I Need Help With Positive Dysphotopsia and Neuro Adaptation
Posted , 8 users are following.
I had my cataract surgery done in March of this year. I have a Tecnis 1 monofocal in each eye set at distance. I developed PCO 2 weeks after surgery and had YAG done 3 months later because my vision had deteriorated. Since the day after cataract surgery on each eye I have had positive dysphotopsia. I was told it would eventually disappear, but it is getting worse. In the outside corners of my eye there is a flickering/flashing which has gone from just being there in the morning for a few hours to being there all day, from the minute I wake up until I go to bed. I don’t notice it when I am outside, but I also always wear sunglasses outside. When I am in a store with florescent lights it gets really bad. Some days it can be quite debilitating. I have had my eyes dilated and checked numerous times and in fact just had an OCT scan a few days ago and nothing is wrong with my eyes.
I have done some reading on this and apparently for the majority of people it can take 6 to 12 months for your brain to neuro adapt to this so you don’t see it anymore. However, there are people who will never neuro adapt and will always experience it. Usually people who have had a multifocal IOL will get more positive dysphotopsia than someone with a monofocal. I have read there are probably a lot more people who experience this, but just don’t report it to their doctor.
I read posts on a couple of forums where people reported their doctor told them the majority of people who have PD have light colored eyes. When you think about it, that makes a lot of sense because you don’t have the dark pigment to prevent light from getting in. I have been told by an optometrist dilation of the eye happens faster with people who have light colored eyes, again because of the pigmentation. I have light colored eyes and my eyes dilate very quickly.
I read an article about neuro adaptation to PD and the person stated there are exercises you can do to help your brain neuro adapt so you don’t see this positive dysphotopsia anymore. However, they did not suggest any eye exercises to do and I have not been able to find any. Has anyone heard of or know of any eye exercises that help you neuro adapt to positive dysphotopsia? Or if you have PD have you found something that is helpful. I would prefer not to use eye drops to shrink your pupil as that has its own problems I heard and have also been told wearing sunglasses inside is not good for your eyes. Thanks for any help.
1 like, 23 replies
RonAKA karin08666
Posted
That is unfortunate you have these effects after cataract surgery. I suspect it is not very common, but it does occur for sure. The other unfortunate part is there does not seem to be a silver bullet solution to the issue. The effect is probably aggravated by having a larger than normal pupil size, and the only long term hope is that our pupil size decreases as we age. I have an AcrySof IQ and a Clareon monofocal and have not suffered from this issue at all. However, I am 73, so probably have a smaller pupil due to age.
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One of the issues with florescent lights is that they actually do flicker at a rate of 60 Hz the same frequency as our AC power supply (in North America, the UK and some other areas use 50 Hz). The assumption is that if lights flicker on and off at a rate higher than 30 Hz we do not notice as the residence time of the image on our eye is about 1/30th of a second. But, not everyone has the same image residence time, and in particular when you look at something with your peripheral vision we can be more aware of any flicker. This is why you see some high definition TV's and computer monitors with higher refresh rates to avoid the visualization of flicker. But this all said, there is not much you can do about being inside with florescent lights. And I am not sure about LED lights if they also flicker at 60 Hz, but they may.
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On a google search I did find one example where PD was solved using a silicone piggyback sulcus IOL lens implant. Here is a link to the article. However, I don't know how available this procedure is and what the larger study results would possibly be. The patient was given a choice of options.
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"Given her worsening PD, she was counseled about several treatment options, including continued observation, IOL rotation with horizontal orientation of haptics, placement of a nonacrylic non–square-edged sulcus IOL, or IOL exchange."
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If this effect does not diminish over time it may be something to consider. Here is the name of the study:
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Management of positive dysphotopsia in a patient with prior refractive surgery Ayushi Chandramani, BS Kamran M. Riaz, MD Published:July 20, 2017
karin08666 RonAKA
Posted
The thing i found odd, the doctor dilated my eyes the other day and the flickering went away. I thought it would get worse.
I could never tell fluorescent lights were flickering before I had an iol. Now the lens reflects the flickering and my brain feels it is something I should see. I believe there was someone who posted on this forum with exactly what I have fluorescent lights and all, and it cleared up for him. Fingers crossed that will happen with me.
I was really interested in finding eye exercises to help you neuro adapt, but I couldn't find anything.
Thanks for the info and the study.
Lynda111 karin08666
Posted
I would go to one of the big well known eye hospitals for a consultation. You can do a Google search with those teams
Lynda111
Posted
I meant terms
soks RonAKA
Posted
the piggyback lens will generally help with negative dysphotopsis - the dark shadow or black arcs. i am not sure if she has more symptoms than just the flickering.
i dont think tecnis had a good lens design for those with large pupils.
