall off your vision is now good enough to fly without them.   What is your age? Sometime in your early 40's you will need glasses again for near "presbyopia"   If you do go this route you might want to consider femtosecond laser as its more predictable to correct astigmatism than LRI.

[Jag737]

Thanks dr. Hagan for sharing your opinion.

I am 33 years old.

It is paradoxical: one of the reasons I chose ICL over LASIK is that I liked the idea of leaving the corneal surface intact. Having a LRI would mean the opposite. On the other hand, my doc. said it is a very small procedure. I will get a second opinion about this, and wont make a rushed decision.

Do I have to wear glasses for this small residual refraction in daily life (outside the cockpit) ? It is my guess that having a + refraction mens my lens has to accommodate a bit the entire time to have a clear image. Does this constant accommodation wear my eye ?  


Thank you again dr. Hagan.

[JohnHaganMD]

That RX is very weak. Many people don't wear glasses at all for such a small error.  So it would be up to you whether you wish to wear glasses when not flying.  Wearing them a lot or wearing them a little will not affect the health of your eyes.

[Jag737]

Alright.

I booked an appointment for a second opinion, as you suggested. Unfortunately it takes 3 months before I can have that consultation.

In the meantime I did some research myself on google (scholar) and scrolled along some (scientific) papers, discussing treatment of residual asstigmatism after cataract/IOL surgery (not ICL surgery).

I read complete wound healing of the incision could take up to 6 months, and that it's normal an eye shifts (against the rule) another 0.25D of asstigmatism during this period. In my amateur opinion this might lower my 0,5D at 15 degrees of asstigmatism towards 0,25D,... which is negligible.

If my interpretation of this article is correct it is better to wait, and not undergo a LRI, to have better vision (required to fly commercially without glasses). After reading, I am not very found of this technique anyway (=more cutting).

I want to mention I did not forget what you said before: "don't sacrifice acceptable in the quest of perfect". At this stage I just want to be fully educated upon the options I have. I am not gonna rush myself into more sugery if that is not really required.

I am looking forward having that second opinion in 3 months. Do you mind making a last comment upon this ? Is it true that asstigmatism usually shifts another 0.25D in the following 6 months after surgery ?

I will close this post soon. Thank you your advice. Great that your are putting your time in helping people with their questions. Appreciate it !


Regards

Jag


https://www.healio.com/ophthalmology/optics/news/print/ocular-surgery-news/%7B400faff8-d029-4f11-b41f-c6d3f9292fa3%7D/managing-excessive-residual-astigmatism-after-toric-iol-implantation

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

Corneal astigmastim changes occur in the axis of the incision and how it changes the glasses RX will depend on whether the RX is written in plus + cylinders or minus - cylinder.   Most modern surgery is done with the incision temporally (towards ear) 9 oclock. ; many years ago it was done superiorly (at the top of the cornea or 12 oclock"   Thus modern surgery reduces  plus cylinder astigmatism near 180 degrees and increases plus cylinder near 90 degree.   With minus cylinder its just the opposite. So you need to know where your incision was and what the glasses RX is written in plus or minus cylinder

[Jag737]

I know the incision is done temporally (9 o'clock position). And the refraction is:

+0.5D  -0.5D at 15 degrees

Does this mean there is a tendency the asstigmatism will get less, or the contrary (=more) ?

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

Worse because the steep axis if vertical not horizontal. ( temporal incision make plus cylinder at 180 and minus cylinder at 90 better  (decreases)  This is not much cylinder though at all and would rarely warrant LRI or laser