High myopia, vitrectomy inbound and anticipated cataract surgery afterwards, any advice appreciated
Posted , 13 users are following.
Been reading on here for a little while, anticipating cataract surgery later this year so looking for recommendations and information.
A little background in case anyone is interested:
At 40, I had what I feared was a retinal detachment, I was walking outside and had a big black shape come down from above. I'm a high myope, so I've always read I was at risk for that and the next morning was being seen. I was told it was a large floater, right in the middle of my vision and shown a picture. They said I had no retinal detachment, and that it would either go away on it's own or I would adapt to it and learn to ignore it.
3 years went by, and it was still sitting dead in the middle of my vision, moving only slightly left and right. I began to notice when I looked in the mirror, that my right eye was turning inward where my left eye was straight; it was as if I was trying to always look around the floater, it looked like I was crosss-eyed just in the right. I heard about the laser vitrectomy (essentially using the laser to break up the floater), and there was a doctor within driving distance of here. I made an appointment, was told it wouldn't be a problem, and had to go twice because he couldn't do it in one go, it was too dense. A piece of the floater he couldn't get an angle to hit, but my central vision was clear and I could ignore the remaining small ones. I was happy for about 5 months, then I started to get more floaters of all types. What was different now is that rather than the one large floater (and smaller ones that were easy to ignore, I always had lots of small ones), it's more like looking through a cloud of floaters.
This has been going on for 7 more years, I'm now 50. This last year I've somewhat hit a wall; the cloud has become denser, I'd describe it more like looking through soup. Everything in that eye is several shades darker than the other, similar to a cataract. Unlike a cataract, I think I can't adapt to just using the other eye because of all the constant movement of the floaters and the soup. If I move my eye rapidly, I can sometimes get it to clear in the center and I can see that my vision is quite good (other than the myopia of course).
I've seen two top retinal surgeons, both say my retina is healthy, and that I suffered a PVD in that eye, probably at 40 when the large floater first appeared. Interesting comments they made included that a doctor there had a vitrectomy for floaters and they had "less than you have" and that they understand why I'm having issues because I have "more than my fair share" of them. Obviously I don't want to risk my sight on eye surgery (the vitrectomy and the cataract surgery that will follow typically 6 months later).
While my vision is better some days then others, I started getting double vision on occasion due to the difference between my eyes looking through the soup. It seems to have become a little thicker. I try to avoid driving at night whenever possible, as I otherwise have to close my right eye. I need to drive 2 hours every day to from work and taking the kids to school, so... the vitrectomy is in 3 weeks. I don't want to do this, but if it hasn't become better after a decade, it's probably not going to. Quite terrified, actually, even though I know it will probably be fine. I tell myself on the brightside, that with the cataract surgery and lens replacement, I can know what it's like to not need contacts (or hopefully need a lower power). I mentioned I've always been highly myopic since I was a child, -15 in the right and -13.5 in the left. I've been told I will see really well with any replacement lens, better than I ever have in my life due to my myopia, can anyone say if that is truly the case?
After reading here, I was really convinced the Symfony was the way to go; then I read about the Panoptix. While I'm used to visual oddities, I think I've come full circle back around and think if I have to make a choice that the mini-monovision is the safest way to go with some myopia, I don't mind if I still need glasses, but it would be nice to not need them for everything. Anyone a high myope or has experience with a vitrectomy and this process, and any advice, particularly with recovery or selecting a lens? It seems there is praise and criticism for every lens, no real consensus or a safe choice. Thanks for taking the time to read this and if you respond.
0 likes, 47 replies
scott10751
Posted
Day after vitrectomy, everything looking good so far, vision blurred after bandage came off today but told it will return to normal in the next week or two. I can finally breath an "eye" of relief. 😃
Until the cataract. But no gas bubble, so that may buy me some additional time, everything I've read says that air/gas bubble is what guarantees the cataract in short order.
RonAKA scott10751
Posted
Probably a good time to have faith in the professionals and be optimistic about the outcomes. I think how fortunate we are to have the technology available today compared to what previous generations had.
scott10751
Posted
One week post vitrectomy, everything going well. Starting working from home yesterday, and have something happening that didn't up to that point; my prescription worsens as the day goes on.
I know my glasses prescription for the eye that had the surgery was about a -.5 diopter off. So I start off the day at that point, by 3pm it's probably -1.25, by 10pm I'm about -2 to -2.5 off. Go to sleep, wake up the next morning, it will be back to -.5. This didn't happen until the last two days when I've been on a computer all day, so I assume it directly correlates with eye strain and the eye not being healed after only 7 days. In the mean time I've ordered another pair of glasses with an extra -.5 tacked on to see how much that helps.