RonAKA soks
Edited
Did you read the article about positive dysphotopsia that I posted? The symptoms of the subject were:
"At 1-month follow-up, she reported flickering lights and streaks in her peripheral vision, most prominent in her temporal visual field; these were worse in bright light conditions and would remit upon closing her eyes...However, 2 months later, she reported that her PD symptoms had worsened."
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That description could be improved for a google search by trying this one to find a more complete article.
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Canadian Journal of Ophthalmology VOLUME 53, ISSUE 1, E27-E29, FEBRUARY 2018 Management of positive dysphotopsia in a patient with prior refractive surgery Ayushi Chandramani, BS Kamran M. Riaz, MD Published:July 20, 2017
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"we inserted a zero-power 3-piece silicone IOL in the sulcus; this offered a less invasive option that also maintained the refractive efficacy of the original IOL.12 We believe that this procedure improved the patient’s PD symptoms because the rounded edge of the silicone optic masked the aberrant reflections and refractions occurring at the square edge of the acrylic IOL."
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The authors of this article appear to be from the Department of Ophthalmology at the University of Chicago.
soks RonAKA
Posted
the approach for putting the iol in sulcus described in the article is also for ND. perhaps this helps with the flicker.
so does this mean the piggy back lens was implanted in front of the original iol with haptics in the bag?
RonAKA soks
Edited
The original lens appears to be a ZCB00 which is a standard Tecnis 1 monofocal I believe. It was left in place as it provided good visual acuity and avoids the risks of complications in doing an explant.
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The lens in the sulcus is a three piece silicone Staar AQ5010V lens.
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Google is not very cooperative in finding this article. The easiest way is to go to the Canadian Journal of Ophthalmology site, click on Articles, Past Issues, and 2018, and then the February Issue. It is one of the last articles in that issue.
soks RonAKA
Posted
interesting. i had assumed that they slip the piggyback lens behind the original lens.
karin08666 RonAKA
Posted
Ron, I have a question for you. Do you know what the symptoms are of weak zonules? Last weekend something weird happened with one of my eyes and I thought I might have a retinal tear. I went to the eye emergency center because it was a Sunday and they sent me to the ophthalmologist and resident on call. The resident put a lot of pressure on my eyeball while she was looking into my eye and it was quite painful. Ever since then my PD has been worse and I seem to notice there is a lot of it when my eyes are moving, like when I am reading. If I move my eye from looking at one thing to another too quickly, I get dizzy. Also, if I open my eyes really wide and don’t move my eyes, the PD stops. I also can see the edge of my lens in both eyes now, which I couldn’t before. I am wondering if this resident did something to weaken the zonule fibers around my lens.
RonAKA karin08666
Posted
I am not at all familiar with that type of issue. About all I understand is that it has to do with the tension of capsule that holds the natural lens, and now the IOL. It may impact the positioning of the lens in the eye.
karin08666 RonAKA
Posted
Thanks. I can't find much about it either. I read something about it once awhile ago, but can't find it again. I am probably just over analyzing everything and trying to find a solution for this PD. Having this constant flashing in both eyes is exhausting.
john66904 karin08666
Posted
Hi Karin,
My name is John, I am 53 years old. Like you I have monofocal Lens in both eyes (ICB00 from Johnson & Johnson). I think these are similar to your lens.
My surgery took place on 22nd June 2023. I have had positive dysphotopsia since day 1, which I am led to believe does improve but the symptom improve through neuro adaptation. The constant flickering & flashes of lights was intolerable for the first 2+ months. I could barely function without being sick. This also caused extreme anxiety and migraines. At one point, my wife had to take me to A&E because the pain due to the migraines.
After 3x months my symptoms improved slightly, it's all relative. By this I mean, I moved from intolerable to severe discomfort, slightly less sensitivity to flashes of light, less headaches perhaps as a result of neuro adaptation. I am not aware of any exercises to improve PD so I have forced myself to go through the pain without medication to force neuro adaptation. I can see the edge of the lens, or the reflection of it. I am used to it now. Outside I have less issues.
If you were to come across any exercise to help improve or reduce the effects of Dysphotopsia please let me know
Warmest Regards
John
Lynda111 john66904
Posted
I couldn't find anything about eye exercises. If you want to read more about PD, you can Google "Dysphotopsia EyeWiki." It's a May 2023 article. Basically, you either neuroadapt or you exchange IOLs This is the prognosis:
"While most patient experiences of dysphotopsia resolve or undergo neuroadaptation, persistent symptoms may still be present despite lens characteristics and surgical correction. Persistent ND symptoms occur in approximately 3% of patients at 1 year after surgery[17], while up to 49% of patients experience PD symptoms with up to a 76-88% improvement in PD symptoms after changing IOL material.[2] Prognosis is favorable regardless of PD or ND without significant visual impairment."
