Astigmatism Correction After Cataract Surgery
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Does anyone have experience with having astigmatism corrected after cataract surgery? Due to my surgeon's reluctance to recommend a toric lens to correct my astigmatism I am expecting to be left with higher than acceptable astigmatism after my upcoming surgery. And, in addition he tells me that it is irregular astigmatism with is harder to correct, and the reason for a reluctance to use a toric lens. These are the surgical reduction methods I am aware of:
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LRI - Manual limbal relaxing incisions is a older technology and seems to be used less and less. My surgeon says he does not do it any longer due to his inability to get predictable results. He recommends a laser procedure instead.
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Laser-assisted in-situ keratomileusis (LASIK) - This is the most common laser method and would seem to be suitable for reducing astigmatism only.
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Photorefractive keratectomy (PRK) - This method is a little more invasive, requiring a longer recovery period, but seems also to be suitable.
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Small-incision lenticule extraction (SMILE) - This is a newer version of the LASIK, but from my initial research may not be all that suitable for smaller amounts of astigmatism. I am expecting about 1 D.
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Any thoughts you may have on these methods would be appreciated?
0 likes, 32 replies
RonAKA
Edited
I got a call back today from the clinic that did the in person consult with detailed measurements. They basically said they cannot predictably increase myopia with laser. This seems to be at odds with many claims that up to +5 D hyperopia can be corrected with Lasik. To correct +5 D you would have to go 5 D in the myopic direction. Perhaps the key is "predictably". I guess if someone is at +5 D and you are targeting 0.0 D and miss by 1 D they may be still happy. I am at -1.0 to -1.25 D and want to accurately go to -1.5 D, which requires a lot of precision. I remember asking my cataract surgeon about the ability to make small changes and his response was that it was much easier to make small changes than to make big ones. But, he is not a laser specialist. He only does cataract surgery.
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I found one article that does acknowledge that correction of hyperopia (movement in myopic direction) is more difficult. A quote:
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"...the treatment of hyperopia continues to pose a challenge to many surgeons due to reports of unfavorable outcomes, including refractive regression, undercorrection, and loss of corrected distance visual acuity (CDVA) [1, 2]. The correction of hyperopia is considered more difficult because excimer laser photoablation must induce flattening in the corneal periphery with concomitant steepening of the central optical zone, in comparison to direct flattening in the center of the cornea for myopic patients. The technique requires larger ablation zones and accurate centration for uniform delivery of energy onto the cornea."
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It can be found when searching for this:
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Comparison of Visual Outcome After Hyperopic LASIK Using a Wavefront-Optimized Platform Versus Other Excimer Lasers in the Past Two Decades Published: 19 May 2021
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The clinic I went to is kind of like a McDonalds chain so you are not sure what surgeon you will get, or what laser they will use. They list that they have a Alcon WaveLight Allegretto EX500 wavefront guided excimer laser but I did not get far enough with them to know if they even have it at this clinic or considered using it. In any case there is not a chance in the world that I am going to push them to do a procedure with a laser on my eye that they are not confident in doing. So it is the end of the road with them.
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I have one hope left and that is at a locally owned and operated laser clinic that has the owner doctor and one associate. I am waiting for my surgeon to transfer them my eye data before they will give a preliminary opinion. They have a excimer laser that based on my research is perhaps a bit better than the Allegretto model. It is the Ocular wavefront (IRX 3) imaging technology paired with the SCHWIND AMARIS® 750S laser. It will be interesting to see what they say. It appears the surgeon has at least looked at what I am trying to do, and has not rejected it outright. If it is a no go with them too, then it is probably the end of the road for this option. The up side is that I have very good reading vision, just not excellent... And, I would not want to drop a few thousand and go from very good to needing reading glasses!
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I thought I have had is that if one is considering the use of Lasik as a touch up after cataract surgery, it would appear to be much better to end up more myopic compared to your optimum target. It seems it is easier to to correct myopia than hyperopia.
