Cataract surgery visual outcomes with severe myopic vision

I am 71 and just had one eye done with an IOL. It was about -2.5 D or so with astigmatism before the surgery. When I was your age my eyes were worse, and in about the -4.5 D range. So, I can't really offer you any help based on experience with high myopia. I do only have one eye corrected, and can comment on that. When I first had the eye done I tried using a pair of prescription glasses with the lens removed in the IOL eye. That certainly did cause me some issues. I think the basic problem is that each eye can get the focus sharp, but the image size is different for each eye, based on where the correction lens is located. This is exaggerated when an eyeglass lens is used to correct a lot of spherical error, because it is located so far in front of the eye. However, I have found that correcting the non IOL eye with a contact to be very good. I do not get the dizzy effect when I use a contact. I believe the reason is that the contact is right on your eye, instead of in front of it. My thoughts would be to try the one IOL plus the contact on the other eye, before going ahead with the IOL for the second eye. I am not sure why the surgeon is dismissing that approach. She/He may be thinking of the one lens eyeglass approach and that does not seem to work.

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On the lens selection be aware that almost all lenses are 6 mm in diameter. As you are younger the chances increase that you will have a larger pupil and may have issues with light going outside the diameter of the lens. In higher correction powers the Tecnis IOLs reduce down to 5.2 mm which makes this issue worse. The other choice is the Alcon lens which retain the full 6mm diameter in all power ranges. This is something you should discuss with the surgeon while considering the power you actually need. Alcon is now making their lenses in a newer improved material called Clareon, and that may be a choice too.

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On astigmatism keep in mind that eyeglass astigmatism is the sum of the astigmatism in the lens (which can be impacted by the cataract) plus the astigmatism in the cornea. The two amounts can be offsetting or additive. When the lens is removed in cataract surgery that astigmatism is gone, and only the cornea astigmatism remains. You should ask what the cornea astigmatism measures at. If it is 1.0 D or more it is probably worth considering a toric IOL instead of the standard one.

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Hope that helps some.

Hi Jennifer...

I was -13.75 in both eyes until last week, with cataracts. I used glasses and contacts. Then I got PanOptix in both eyes, and now I’m 20/40 for close and far, and still healing. No glasses for anything. Hoping to improve further in the next month. Contacts vs surgery comes down to personal preference. But for me, not using contacts is an amazing freedom. My suggestion is to do both eyes since both are highly myopic and both have cataracts, even tho the right cataract is less developed.

Perhaps your doctor is thinking, “Let’s just correct her vision now rather than taking half-measures that will inevitably fall short in a few years.” And of course, if you feel uncomfortable with your current doc, get a second opinion.

Also remember, if you get an IOL monofocal, you WILL need glasses for near vision, unless you intentionally request an over-correct and essentially give yourself myopia again. One doctor told me about a jeweler he did this for, IOL monofocals with close vision that started at 10 inches. Remarkable.

In any case, needing reading glasses for near vision in one eye while correcting for high myopia in the other may produce an unsatisfactory result. Perhaps you should do both eyes.

I am in the same boat. -10.5 in both eyes with one eye possibly needing surgery. I'm a little older at 45 but have all the same concerns as you. I would get a second opinion, you have the right to fully understand the process and why a surgeon reccomends one option vs another. If you are located near a major city, I would seek out a cataract surgeon there.

“My doctor seemed to be much more pessimistic about my vision when I met with him. He made it seem like I would most likely need glasses most of the time no matter what, and there are no guarantees of getting any outcome all that close to the chosen target.”

What were the specific concerns he gave that he came to this conclusion

I was nearsighted and wore contacts for decades, but not as myopic as you are. I always say don’t get a diffractive IOL if you have any other eye conditions other than cataracts or mild astigmatism. I do not know if server myopia is also a problem. Is there an issue with IOL size or IOL placement when dealing with severe myopic patients?

My best guess and it is only a guess, if there are no other eye issues they should be able to hit your refractive mark. Now if you go around not using your contacts a lot and then hit hyperopia with the other eye that might be a shock to you.

You might look at a doctor that uses the ORA refractive analysis machine to better hit your refractive mark or choose the Light Adjustable Lens.

But my first thought is either get this doctor to explain in details exactly what your conditions are that will make it difficult to hit your refractive mark or find another doctor who will.

“Plus he believed that I would have awful distortion between my two eyes and there wouldn't be really any option to help it,”

Hmmm, I have 20/20 in one eye and not even 20/200 in the other eye and I am able to live with it.

I can see where it might be an issue, but don’t agree 100% with the statement. Yes studies show people binocular implanted are happier, but that is a bit misleading IMHO and not really surprising. In general you will be happier if the 2 IOLs project the same or similar picture to the brain. But normally those studies are done when getting the same IOL in both eyes, so yes if you have a severe cataract in one eye and a mild cataract in the other and you get a PanOptic IOL in just one eye, it is not a shocker you will have better vision if both eyes had a PanOptics IOL (assuming you don’t have negative issues with that IOL).

I suggestion procrastinating. If you can correct your distance vision to 20/40 (driving requirement) then I would procrastinate as new IOL and Lens materials are in the making. As Ron pointed out Alcon has the new Clareon. And if you wait long enough they might finally approve an actual accommodating IOL with a modular base. The modular base IMHO is actually more exciting as it keeps the capsular bag open, bye bye PCO and turns lens exchange into minor surgery.

