Cataract Surgery Concerns

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20 years ago I had 4 cut RK in both my eyes. I have been wearing glasses for the last 15 years. In September 2016 I started having issues where mid and distance vision deteriorated to the point that I had to look out of the bottom of my glasses to read highway signs. Vertical and horizontal lines had a slight shadow alongside the line. I had surgery to remove cataracts from both my eyes. At the consultation I was offered the opportunity to upgrade the lens implant to a bifocal lens or an accommodating lens. I was told that my distance vision would be corrected with any lens I chose. I was also informed that since my prior RK correction was minor, if I chose to upgrade to an accommodating lens that I may have an opportunity to correct for near, mid and far vision. The downside would be that I may require reading glasses. I chose to upgrade and pay a premium for an accommodating lens. My left eye was done first a TRULIGN IOL lens was prescribed prior to surgery. The morning of the surgery the surgeon said that he decided to implant a normal Crystal IOL lens and that if required he would complete a laser correction at a latter date. Two weeks later a Crystal IOL lens was implanted in my right eye. Both implants are: AT-50AO, Diopter 25.50, Optic Dia 5.0mm, Overall Dia 11.5mm.

I am now experiencing vision issues for mid and distance vision. I can still distinguish a shadow on lines. Near vision is good.

My 2015 and 2016 vision prior to cataract surgery was:

OD +1.25 +1.00 165 Add+2.50

OS +1.50 +1.00 179 Add+2.50

After surgery:

OD -2.00 +1.75 178. Add+2.50

OS -1.75. +1.25 180 Add+2.50

The technician and optometrist that examined me after the surgery said that they can understand why I am concerned. My surgeon suggests that the outcome is within the acceptable range. The surgeon provided a prescription as noted above. It almost seems like they had in stock IOL's to use. I am not sure what to think and do not have access to experts like you. I would value your opinion.

Thank you,

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  • Posted

    I had a Trulign implanted in my left eye over 2 years ago and never got good distance nor any clear near vision. No indication the lens was working/ accommodating at all. Plus had annoying halos, rays and flickering. Had stabilizing ring, then a piggyback lens put it in attempt to alleviate the problems. The piggyback lens did reduce the flickering, but the other problems remain and are maybe worse than before teh piggyback. I have considered lens exchange, which is more risky since the Trulign has been in place so long now. Have held off having my right eye done, considering all the problems with the left.

    If you read a lot of the posts on here (there are number of other relevant discussions), you'll see that in many cases, when problems occur, docs are very reluctant to admit it. That was certainly true in my case. I too had the techs far more sympathetic to the problems than the surgeon. Have now seen 4 different docs, but it seems when things don't turn out well and they don't really understand what's causing the problems, it can be a real can of worms trying to figure out what to do.

    In any event it certainly might be worth your while to get a 2nd opinion from another doc.

    Good luck.

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    • Posted

      Thank you for your response. I am concerned that the Trulign was not implanted as was prescribed prior to surgery and a Crystalens was implanted. My notification of the surgeons decision to use a Crystalens was as I was lying on the bed already prepped for surgery. Kind of took me by surprise. My other issue is that when I had the consultation with the opthmologist to discuss lenses, I had the mono lens for distance, a bifocal for reading and distance or an accommodating IOL. I chose the accommodating IOL which was $1500 per eye more than the standard mono lens. My expectations were that I would have good distance and mid vision. I did recognize that I may need to utilize reading glasses and I agreed to that. My concern is being upgraded to premium and paying for premium but not receiving the results. Are surgeons, surgery centers and Bausch & Lomb exponentially profiting on selling upgrades? The discussion boards on this issue seem to support the contention that the upgrade is profit driven. Who would pay for an upgrade and then pay for progressive lenses and glasses to correct vision four months after surgery? Buyer beware.

      Thank you

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    • Posted

      Unfortuntely most  of the people posting online are the minority who have problems so its possible to get a skewed sense of the results. Also unfortunately those with prior refractive surgery are less likely to be happy with the results due to the complications that provides, though I suspect most with the Crystalens are still happier than they would have been with a monofocal. Unfortunately it sounds like they may not have given you appropriate cautions regarding the risks and comlications due to prior refractive surgery.

      Obviously the upgrade is profit driven, but the reason people go for it is due to the fact that there are benefits, it isn't merely hype. Most people have great results after cataract surgery, and most with premium lenses are happy with the results and recommend the lens to others. 

      In my case I was fortunate enough to not have much astigmatism, and that I didn't have prior refractive surgery. I went with the Symfony rather than the Crystalens (a noticeable minority don't see any more near than a monofocal, even if most do, and some risk of complications that dont' happen with the Symfony). In that case due to choosing a premium lens   I have at least 20/15 vision at distance, 20/20 at computer distance, 20/25 at best near (at least 20/30 measured a 40cm rather than best near, they didn't have a 20/25 line, but I saw some on the 20/20 line).

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    • Posted

      Crystalens and Trulign are basically the same lens; the difference is that the Trulign is toric so can correct astigmatism as well.  From my understanding, this type of lens, while it sounds wonderful in theory, tends to provide poorer results than a multi-focal.  Perhaps your prior refractive surgery was a factor.
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    • Posted

      Many people who had prior refracive surgery aren't considered good candidates for multifocals due to concerns irregularity of the cornea may not play mix well with the lens optics, especially those who had earlier lower quality versions of the surgeries. Some surgeons don't consider multifocals for anyone who had refractive surgery, but the better ones will evaluate the actual state of the cornea to see if they are an option. Many think the Symfony may be better than multifocals for those with prior refractive surgery, but there are still patients with prior refractive surgery they won't use it for (unfortunately I don't think there has been enough study on who its safe to use it for, partly due to the problem of not wanting to risk problems by trying it in those who are more likely to have problems).