RonAKA
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I got a bit of promising information today. The surgeon at the clinic which I had evaluated to be the best in our city to do this kind of Lasik has reviewed my file and is willing to do a consult. I had sent them information making it clear I wanted to correct the astigmatism while increasing the myopia to -1.5 D sphere. They did not dismiss my request outright and I have an initial consult now in August. I guess I will see at that consult what the risks are and how likely I am to achieve my objective of getting to -1.5 D sphere and as close as possible to 0.0 D cylinder in my near eye. Fingers crossed that they will be able to confidently do it.
valerio01538 RonAKA
Posted
Have you ever researched something about "Sulcoflex Toric" by Rayner? Provided in Spherical Equivalent: -7.0 to +7.0 D (0.5 D increments) and Cylinders: +1.0 to +6.0 D (0.5 D increments).
RonAKA valerio01538
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No I have not considered that approach yet. I guess they would fit into the piggyback lens category of solutions. The one comment I got from the Lasik place that I had an evaluation at was that a toric lens was not going to do much for my astigmatism as it was irregular. It is not a symmetrical hourglass or bowtie shape. Toric lenses work best for symmetrical astigmatism. Lasik does work with irregular astigmatism (according to the tech), but I need more than a correction for astigmatism or I am actually going to lose some reading ability that the astigmatism gives me.
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With my upcoming appointment at the Eye Q Premium Laser clinic I hope to get to talk to the specialist doctor there, Dr. Leong-Sit, and discuss the risks of Lasik, and possible other options. But I am going to have to wait until August to get in to see them. I don't mind the wait, as I want to be sure my operated eye is totally stable before any correction is made.
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Thank you for the suggestion. I will look at it.
valerio01538 RonAKA
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In a consultation I had with my ophthalmologist yesterday, he mentioned this lens as the easiest, most accurate, safe and fully reversible way to correct residual refraction, but unfortunately in my case it wouldn't work, as it starts at +1.0D cylinder and that would put a lot of myopic. I don't know if in your case, also correcting the astigmatism, a 1.0D cylinder would be too much. You are very patient. I would even wait until August to have the surgery, but I don't think I would have the patience to wait just to see if it's possible.
RonAKA
Edited
I had my Lasik consult today with the specialist doctor. I was very impressed with the clinic staff and the doctor. He did a much more thorough exam and consult than the previous specialist I saw. However the outcome was still bad news. First he diagnosed my irregular astigmatism as Keratoconus. This is a condition that is very rare (I read 1 in 2000) and is typically caused by a thinning of the cornea that distorts the symmetry of the cornea. He said that it would be very risky to use the laser on a cornea with this condition. He also said that if it was determined to be safe (stable condition) and the astigmatism was corrected I would lose my myopia and reading vision in this eye. This is consistent with what the other specialist and my optometrist said. I still have trouble accepting it, but I certainly am not going to encourage them to use a laser on my eye when they don't recommend it. So, it appears Lasik to reduce my astigmatism and increase my myopia is out.
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The further bad news is that he is not sure if the Keratoconus is stable, and if it progresses I could end up needing further treatment up to a cornea transplant. Ouch! So I have another appointment in three months to measure my eye again. In the interim he is going to contact the surgeon who did my cataract surgery to get copies of the cornea topography images taken before my cataract surgery so he can compare them to what he measured today.
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This Dr. is very through and up until this exam today my optometrist, or cataract surgeon had never raised this as an issue.
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Since the Lasik is not going to happen, I am going to get some up to date progressive glasses for times when I need the best vision. I suspect unless my vision starts to deteriorate, they will be seldom used. Fortunately my mini-monovision is quite useable.
Bookwoman RonAKA
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Ron, I'm sorry to hear about your diagnosis, but glad that the doctor was so thorough and made you aware of the condition.
I have a friend whose son (in his 20s) has keratoconus, and he wears special contact lenses but has not needed a transplant. I hope yours turns out to be stable.
