Avatar universal

restor 3, pilocarpine, large pupils and cataract surgery

I had   cataract surgey and implant of Restor 3 lens  in Sept 2009, with improvement in distance (20/30) but very poor near vision (can't read AT ALL  uncorrected) and poor intermediate. I cancelled the 2nd planned cataract surgery for the other eye (currently 20./400 but can read well with that eye uncorrected and don't want to lose the reading ability. I am an avid reader and teacher of reading!.

The doctor (very well regarded in NY, famous for problems other doctors can't  fix) said problem is that my pupil is large and doesn't contract for near vision. We tried pilocarpine in Oct, 4x daily at 1 % solution, started this about 4 1/2 weeks after surgery.. My near and intermediate vision improved greatly but after 2 days,but  I had a severe reaction ( redness, tearing, pain, swollen eyelid) and the inflammation and pain continued until recently, was on steroidal antiinflammatory- prednisolone (which elevated eye pressure and created new problems). I still have pain which concerns me. I now take Systane several times  day for dry eye,, but still have pain since the pilocarpine in Oct, and as I said, the inflammation lingered for a long time but now is gone..

He wants me to go back on pilocarpine, but, lower dose, 2x daily and try again since it helped the near/intermediate vision..

I recently had another opinion and was told that some of his Restor 3 patients have have had problems like mine, that problem isn't with pupil size but with Restor 3, and this MD said he no longer uses it on patients.  He also counseled against pilocarpine, said I'd be trading near vision for diminished distance vision, plus pilocarpine can have other side effects.

Any information on Restor 3, which is fairly new? I have been following the threads, though which Restor is used isn't mentioned.

Any recommendations on using pilocarpine again ? I'm frightened since I had such a hard time, but it helped my near and intermediate vision for the 2 days I used it.. Side effects? Does it diminish distance vision? If that is true, then there is no gain-- the only benefit I got from the cataract surgery was improved distance vision.

Any information on pupil size and difficulty with cataract surgery? the doctor under whose care I am currently says I would have problems with all multifocal brands, not just Restor,and monofocal would have been even worse for near vision.  He recommends a YAG (I see him in a week) for opaque capsule, but I am afraid of being locked into the lens I have, Restor 3, if I do the YAG , as I know that makes any explant very problematical,but don't know if I have any options. The doctors I've seen think the capsule doesn't explain the problems with near visiion, but would clear up some of the distance  problems. Do other people have similar problems with pupil size? THis is all new to me-- never told before there was a problem with pupil size.

The 2nd MD said to live with what I have-- distance  vision in the eye that has the Restor, and near vision with the eye that had the cataract, as I can read with that eye without glasses ( before cataarct surgery,I used to read with both eyes, with a mild RX for glasses, or  sometimes no glasses). That cataract is getting worse over the last few months  (now 20/400!) and don't know if I can postpone surgery indefinitely, but right now I CAN READ with that eye, and I don't want to lose that.

What should I do about intermediate vision? It is very poor- difficulty with computer, shopping, cooking.

The doctors don't seem to think glasses or contacts would help, as my eyes are too divergent and the brain can't accommodate. Any thoughts/ experiences with that?

also, in Nov, i was having so much eye pain, I decided  to go off all medications, which was  a mistake, as i went off prednisolone 4x daily  to zero, and had a rebound reaction. It increased the inflammation, and  am now light sensitive, which I never was before. I read the insert in the prednisolone box and it said to stop taking prednisolone if there is increased pain, so I did-- I didn't know it had to be tapered off gradually. I am now tapering it off but am still light sensitive. Might the light sensitivity diminish over time? I was experimenting with light bulbs that simulate natural light, which actually helped my reading a great deal, but it was the same weekend that I had stopped taking the prednisolone
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Avatar universal
The ReStor is a bifocal lens, with near and distance vision zones.  There is NO intermediate vision zone in a ReStor lens, so intermediate vision is never great.  Apparently, your pupil does not contract enough for you to access the near vision zone of the ReStor.  By contrast, a monofocal lens has only one vision zone.  If a monofocal lens were set for distance vision, you would not be able to read without glasses.  (However, with glasses your reading ability would be excellent, regardless of the size of your pupils.)  I believe that this is what your doctor referred to by his comment about near vision "problems" with a monofocal lens.  (I suggest that you call his office to clarify this.  I think you misunderstood him.)

To sum up your current situation, you have poor near and intermediate vision with your ReStor, and your distance vision is 20/30.  This suggests that in addition to the problems with your large pupils, the power of your ReStor may be slightly off.

Before you go ahead with the Yag, please be absolutely certain that you don't want to exchange the ReStor for a monofocal IOL.  A Yag can be done at any time--it is not an emergency.

Please re-post your questions as a new thread so that you can get feedback from a forum M.D.  