Other than that, eye looks fairly white and only the smallest bit of irritation, extremely happy with the results. If/when I develop a cataract or if there are any other updates of interest, I'll post them here.
scott10751
Edited
Had my appointment today, and didn't realize until they took preliminary measurements how much of my research was futile. It does make things easier though.
Through research and gut the Envista was what I was leaning towards, but I wanted to hear an expert opinion from my Doctor. He can do the Envista, but said if it were his eye he'd go with the ZCB00 Tecnis. He likes that the overall dimensions are 13mm (Tecnis) vs 12.5 compared to the Envista, but of course it was up to me.
After taking preliminary measurements just to get a ballpark (I need to go three weeks without contacts to get more precise numbers), my prescription came in at essentially 0 in the right, 4.5 in the left. So, no Acrysoft IQ, they don't offer that in this range, no Tecnis ZCB00, also not offered in this range. No toric lenses manufactured in this range. I wasn't considering any of the multifocals, but more than likely none are offered in this prescription anyways. Envista starts at 0, so that should still be an option or a different J&J 3 piece monofocal I haven't heard of before.
Before I knew the ZCB00 wasn't an option, I thought "If I go with his recommendation, and have a bad result, I'll be kicking myself thinking I should have gone with the Envista, and if I go with the Envista and have a bad result, I'll be kicking myself thinking I should have listened to the Professional". Now I can most likely stick with what I thought originally, and if I don't have a good result I hopefully can't blame myself for making a bad decision. I wanted the toric but was concerned about rotation, etc. Now it's totally off the table, it's actually somewhat of a relief. I suppose I could consider relaxing incisions just for the right as the left doesn't have much astigmatism.
My remaining decisions are what to target, near or far. I've really leaned to near with glasses for far as I've posted elsewhere, but the Envista when targeted for far has a very high rate of people getting good 20/32 intermediate or better, so that tempts me to go with far. Second, my left eye despite still being a high prescription is ok, no excessive glare like the right and I see great with it. I've read of some having their Doctors insist in doing both because the discrepancy between eyes is too great; I couldn't wear glasses with one eye corrected, I'd always need a contact in the left eye. Should I have the left eye done as well? I would definitely wait to see the results of the right eye first.
Thanks for any feedback.
scott10751
Edited
Tidbits for anyone in a similar boat reading this at a later date:
The more low or negative power lenses you require, typically from 2 to -10, the far more likely the calculations will be off by greater than a diopter, so you want to target myopia higher than that to avoid ending up farsighted, so you can't actually target far in this case.
When measuring the eyes and needing to go without contacts for 3 weeks, they thought I had gas permeable lenses, where I have soft disposable contacts. One to two weeks is sufficient then as soft lenses don't affect your eyes to the degree that the hard lenses do. The expectation is that the measurements will change little if at all with soft lenses.
RonAKA scott10751
Posted
When will you have the surgery? Will you be doing both eyes or just one and wait a bit for the second?
scott10751 RonAKA
Posted
I'm going to stop wearing contacts today and get the final measurement the following Friday. Then the following week I would be called to schedule. I would prefer to do it sooner rather than later, but it depends on how long before you can drive after the surgery; otherwise I may have to wait until there is a break in the kids' school calendar, my wife can't drive them every day.
Right now I'm leaning towards doing just the one first and seeing how it turns out.
RonAKA scott10751
Posted
I guess each case could be different. I had my wife drive me to my appointment with the surgeon at the 24 hours post op point. I was using dark glasses and my eye was quite sensitive to traffic lights and brake lights on the cars ahead of us. I would not have been safe to drive that day. Probably could have driven the day following, but I didn't.
kevin77191 scott10751
Posted
Interesting read and glad to hear the vitrectomy went well. I have considered getting a vitrectomy for floaters from a YAG but the vitreo-retinal surgeon I saw suggested against it as the risk is high. He told me that I should try to ignore them... like dude, you dont think i've been trying that?
Is the reason they didnt use the gas bubble to try to reduce the risk of cataracts? Looks like in the end you got cataracts anyways. I wonder what percentage of people get cataracts after a vitrectomy.
scott10751 kevin77191
Posted
When I was researching the vitrectomy, I read quite repeatedly about the high risk. If I remember correctly, most of the higher complications were from older studies and with the larger gauge (20) instruments, and that is what was accepted as common wisdom. Once the tools became smaller (25 gauge) there are studies that said the risk is low. Just googling quick, search for "Pars plana vitrectomy for vitreous floaters: Is there such a thing as minimally-invasive vitreoretinal surgery" and "Small-gauge PPV for vitreous floaters". I interpreted most of these as saying that risk is low now with the smaller gauge, but there is always the risk of a serious complication and you need to be ready to accept that. Both retinal surgeons I saw didn't express any major concerns and didn't try to dissuade me at all, just discussed the potential complications like a retinal detachment, percentage chance it would happen during the procedure and what they would do to correct it if it occurred.