RonAKA Bookwoman
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The comment the doctor made was that if I presented with my condition and was 14 years old, he would be quite concerned. I am thinking my condition is likely stable, but now it is on the radar so it can be monitored. The condition should be roughly indicated by the astigmatism. I had -1.5 D in 2001. It increased to -1.75 D by 2011-12. Then it has decreased to -1 D by 2019 when I did not have a significant contract. It has not changed much since then, and went down from -1.25 D right before cataract surgery to -0.75 D after. I guess what is unknown is how irregular the astigmatism was over those years. Up until my cataract surgery nobody had even mentioned it was irregular. I suspect it takes fairly sophisticated topographical measurements to determine that.
valerio01538 RonAKA
Posted
Doing a quick search, I read that keratoconus is a rare condition that appears in puberty or late adolescence. If so, I believe you've developed this a long time ago and in that case it shouldn't evolve from where it is. I also read that in severe cases, before considering a corneal transplant, there is a technique called the Ring of Ferrara.
RonAKA valerio01538
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Yes, that would be the optimistic way of thinking about it. I believe the earliest I ever had the detailed eye measurements done that would have detected it, would have been in January 2020. So, hopefully this surgeon will get those results and compare it to where I am now.
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Over the years my sphere and in the last two decades my cylinder has been going down. This would seem to be the opposite to what might be expected with keratoconus. The cornea is supposed to become more pointed and steeper.
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The other method I have seen for treatment is this one:
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"Progressive keratoconus can be treated by corneal collagen cross-linking. This one-time, in-office procedure involves the application of a vitamin B solution to the eye, which is then activated by ultraviolet light for about 30 minutes or less. The solution causes new collagen bonds to form, recovering and preserving some of the cornea’s strength and shape."
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In doing my research of Lasik clinics I came across this treatment option and didn't know what it was about. Now I understand better. I suspect this clinic I went to yesterday does it as well, and perhaps that is where he is headed.
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My other optimistic thought is that if it is progressing and makes me more myopic, then I just have to monitor it, and do the collagen cross-linking thing when I have optimized my reading vision! Not likely an option!!!
jimluck RonAKA
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How about a scleral contact lens? My understanding is the corneal astigmatism correction is inherently perfect and comfort is excellent.
RonAKA jimluck
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Yes, even a soft contact lens would provide much of the correction I need, and a hard one would be better still. The issue is that I absolutely do not want to wear a contact lens of any kind. I did it for over a year to simulate monovision, but it was a pain for me. For me the better alternative is to simply put up with the less than perfect vision without glasses.
RonAKA
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I had my regular eye exam today with my optometrist. He confirmed that I do have a PVD in my left eye which I noticed just over a couple of weeks ago. Same as the other eye, not much can be done about it other than hope it fades over time.
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I told him about my potential diagnosis of keratoconus in my left eye by the Lasik surgeon I saw. His opinion was that he thought keratoconus was not all that likely. But, he does not have all the instruments required to detect it either.
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What he did say was that I now have signs of PCO in my left eye, and he would recommend getting a YAG in that eye. Kind of disappointing as it has only been 14 months since surgery. My other eye is more like 30 months post surgery and no evidence of PCO in it. I have another follow up appointment with the Lasik surgeon in October and he does YAG so I will discuss it with him then. There is nothing that I can see that I would attribute to PCO, but the optometrist claims that I would see an improvement if I had it done.
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If the Lasik surgeon confirms that I need it, I guess I will go ahead with it....
Bookwoman RonAKA
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Or, you could just wait until you feel your vision is actually being affected. I've had moderate (level 2) PCO in my left eye for a couple of years, and I can't see any difference in visual acuity between my two eyes. If it ain't broke....
RonAKA Bookwoman
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I am kind of thinking the same. My appointment with the Lasik surgeon for a check on the keratoconus is not until October. So, my thoughts are to watch it until then, get his opinion, and then decide if and when to go ahead with the YAG.