Helpful - 0
Avatar universal
I am wondering about your response to my further questions--

what is your experience with patients with large pupils and difficulties after cataract surgery? My MD is very adamant that the large pupils  are what caused my problem with the cataract surgery, that any brand lens, not just Restor,  would have  led to this  inability to read/near vision problems , and says a monofocal lens would have been even worse. Yet Jodi has responded that she herself has large pupils and does well with a monofocal.

Jodi- my distance vision with the Restor 3 is 20/30 uncorrected, 20/25 corrected. I am scheduled for a YAG inext Monday-- all the consultants agree there is an opaque capsule and haze and recommend a YAG- my fear is that it locks me into the lens I have and there are still uncertainties.

Dr.O--If I do go back on pilocarpine, as my MD recommends, might it diminish my distance vision if my pupils are fixed at a contracted position, even if it helps near vision? This is another concern- don't want to lose what I gained from the cataract surgery, however problematic it has been. The 2nd MD I saw said that it could happen, and actually offered  to call my doctor with that opinion! I'm confused and fearful about the pilocarpine, though it did help me for the 2 days I tpook it- just was too high a dose (4x daily) and led to reactive inflammation, tearing, swelling and the inflammation lingered for months.

What does Dr. O recommend for intermediate vision?
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Avatar universal
Perhaps your pupil doesn't constrict enough for you to access the near vision zone on your ReStor lens.  In this case, your ReStor is essentially functioning as a monofocal (distance) lens.  If your distance vision in your ReStor eye is excellent (and this is your dominant eye), a monofocal IOL in your second eye set for intermediate vision would give you a larger range of focus.  You would only need glasses for prolonged reading or seeing small print.

If your distance vision with your ReStor eye is less than excellent, please consider explanting it.  I can't think of any reason for you to get a ReStor in your second eye.

Having large pupils is actually an advantage if you have aspheric monofocal lenses.  Even if both eyes were set for distance vision with monofocal IOLs, progressive glasses would give you excellent vision at all distances.  You would not need glasses for driving, watching movies, etc.

If Dr. O doesn't respond to your questions, try posting again in a new thread.  
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Avatar universal
I thank Dr. O and Jodie for responding.
I want to understand more about large pupils and difficulties with cataract surgery.
My doctor is very adamant that my problem is from large pupils, and that monofocals would have made near vision/reading even worse. If I understand correctly, Josie says that she has large pupils and that the monofocal was not a problem, though probably I would need reading glasses.
Right now, with the eye that had the cataract surgery with Restor 3, I cannot read at all uncorrected, everything looks like brush strokes and squiggles, not letters, but I have experimented with readers at different strengths (2.75, 3.25, 3.50), all of which help.However,, because of the cataract in the other eye, the doctor says I can't tolerate/accommodate  glasses  for both eyes because my eyes are too divergent. I've been alternating between the reader in that eye, but more often, and more comfortably, using the other eye (with the cataract). to read.

Dr O and Jodie, are you both saying that I'd be better off with a monofocal lens in the 2nd eye, that has not yet been operated on--as  my doctor the opposite.????
  I can read now in 2nd  eye, despite the cataract of 20/400, without glasses, and I am fearful of losing this ability and winding up worse.

Dr O, might pilocarpine diminish my distance vision, as the 2nd doctor told me? What is your experience with that? I don't want to trade distance for reading, as distance vision was the one benefit I got from the cataract surgery.. I heard what Jodie recommends, and am thinking about all options.

I thank both of you again for responding.
Helpful - 0
Avatar universal
Why does your current doctor think that you would have a problem with a monofocal lens?  Aspheric monofocal lenses work fine with my large pupils.  In your place, I'd opt to get the ReStor explanted and replaced with a monofocal IOL.  I'd probably go for a mini-monovision correction (distance vision in dominant eye, intermediate vision in non-dominant eye) and wear glasses for prolonged reading.  And I'd lose the pilo.
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Avatar universal
Thank you for your reply. Could pilocarpine diminish distance vision by keeping my pupils contracted?

What is your experience with larger pupils? Do patients with larger pupils have different responses to and problems with  cataract surgery? The MD said I would have had problems with all multifocal lenses, and that monofocal would have been even worse.

What to do about intermediate vision-- a problem in both eyes.?

What to do about the significant cataract ion the unoperated eye, (20/400) but with which I read well, without glasses? Do nothing? If  I eventually have surgery on that eye, what kind of lens?

What about glasses/contacts mix? Might that help?

Should I keep the Restor 3 or have an explant? The MD thinks I would have problems with anything (see comment above) but I don't know if that's correct.. He has a reputation for "fixing" cataract surgery  of oyher doctors that hasn't gone well, but  onetheless, still might not be correct in my case.
Helpful - 0
711220 tn?1251891127
I rarely implant multifocal.  I have implanted them from 2000.  Surgery can be prefect and patients have problems.  My preferred premium IOL is Crystalens.

I would try pilo 1% or 1/2 %.

Dr. O.
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