You are probably right that they didn't use gas with mine to reduce the risk of a cataract, although I wonder if gas is required for a floater procedure. I didn't have a retinal detachment or other condition that the gas bubble would be pressing against. I do believe a high percentage of ppv patients do develop cataracts, how quickly is the variable, but usage of the gas seems to bring them on quicker.
scott10751
Posted
More tidbits for high / extreme myopes:
As this is not my area of expertise, please feel free to point out any errors or false conclusions if you think I've made them.
Trying to choose between the envista MX60e one piece and three piece monofocal lens my Dr normally uses with my prescription, my research roughly went down this route; despite it's length I've left out quite a bit. It's a bit of a ramble but I hope it's useful to someone else in the future to save them some time:
The three piece monofocal is commonly used when you go below 5 power, at least in the US the envista is the only option I see in a more advanced (aspheric) lens. The 3 piece in my case is spherical and adds positive aberration, acrylic, and larger at 13.5mm so theoretically better for a myope with a larger capsular bag. It is also available in .5 diopter increments, an advantage I'll mention later.
The envista MX60e is available starting at zero power in 1 diopter increments, aspherical, doesn't add or subtract aberration, and is glistening free. Glistenings have been discussed by many here, some care and some don't. For me they are still a concern. I recall reading somewhere regarding the improved manufacturing to reduce glistenings that, someone correct me if I'm mistaken, stated they now won't start for at least 3 years, which if I was 70 or 80 might not concern me but in my 50s it does. If they start later they probably also progress slower so this really may be a complete non-issue; I haven't determined if the same acrylic is used in the 3 piece as the 1 piece lenses. I'd prefer to just avoid the concern if possible.
Looking at the differences, is there any reason I (or anyone) would want additional positive aberration vs the neutral aberration of the envista (or negative aberration if you can use one of those types of lenses)? Turns out there is. Search for "Analysis of Corneal Spherical Aberrations in Cataract Patients with High Myopia". According to that study, myopes have less positive aberration than the normal eye. There is a greater chance they may have negative aberration, in which case a lens introducing negative aberration (-27 or -20) to counter the expected average positive aberration will make for a bad result; their conclusion was that if you didn't know, a high myope should never get a lens with high negative aberration. The spherical positive aberration adding 3-piece lens could bring you a better result if you are negative. High myopes tend to have a flatter cornea, which seems to corespond to the lower positive aberration. The only way to know is to ask to have the aberration measured. I was told I'm different from most myopes in that I have an excessively steep cornea, so more than likely I have more positive aberration than normal. My Doctor offered to measure it, but as no negative aberration lenses are available in my power, there isn't any point. As I most likely have high positive aberration anyways, I don't want to add to it, so this really doesn't make me want the 3 piece spherical (if you have a flat cornea or negative aberration on your cornea, you might).
The next question I had was stability in the eye. The 3 piece lenses are larger (13.5mm and 13mm) so that they will center better in the eye with more outward force. Can I find anything on 1 piece vs 3 piece in that regard? Search for "Short-term Dynamics after Single- and Three-piece Acrylic Intraocular Lens Implantation". A 1 piece appears to have a little more tilt and decentration initially, but after 4 weeks there is little difference. That looks fine. The envista however is 12.5mm, which is a full mm smaller than the 13.5mm 3 piece. Big eyes supposedly have larger capsular bags, should I be concerned the lens is too small? Turns out a large bag is still smaller than the lens, and I buck the trend again that despite the high myopia my capsular bag is 10mm, fairly normal. As I've read about the envista quite a bit, I remember it was a harder acrylic, so I wondered if despite it's smaller size that there would be less compression of the haptics in the bag. Little chance I'd find a study on that. Search for "Comparative Assessment of Outward Radial Forces Exerted by Hydrophobic Acrylic Intraocular Lenses and Capsular Tension Rings Under Common Degrees of Compression". I'm guessing Baush & Lomb may have sponsored this; as it doesn't include an Alcon lens I'd suspect it performs better in this regard. It does however show that in a 10mm bag the envista has over 20% more outward compressive force than a 13mm Tecnics despite being 12.5mm in size. This alleviates my concerns about the potential size and stability benefits of a 3 piece, so I feel good about going with the envista.
Regarding Dysphotopsias, search for "Dysphotopsia: Not Just Black and White", found the section interesting about orientating the optic-haptic junction of an acrylic lens at 3 o’clock and 9 o’clock, so that the optic-haptic junction is horizontal; this supposedly reduces dysphotopias from 25% to 5%. You obviously couldn't do that with a toric lens. I asked my Doctor if we could do this, and he has no problems with it.
I posted previously about using a CTR for PCO prevention, I was told using a CTR has it's own set of risks, if I need one (which you really don't know in advance) they will use one.
