Can iol explant/exchange be successful 4 months post cataract surgery?

[lawlipop]

I had cataract surgery on my left eye set to plano with a tecnis toric monofocal lens.  The iol was rotated on May 26.  I think the astigmatism in my left eye is still holding okay.  I do see ghosting or double images in letters sometimes, but not nearly as badly as it was before the iol was rotated to the correct axis.  My surgeon says it may because there is a lot of wrinkling in the posterior capsule which could be fixed later on with the YAG laser.  

Onto my present problem.  My right eye was done with a different surgeon that suggested I  have it set for mini monovision.  I was dumb and went along with it even after telling him that I had a lazy right eye and very dominant left eye.   He targeted -1.00 , but it came out to be -1.50 and has now settled down to -1.25.  It was done February 10 and I cannot get used to it.  

The surgeon that did my left eye set it for plano and thought that would help.  Well it has somewhat, but I just cannot stand it.  I have an appointment with my surgeon on Friday to speak with him about an explant/exchange targeting my right eye for plano to match the left eye.  I have/am trying progressive lens presently and still cannot adjust.  When looking near or intermediate I feel my eyes are fighting each other.  I know there are a lot of risks and the surgery can be challenging.  That said the surgeon I have does a lot of cataract surgeries (maybe 100 a month) although he says he has not done a lot of explants, but a while back, he said that he could do it.  He prefers to explant at 3 months, but said that he could do it at 4 or 5 months.  This Friday will be 4 months post surgery in my right eye.  I am going to ask him to put in a contact in the right eye to see if that helps more than the glasses, but I'm not sure I can put a contact in that eye everyday for the rest of my life.  I have anxiety about this and do not think I can stand to live like this forever.  I'm wondering if I have strabismus after reading about it.  When I was younger I do remember seeing double and kind of feel the same way now.
Of course, someone with strabismus should not have mini monovision because it can cause double images.  My eyes do not have a shifting deviation that can be seen.  However, my right eye is higher than the left eye and is more than most people have normally.

I really don't want lasik or prk because I've heard so many problems with those procedures and then those problems can even develop years later after the procedure which would make me worry for years on.  I'm leaning towards the explant.  Do you have any names of surgeons in the New Orleans LA area for second/third opinions?  I looked on aao.org and really don't see any in my area that are specific to explants.

Your thoughts please.  

[chazas]

I can't add too much to what Dr. Hagan has said, other than that PRK to correct a significant iol refractive error worked spectacularly well for me, so I wouldn't be too scared of it if that's what you decide on.

[JohnHaganMD]

Agree.

[lawlipop]

My vision is 20/20 in the LE that is at plano with no correction.  My vision in the RE is 20/30 uncorrected, but with the progressive eyeglasses it corrects to 20/20.
The prescription for it is
-1.25  +75  137.  

Before the cataract surgeries, I was farsighted at +1.50 in both eyes so would PKR or lasik work with my eyes.  Dr. Hagan, you suggested lasik instead of PRK.  Do you prefer lasik over PRK?  I know the procedure is easier, but what about the flap?  

I don't mind wearing glasses at all.  I just still don't feel right even with wearing them.  Do you think I may adjust more with time?      

[JohnHaganMD]

Yes I think there is a excellent change you will adjust to the glasses. Usually works best if you put them on and wear them all the time for a week or so till you are comfortable with them.  It took me 5-6 months to get use to my progressive no line bifocals when I went into them. I use LASIK to include PRK. Your surgeon can explain which one might work best for you.  Think about this and be sure you wear the contact lens as I have had several people do what you are thinking of and ended up very unhappy

[lawlipop]

I am quite terrified to have the iol exchange.  That is what you're talking about in your last sentence.  I will ask to try a contact lens and see how it works compared to the glasses.  I have worn progressive eyeglasses and never had a problem adjusting to them before the cataract surgery.  However, I do know that all of this "new" vision is going to be an adjustment for me.  It's strange to see things so bright and clear.  My concern was in missing my window to get the iol exchange before it is too late.  I guess that I can always choose much later on to get lasik or PRK, but I'd really not prefer to do that.  I know people who were not pleased with the result from that.  I'm sure you know a lot of people that were sorry that they had the iol exchange.  Thank you for your replies.