RonAKA Lynda111
Posted
There are some studies which refute that the material index of refraction is a significant factor. The thinking is that a higher index of refraction results in a thinner lens, and increases the risk of PD. As an example here, @soks, got a J&J Symfony replaced with an Alcon PanOptix, and got relief from PD. PanOptix has a higher index of refraction than the Symfony.
soks RonAKA
Posted
that's correct. the PD hits some people with tecnis lenses. with panoptix i can see a turned on light bulb and see the bulb glass and filament without a halo. with one eye i do see upward nasal arc in low light but the size of the arc is small and close to the light source unlike Symfony. with symfony even the yellow lid of costco storage box would have a glow around it.
the only complaint with panoptix is that i need astigmatism (-0.75 both eyes) glasses at night especially if going outside. they make a huge difference for outside night vision and small price to pay i think for very good near vision.
Lynda111 soks
Posted
I have a Tecnis ZCboo 1piece in both eyes. The only time I notice any dysphotopsia is at night when I walk around an area with bright street lights. I can see halos in my peripheral vision, but then after a few seconds I don't notice them. Thankfully, I have no dysphotopsia while driving at night.
soks Lynda111
Posted
pd is usually a factor of large pupils. i am 47. 41 when i got symfony. it has been a living hell since. same with Adam who has zcb00 and is in 20s. i know people get offended and protective about their IOLs but this is a very serious condition which remains unaddressed.
RonAKA Lynda111
Posted
I think positive dysphotopsia is a somewhat general term. Some use it to describe what I would consider normal and expected side effects of MF and even EDOF lenses - in other words halos, flare, and spiderwebs, which is a combination of both. To my thinking the more specific positive dysphotopsia that unfortunately some suffer from is caused by reflections off the very outside edge of the IOL. This effect is aggravated by having large pupils. It can be mitigated by using IOLs that have rounded edges. They are not very common because rounded edge IOLs are more prone to PCO. Another aspect which is more controversial is the refractive index of the lens. The higher the refractive index the thinner the lens, and potentially the more the lens can sit to the posterior side of the capsule, exposing the edges to more light. Silicone lenses have a lower refractive index and are thicker, and are thought to be less susceptible to edge reflection PD. But, silicone is not a popular material as it has had other issues like PCO and opacification.
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What makes this complicated is that optometrists and ophthalmologists have no way of measuring or seeing this edge reflection. They just have to take the patient's word for what they are seeing. In my experience, and probably for that reason they don't like to talk about it. I'm sure I have very minor issues with edge reflections with both my AcrySof IQ and Clareon monofocal lenses. I only see them when it is very dark, and there are lights off to the side in my peripheral vision. They look like arc shaped very sharp flashes of lightning. To me the issue is trivial and more of a curiosity than anything else, and I don't worry about it.
Lynda111 soks
Posted
I am 72 with small pupils. That makes a difference. I am glad you are better now.
soks RonAKA
Posted
using pd to describe expected artifacts has probably prevented addressing the more serious edge glare. with both eyes the edge glare showed up 6 days post op. might correlate to iol settling to the back of the capsule by then. funnily the exchanged iol has no edge glare, probably because the capsule is stiff and lens can settle.
while panoptix arcs are not trivial they are not debilitating like the symfony ones.
karin08666 john66904
Posted
Hi John,
Unfortunately, I have not come across any exercises for neuro adaptation and believe me I have searched. It sounds like you have it even worse than I did and mine was debilitating. There were days I too got headaches, I got dizzy a lot from all the flickering and flashing, I would have to stop reading because I just couldn't see the words with all the flashing. It is not something you can fully appreciate until it happens to you. I am 7 months out from surgery and my flickering/flashing has gotten better. I am not totally rid of it, but I don't have it all day anymore, mostly in the morning (hoping I'm not jinxing myself by saying that). There are still days where I do have it for a good portion of the day, but those seem to be getting less. My doctor told me it takes about a year.
Just out of curiosity, do you have light colored eyes. As you read in my original post I have read this happens to people with light colored eyes more than dark colored eyes. I have also read it happens to people with larger pupils, however, when I get my eyes dilated the flickering/flashing goes away, so not sure about that theory.
I have read a lot of different theories doctors have: improper positioning of the IOL or tilting of the IOL; an IOL placed more posteriorly may reduce the risk; refractive error can cause PD; corneal abnormalities. These are just a few theories from doctors I have read.
Some doctors think it is the square edge of the IOL. They started making square edge IOLs to reduce the chance of getting PCO. I have a square edge IOL and got PCO 2 weeks after cataract surgery, so I would have preferred a rounded edge IOL and maybe not have positive dysphotopsia.
Some doctors think PD has to do with dry eyes. I have had dry eyes ever since cataract surgery and have tried many different drops for dry eyes. One thing I did notice was some drops for dry eyes caused my positive dysphotopsia to get worse. If you are using drops for dry eyes maybe using a different kind will help.
I am sorry you are having to deal with this dysphotopsia. With all the advances in the field of eyes I wish they would come up with an answer for dysphotopsia.