Worse case get 1 eye done, try various correction methods as needed, give some time to adjust and if vision produced from the 2 eyes cannot work in combination then you can always get the 2nd surgery.

Jennifer, my situation was similar to yours, but my myopia wasn't as bad as yours. I was between -6 and -7 in both eyes (I don't have the exact numbers at hand). I had slight astigmatism. My right eye had a rapidly growing cataract; my left eye had a small cataract that wasn't ready for surgery.

My doctor mentioned getting surgery on the eye with the small cataract that wasn't ready and I originally told him "No". He then told me that he wouldn't be able to do a full vision correction on one eye only. He said that there would be too much of an imbalance between the eyes, and the brain will never get used to it. He would give me somewhat better version (say -3 instead of -6) in that eye. I would still have to wear prescription glasses all of the time.

My surgery last year was delayed due to Covid and the more I thought about it, I was not comfortable with the idea of only having a partial correction done. I called him up and told him I wanted to have cataract surgery on both eyes. (They were done one month apart). My lenses are plain, non-toric lenses by Johnson and Johnson. I am very happy with the outcome. I have 20/20 vision in one eye, 20/40 vision in the other eye, and 20/20 vision with both eyes. I no longer have to wear prescription eye glasses all of the time. (I've worn glasses since I was eight years old). I don't need to wear glasses to drive or to use my lap top. I use readers for my phone, reading books, etc.

Medicare paid for the surgery in my left eye with the small cataract because once my first eye was corrected, I had an imbalance as the doctor said. But I had told him that I would pay for it myself if Medicare didn't cover it.

I am 72 years old. I already had presbyopia, so that did not factor into my decision. Your doctor is right about the imbalance between your eyes, if you don't have surgery on the other eye. After I had the surgery on my first eye, I had nausea and headache because of the imbalance between my eyes. That happened right after I had my surgery (the same day). I had to wear a patch on the eye that wasn't operated on for a month until I had the surgery on that eye, so that I wouldn't get the headache and nausea.

My recommendation to you is to get both eyes done, rather than to wait for the small cataract to get bigger. But also, I think you should go to another doctor and see what another doctor says.

I did a little more research into IOLs for high myopia. It seems the biggest issue is measuring the eye accurately and getting the normal formulas used for calculating power adjusted to get an accurate result. There seems to be a few different adjustment methods used with varying degrees of accuracy. It may be worthwhile trying to find a surgeon that specializes in doing cataract surgery in those with high myopia. This is perhaps why the surgeon you went to is guarded on accuracy and need to wear glasses after surgery. On the power issue I mentioned before it seems that a high myopia eye requires a low power lens, and sometimes even negative. One of the issues is selecting a lens that can go as low as you need. Here is an article to google to get a more in depth explanation.

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EyeWiki High Myopia and Cataract Surgery

I am 53 and having both eyes done in the next 4 weeks, 2.5 weeks apart. Before cataracts my prescription was in the -6D range, which has rapidly progressed to -12D over the past 9 months. I have spent weeks reading journal articles and clinical studies and everything else to make my lens decisions. Here are some pointers:

• The myopia is a secondary effect. The primary cause you care about is your "axial length" (AL). That can be hard to measure when it gets abnormally long (mine is about 28mm). Ultrasound is less accurate than laser. If you can, find someone who uses a Lenstar or IOLMaster. Ideally get a doctor to do your eye measurements first, and then use those as the basis for future decisions. Your current prescription (both sphere and cylinder) is really irrelevant - after all you're going to have that lens removed. What you care about is what's left - your basic eye geometry and your cornea shape. Don't worry about toric lenses until you know what your corneal astigmatism is.
• There are a wide variety of formulas that are used to convert eye measurements to IOL power. All of them do well with "normal" eyes, but most go haywire with very long or very short eyes. Make sure your surgeon is using the Barrett Universal Formula II (or, maybe, a combination of Barrett and SRK/T if they know what they're doing). Barrett works well for extreme myopes, usually getting the power right to within about 0.1D. SRK/T does only slightly worse, erring up to maybe 0.2-0.3D in the direction of hyperopia.
• The more "unusual" conditions you have (extreme myopia, extreme astigmatism, glaucoma, retinal detachment, etc. etc.) the more you should go for the simple lens. A friend is the head of ophthalmology at a major university (but not local so not my surgeon), and I called him up to ask his advice. As soon as I told him my AL he said to not even think about a fancy lens like Vivity, that I was guaranteed to be unhappy with the results. Of course this won't be universally true, as the guy in this thread with the PanOptix showed.
• I'm about to suffer the problem with one uncorrected eye for 2.5 weeks, with a 12D difference between eyes. From what I've read elsewhere, apparently I should basically plan on throwing up the whole time. I'm planning to always use a patch over one eye or the other, but we'll see how it goes in reality.
• I don't blame you for not wanting to do the "good" eye until forced. If you can tolerate a little downtime, I might get the bad eye done, then try a contact in the good eye and see how well you tolerate it. If you can't stand it after a few weeks, schedule the second surgery.

Regarding this particular surgeon, get a second opinion. There is nothing worse than having a surgeon you don't have confidence in. If you can afford it, and can find one that uses the latest technology (including ORA), you will have a better result. Also find one who really cares about getting it right. I know people who had their eyes measured 5 times because the results just weren't consistent enough for the surgeon.

Good luck!