[JohnHaganMD]

Okay, hope it turns out well

[lawlipop]

I saw the dr today (Friday), but it was too late to try the contact.  I'm set to go Monday morning and try wearing it for the day to see if it helps.  I spoke with him about PRK or lasik, but the refraction has changed again today so it will need to be stable before that can be possible.  Today the refracted was prescription -.50 with no astigmatism in the right eye.  The left eye was +.50 with -1.00   180.   Uncorrected the vision in the right eye is 20/30 and the left eye is 20/20.  I'm still seeing double images, but not all the time.  In the morning my vision is very clear.  The images come when I am getting tired.  I'll post Monday to let you know how if the contact lens helps.  

[JohnHaganMD]

OK

[lawlipop]

Dr. Hagan,  Do you think that the left eye with +.50  -1.0  180 can be corrected to get rid of the astigmatism.  Right now reading is not comfortable.  I'm at the point of not knowing what to do.  I know it's still healing.  Today is day 16 after the rotation, but I really don't think it's going to get any better.  I wish I had never had the toric lens put in.  I think the spherical monofocal would have left me with less astigmatism than I have now.  Any advice?  

[JohnHaganMD]

You would not expect your reading vision to be clear with that Rx. What would be important is your distance uncorrected vision (20 feet) and I suspect that is rather good.  To read you would need anywhere between a +1.25 to +2.25 reading glass.  That RX is a distance RX not an intermediate or reading RX.

[lawlipop]

Dr. Hagan,
I have been to 2 strabismus doctors.  I have vertical hypertropia that was congenital due to one eye being higher than the other. Neither one thinks that the double vision and fluctuating vision I'm experiencing is the cause of the 1 diopter difference between my eyes.  The strabismus doctor I saw today at Ochsner thinks I'm having the double vision because of the astigmastism that may not be corrected by the progressive lens I have because he suspects I may have irregular astigmatism and that the toric lens in my dominant eye is the problem.  He has scheduled an appointment with a cataract ophthalmologist for me in the morning at Ochsner in New Orleans to see what his opinion may be.  The initial surgery was April 14 and a lens rotation was done on May 26.  If Dr. Shah does recommend an iol exchange, it will need to be done soon so I'm trying to get all the information and opinions that I can.  I have read other people on this board recommend Dr. Samuel Masket in Los Angeles and also Richard MacKool in New York.  I have Blue Cross insurance and will call to see if it is a nationwide plan, but I'm not sure if I can realistically get to see either one so far away.  Can you suggest someone to consult with that is closer to my hometown north of New Orleans, LA,  maybe perhaps Houston or Dallas.  Any advice will be appreciated.

[JohnHaganMD]

First of all what is your vision in each eye with and without glasses?  The problem is neither the first or second surgeon as both have reached their targeted post op refractions and your RX  LE plano (0.00) and RE -1.25 works fabulous for many people (mini-monofocal distance bias).  

For the sake of discussion let me assume your vision is 20/20 or close to that with glasses.  1. If your problem is due to strabismus explanting the IOL is not going to help. Most cataract surgeons don't do much of a strabismus exam and you will probably need to ask one of the surgeons to refer you to a strabismus Eye MD for their opinion.

2. Try a -1.25 contact in the LE even if just for 30 minutes in the surgeon's office. When you do this you will not your vision will not be clear unless you are 19-20 feet away from something. You will have to wear progressive no line bifocals RX Plano RE and LE  if you have a successful IOL exchange and the new RE RX is plano. So you are still wearing progressives and reading glasses.

3. You understand that rather than an IOL explant you are talking about an IOL exchange. You would need a new IOL put in your eye to change the RX from -1.25 to plano. You have the same risks of infection, bleeding, macula swelling and being left under or over corrected.

4. If you really do choose this option the risks are much lower doing a lasik on the RE rather than IOL exchange. Costs will be much lower also.

5. I do not know any ophthalmologists in New Orleans.  I would get a lot of opinions before you jump from the frying pan into the fire.

Please confirm that with -1.25 your RE sees 20/20 and your left eye 20/20 without glasses at distance.