       

      I've heard that despite theoretically fairly decent study results for near for the Crystalens/Trulign, that pragmatically perhaps half need readers, which is a higher percentage than other premium lenses, but it is better than a monofocal. If I hadn't been able to get a Symfony or a multifocal, I'd likely have gotten the Crystalens.

       

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  • Posted

    Since he says he'll do laser correction at a later date, its too soon to know what the final result will be like. Its also not possible for us to tell for sure how good the surgical result was due to the complications in your case. You would need to get a 2nd opinion from another surgeon who could look at all the scans and measurements taken before surgery to be able to tell that, not merely the summary you give here (and it might involve doing some calculations, unless your records record all the calculations your surgeon used for them to check). Part of the oddity with your results is of course the fact that the astigmatism wasn't corrected at the time of surgery as it usually is, and that he planned for later correction. 

    Astigmatism can be corrected by using a toric lens like the Trulign, or through making an incision which causes the eye to reshape itself. How much the eye reshapes itself in response to an incision does vary a bit between people (they rely on formulas based on statistics of past results), so it isn't as precise as an IOL correction can be. However the astigmatism exists on the cornea, so in some ways its cleaner and has less risk of distortion  to correct it there on the cornea rather than having to have a counterbalanced correction in the lens. So for small amounts of astigmatism most surgeons use incisions, and for larget amounts they use toric lenses, but the cuttoff point varies by surgeon. Some use more precise laser incisions and correct even a few diopters by incision. Your preop astigmatism of +1D was in the range where either approach is often used, incisions would be a common choice. Usually they are done at the time of cataract surgery, it isn't typical to do it later. However it may be that the surgeon doesn't use a laser for cataract surgery but has one available for incisions so he preferred to do it afterwards.

     Or it may be that he planned all along to expect to use LASIK/PRK or some other laser correction method rather than an incision. Usually if they are only correcting astigmatism that an incision is the best approach. However   since in your case there was a good chance of residual spherical  refractive error, perhaps the surgeon decided that since he would likely need to correct that via laser anyway, it was best to wait and see if that was the case and correct both via laser at the same time.

    Unfortunately the lens power required isn't an exact formula, it is based on statistics regarding the eye measurements of prior patients and their results with different IOL powers. For most people with low prescriptions, the formulas are fairly accurate, with decent odds of landing within +-0.5D of the target and likely within 1D of the target.

    Unfortunately there is more risk of error for those who had high prescriptions prior to surgery (in part I suspect since there is less data for them). Those who have had prior refractive surgery due to having high prescriptoins still have internal eye measurements similar to those who still have high prescriptions, so there is more risk of error due to that. In addition, the refractive surgery itself introduces more factors that complicate determining lens power. They are refining the methods for determining lens power all the time (and unfortunately not all surgeons keep up with the latest, or go to the trouble of trying multiple formula approaches to try to figure out how they compare.

    I don't know for sure what the current results are like, but I get the impression that although most results are within 1 diopter of the target, that a decent minority might not even be within 2 diopters of the target. It also isn't clear what the target correction was, as I'll get to, it may not have been 0D. So it is difficult to know for sure whether your results are the best that could have been achieved, or if the surgeon didn't go through the extra work that is required to get better results with someone who had prior refractive surgery. Unfortunately many surgeons of course are focused on medicine, statistics and optics aren't their strength.

    It is odd that your astigmatism *increased* after surgery. The incisions required to perform cataract surgery can induce astigmatism, "surgically induced astigmatism" used to be a big deal a couple of decades ago, but it is a minor amount using modern techniques. Also usually surgeons plan the incisions so they counterbalance and *reduce* your existing astigmatism, rather than increasing it. The fact that both eyes increased astigmatism may suggest a problem with the surgeon, but I'm not positive since I don't know if prior refractive surgery can interfere with predicting the outcome of that sort of incision and lead to surprises like that. 

     I don't know if the surgeon might have been hoping to be able to use an incision to correct the astigmatism later. As I just confirmed, a limbal relaxing incision corrects astigmatism but leaves the "spherical equivalent" the same.  (the spherical equivalent is essentially the average refraction needed for your eye, which is gotten from adding the sphere to 1/2 the cylinder). Your spherical equivalents are oddly both  -1.125D, so if the target was to leave you at 0D they were a bit over 1D off the market, which seems to be within the realm of what might be expected with someone who had prior refractive surgery.

    For most people the Crystalens does give you more of a range of vision than you would have had with a monofocal lens. Hopefully a laser will correct your refractive error. However even if the refraction is off and you need to wear correction, the larger range of vision you get with the Cystalens will probably still provide more usable vision. 

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    • Posted

      Oh, I should add another reason surgeons often prefer not to ues a toric lens for a small amount of astigmatism. Although the cylinder power   of a toric lens may be  precise, the power depends on the IOL being oriented at the correct angle, which complicates placing it into the eye.  A spherical lens can be rotated and it won't make a different, but any rotation of a toric lens changes the cylinder. A toric lens sometimes rotates after surgery, before it heals into place fully. Even if the best surgeon placed it correctly it may still later   need to be rotated back into postition. The added complication of implanting a toric lens, and perhaps dealing with rotation issues, is another reason why surgeons often prefer to correct small amounts of astigmatism via incision rather than via toric lens.

      Or as I noted, rather than an incision (laser or blade), if they are correcting spherical refractive errror a the same time they might use something like lasik or prk.

       

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