I will say my Doctor is absolutely great. I have to be the worst case scenario patient questioning every detail. He has spoken to me 3 times at the end of the day going into the evening that if you add them up was well over an hour. Answered every question patiently as I ran through my notes. He spent 5 times as much time answering my questions on the phone as the procedure will take. There really is only one remaining question, which is the power. I didn't think we could aim for distance, he feels strongly we should target -.5. No guarantees of course. If I go up 1 in power, the target becomes -1.1. Statistically speaking, as best as I can figure, there is a 69% chance I wouldn't end up farsighted with -.5, 98% chance I wouldn't at -1.1. That's just me combining statistics based on the lens formula used in studies with high myopia and throwing vitrectomized eyes into the mix. He is an extremely talented Doctor, do I go with the -.5, which based on my contact lenses now would be great, or do I play it safe with the -1.1? This is where I wish the envista had the half diopter power option, I would split the difference, aim for -.8 and call it a day.
Surgery is 2nd week of April.
kevin77191 scott10751
Posted
Wow. Lots of great notes here for people to read through. I just saw that there is a newer IOL. Clareon IOL. You should check it out.
scott10751 kevin77191
Posted
Unfortunately the Clareon, like most of the new IOLs, starts at too high a power (+6) for it to be a consideration for me.
RonAKA scott10751
Posted
Thank you for the detailed post. There is a lot of good information especially for those high myopia. I never considered a lot of those details. A couple of comments:
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With respect to the glistenings I believe these are a manufacturing defect where there are small voids in the material. These voids fill up with fluid to cause the effect. From what I have read this happens fairly quickly. I am at about 6 months with an Alcon AcrySof lens and I don't see anything like this.
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As far as a correction target, I believe it is standard practice to shoot for -0.25 under correction. The idea is not to go into the + range as it will impact reading ability. If the choice is +0.5 or -0.5 D then I think the correct choice is -0.5.
scott10751 RonAKA
Posted
Thanks Ron,
It's surprisingly difficult to try and sort this out. I wanted to find the reference I read to glistenings in 3 years, which I remember being a European document, I can't find it. I did find this, which is an example of how one can be mislead; search for "Comparison of glistenings formation and their effect on forward light scatter between the Acrysof SN60WF and Eternity Natural", it's not the top result for me but a .pdf 3rd down (I wish we could post links). In this document, it contains the quote "These lenses have been shown to be associ-ated with significant glistenings formation following implantation. Indeed, Colin et al,18reported that out of 111 eyes implanted with the Acrysof SN60WF IOL, 96 (86.5%) of them developed glistenings despite following manufacturing changes, reduction although not complete elimination of glistenings has been reported." BUT, go to the source he cited in this document from 2019, and it's from a study in France, from 2011. It's my understanding the manufacturing changes were made in 2013. But this 2019 document specifically states after manufacturing changes, and quotes a study from before those changes. I'm sure the French study is not where I read the glistenings in 3 years, as the 2011 date is all over it and I wouldn't have missed that.
Regarding the corrective target, I may have not worded that clearly, he wants to aim for -.5, so a half a diopter of myopia. The percentages I quoted were the odds of being within a half diopter positive or negative (69%) and within 1 diopter positive or negative (98%). So if we target a half a diopter of myopia, 69% chance I'll be between plano and -1. If we target -1.1 diopters of myopia, 98% chance I'll be between -.1 and -2.1 of myopia. That's my final decision to make, as the accuracy of the final outcome is decreased compared to a normal eye.
RonAKA scott10751
Posted
The surgeon will know best where they are most likely to end up. I just think that you do not want to end up significantly positive rather than negative. I am forgetting the details now, but I recall my surgeon was targeting about -0.35 D and did not want to go to the next step as he said I would not thank him for leaving me far sighted. I was also supposed to have about -0.25 cylinder (astigmatism) and he said that is too little to correct with a toric. I ended up with 0.0 D spherical, and -0.75 D cylinder. So he was real close on the spherical but induced some astigmatism with the surgical incision. I am not too bothered about it as I think it helps me read. With the rule of thumb that cylinder contributes about 50% to the overall correction, I am effectively at about -0.35 D. I have easy 20/20 vision and about half of the next line.
RonAKA scott10751
Posted
I had bookmarked this article on glistenings. It is actually two articles with differing opinions. The first one says they can be a problem. The second article essentially says that that opticians can often see them, but the patient almost never does. The author also suggests that in the rare cases that glistenings are blamed for vision problems there may be other coincidental issues causing the loss of vision, like PCO or macular degeneration.
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CRST How Serious a Problem Are Glistenings? Kenneth J. Rosenthal, MD; Nandini Venkateswaran, MD; and Donald Serafano, MD