Cataract Surgery Concerns

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.

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.