Poor visual quality after cataract surgery

[erdpoyu]

I had PRK in 1996 for -10 OS and -12 OD.  Had cataract surgery OD June 2014 and a ZCBOO +27 monofocal Technis lens was implanted. Yag August 2014. Prior to cataract surgery, uncorrected 20/40 vision. Post cataract surgery 20/200. Immediately after cataract surgery noticed loss of detail and contrast, poor visual quality with low light including indoor light. Difficult night driving. Drops to constrict pupil did not help.
Can not see facial details inside areas even the size of my living room even with glasses. Dr. who did the cataract surgery stated that is because my "cornea is ruined" from the amount of PRK in 1996. I had retinal consult to R/O
any problems in that respect - he found things to be ok as far as he was concerned. Had much trouble with depth perception. Tried RGP lens but too uncomfortable and did not help lowlight vision. Had 2nd PRK in April 2015 with a different MD. Central cornea 413 pre-PRK and 383 post-PRK and about 20/30. Helped with depth perception, but not with details, contrast, and low light vision. March 2016 PRK regressed to 20/50. Prednisone taper got it back to 20/30 but IOL clouded again and had 2nd YAG April 2016. December 2016 vision is 20/40 - 20/50. Corneal specialist feels it could be do to high amount of corneal aberrations - feels topo-guided PRK may help visual quality. Also feels steep ablation zone maybe why it keeps regressing. I did see a 2nd retinal specialist and he felt the diameter of the IOL in relation to my high myopia maybe a factor - that some light is not refracted back to my retina as well as a larger diameter lens could do and that possibly an IOL exchange with larger diameter lens could help. Glaucoma  specialist does not feel its a glaucomatous field but possibly one time ON assault due to pressure during cataract surgery. She did note inf TI defects OD. My eye has had a sore, irritated feeling since the cataract surgery and red.

My questions are:                                                                                                                                                      ---By not doing IOL exchange that the retinal MD referred to, could the lack of light to the retina result in my brain shutting down vision to that eye or impair the the retina in some way neurologically speaking?
-Has anyone had experience with an IOL clouding twice?
-Could the IOL be reversed and is there any definitive way to tell?  I have been told that is not possible for it to be reversed and even if it were it would not matter with this type of lens. I did read on one site that this could impair scoptic vision even with this type of lens.
-I did have a UBM and was assured IOL is in place but am wondering
what could account for the inf TI defects and could it be determined from UBM if IOL is reversed?
-What are your opinions on topo-guided PRK in my case?
Thanks for any help

[JohnHaganMD]

First I have an observation. If your vision was 20/40 (best corrected meaning with the best pair of glasses you can be given) and after cataract surgery best corrected is 20/200 (note WITH glasses not without) then the problem is NOT the cornea since an uncomplicated cataract operation that takes 15-20 minutes does not damage or alter the cornea. So the cataract operation may have been too much for your cornea and it gave out or was damaged by the surgery.

--By not doing IOL exchange that the retinal MD referred to, could the lack of light to the retina result in my brain shutting down vision to that eye or impair the the retina in some way neurologically speaking? ANSWER: No it would have no effect on the retina. Also if that was a big part of the problem then when your pupil is small as in bright light or if they tried Alphagan-P drops on you then you should see much better. If you don't see better with small pupil likely not a problem.
-Has anyone had experience with an IOL clouding twice? ANSWER: The IOL doesn't cloud over. The membrane (posterior capsule) which is part of the person's natural lens turns cloudy. Very unusual to have to do a Yag capsulotomy twice. I do over a hundred yag capsulotomies a year and have not had to do one a second time in over 16 years.
-Could the IOL be reversed and is there any definitive way to tell?  I have been told that is not possible for it to be reversed and even if it were it would not matter with this type of lens. I did read on one site that this could impair scoptic vision even with this type of lens. ANSWER: Yes its possible the IOL could have been inserted backwards. It should be obvious by looking at it or there is a way they can look at certain images to confirm a proper orientation.
-I did have a UBM and was assured IOL is in place but am wondering ANSWER: What is UMB abbreviation?
what could account for the inf TI defects and could it be determined from UBM if IOL is reversed? What is TI?
-What are your opinions on topo-guided PRK in my case?
ANSWER:  Since the working hypothesis of your problems is damage from previous PRKs you should probably get one or 2 more consults from cornea surgeons who do that type of surgery. If your problem is irregular astigmatism and cornea aberations a ridgid contact lens fit over your cornea should pretty dramatically improve your vision. If it doesn't not likely more cornea surgery is going to be helpful.  
Thanks for any help

[erdpoyu]

Hi,
My uncorrected vision prior to cataract surgery was 20/40 and post cataract surgery 20/200 uncorrected.  The surgeon who did the cataract surgery said he had to do a YAG cap. three times on a 45 year old patient. He said young people are aggressive healers. I was 45 years old at the time and do not plan on ever returning to him. A corneal specialist stated I had surgery that I didn't need and that if I had any amount of cataract that this should have been an improvement.   I had noticed that street signs appeared darker at night and I was concerned that there may be some thing degenerative going on with my eye. The cataract surgeon said it was a cataract so I trusted him. He did say it would be harder to measure.  But I was not expecting it to be 200 feet off. Two months after the cataract surgery he told me about ORA and that "a buddy of his had one".  Big help at that time in the game.  
Are the haptics able to be seen in my eye at this point? As I understand it, they should be like a z not an s as in stop its in backwards. What are the certain images that can be used to check the orientation at this point?  When I have asked if it could be in the wrong way I don't get the impression that they take me seriously.  I have explained my vision was not like this prior to cataract surgery and have seriously wondered if this could be the cause. They look through the slit lamp and say its fine but I'm not sure if I'm just being told that.
UBM is ultrasound  biomicroscopy. TI is transillumination defects.
Thanks        

[JohnHaganMD]

I want to ask an ultra important questions. What is your vision corrected? Saying your vision was 20/40 uncorrected before surgery and 20/200 uncorrected after surgery is not helpful. First it doesn't say whether the uncorrected vision was at distance or near.  Second many people with myopia or after a very successful cataract surgery have uncorrected vision of 20/200 at near but read 20/20 without glasses and with a minus lens to correct their vision at distance see 20/20 there also. physicians are mainly worried about vision that does NOT improve with glasses. So please furnish your vision with glasses now. It's its good you don't need more surgery you need glasses.

[erdpoyu]

I'm  not sure what my corrected vision was prior to surgery - both the 20/40 and 20/200 are for distance. Corrected vision now is 20/25 to 20/30 for distance but still does not help with indoor or low light conditions. Details and contrast, facial features are a blur. Even the big E on the snellen chart has a haze around it like I'm looking through a mist. This was apparent right after cataract surgery - hence my concern that the lens could be reversed. I would feel better to know that I could rule this out somehow and stop trying to figure this out. Also to know that this would not happen to my left eye if I ever had cataract surgery on that eye.
Can the haptics be seen on a dilated exam with any certainty? My left eye is 20/20 distance and no cataract surgery.
I live north of Syracuse ,NY.  Is there anyone you would know of to recommend in this area?
Thanks

[JohnHaganMD]

I do not know anyone in your area but it requires a special skill set dealing with post operative problems. You might look into SUNY Dept of Ophthalmology seeing a cornea specialist.  This is an article on IOL that was reversed and did fine without replacing  http://www.scielo.br/pdf/abo/v75n6/a12v75n6.pdf  

[JohnHaganMD]

Also the research instrument that can be used to determine orientation of IOL is "Scheimpflug images"  It is not widely used in everyday practice and I have no experience with it.