IOL Choice for Amblyopia (lazy eye) - Need Opinions
Posted , 7 users are following.
My wife went in for her cataract pre-op consultation today. I did not go with her due to COVID restrictions. I thought it would be a simple consult and that I could not add much. I had her primed to ask if the Alcon Clareon lens was an option instead of the Alcon AcrySof IQ. But, wow, did that open a can of worms, and I am interested in opinions of what to do next.
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Here is the situation. She has one eye suffering from amblyopia for her lifetime. When she gets eyeglasses it is so bad that they don't even prescribe any correction. She just gets a plano lens and essentially can't see anything but a blur out of it. The other eye up until the cataract has been good. She gets a very mild prescription and most of the time she does not wear prescription glasses at all.
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Now for the complications. Her eye was measured and she has mild astigmatism in the good eye at 0.50-1.25 D, and a cataract of course. The amblyopia eye has severe astigmatism at 7.3 D, and the cataract is worse in that eye. The surgeon recommended doing the amblyopia eye first as he likes to do the worst eye first and says he learns things that he can apply to the better eye which he leaves to be done second. He feels there is benefit in doing this eye as it will get rid of the cataract and let more light in and possibly achieve some vision...
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When she asks about the Clareon option he says he likes the lens and recommends it. It costs $300 per eye more than a basic AcrySof IQ, but is done in his clinic and is available much sooner (6 weeks)... It seems his recommended course of action is to do both eyes with the Clareon lens. We will have to confirm it, but I don't believe the Clareon is available as a toric yet. So this will leave here with mild astigmatism in her good eye, and severe astigmatism in her amblyopia eye. I guess the assumption is that eyeglasses would be used to make the final correction if needed.
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But, then I read the package of information she was given, and it does not talk about the Clareon option at all but says she qualifies to use a toric lens at and extra cost of $1050 per eye. My wife does not recall him recommending a toric though.
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So what do you think? The course seems to have been set to do both eyes using the Clareon non toric lens, with the amblyopia eye first. The other option would be to do both eyes with AcrySof IQ Toric lens and possibly wait 6 months or more for the surgery. Or, reverse the order from what he prefers, and ask for the Clareon in the better eye, and wait to do the second eye with a AcrySof Toric? He apparently did mention that he likes to use the same model of lens in both eyes. I think that is bogus as the lenses are so similar. And underlying all of this is that I am skeptical that she is going to see anything out of the amblyopia eye regardless of what lens is put in it.
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Thoughts???
0 likes, 18 replies
lucy24197 RonAKA
Posted
I'm not sure if it's approved in Canada, but a quick search for Clareon Toric showed that there are toric Clareon lenses and they were approved by the USA FDA on the same date as the standard lens. The model numbers are CNW0T3, CNW0T4, CNW0T5, CNW0T6, CNW0T7, CNW0T8 and CNW0T9. If they were submitted/approved at the same time here maybe they're available in Canada.
RonAKA lucy24197
Posted
That is very helpful. I was not there so I am getting all this info second hand from my wife. All they gave her was an extra form saying she was "eligible" for toric lenses, and the price of $1050 per lens. Will have to clarify with them that the toric is available to them in the Clareon material. That CNW0T9 sounds promising, as it looks similar to the AcrySof toric model number that provides 6 D of cylinder power, which is the maximum. If the Clareon is available in a toric that resolves the issues. There is still the cost but if vision can be improved that is not an issue either. I will do some more searching and questioning of the surgeon.
kathleen07994 RonAKA
Posted
I have a very similar situation. I have a high degree of amblyopia in my left eye. Cataract surgery will generally not improve the vision in a highly amblyoptic eye. It will remove the cloudiness and allow more light to enter the eye. Uday Devgan has a good video on amblyopia and which eye to do first. The title of the video is "Cataract & Hx of Amblyopia. Which Eye Gets Cataract Surgery First? Why?" From everything I've read (and I've searched extensively for articles about amblyopia and cataract surgery) it would be unusual to operate on the amblyopic eye first. I am scheduled to have surgery in four weeks on my functioning right eye. Surgery on my left amblyopic eye will follow 2 weeks later. My left eye will receive a basic monofocal lens. The right will receive a premium lens to achieve the best vision possible in my only functional eye.
RonAKA kathleen07994
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I have to admit I am a little skeptical that vision can be improved in her amblyopia eye, but cost is really not an issue, and if there is any hope we would be willing to try it. 40 years ago or so when a cataract surely was not an issue, one optometrist convinced her to try patching the good eye to force the other eye to start functioning. She did not stick with it, as there seemed to be no progress. For that reason I find it hard to be optimistic. However, -7.3 D of cylinder is a lot, and she may have had that at the time and had no correction for it. I guess it is in the faint hope category. Thank you for the video title. I will check it out. What the surgeon told her was that he likes to operate on the worst eye first, and the cataract is worse in the amblyopia eye. He said that they always "learn things" when they do the first eye that they can apply when the second eye is done. Sounds a bit crude, but seems like he likes to practice on an eye where there is not much at risk, so he gets it right on the second eye. It may make a bit of sense because I see from posts here that the surgeons do miss on the power at times. I recall he said something similar to me when I had my eye done. It was something like I like to do the distance eye first, and depending on how it turns out we can consider other options for the second eye...
RonAKA kathleen07994
Posted
I watched the video. I think basically what he is saying that if you do the amblyopia eye first the patient will likely be disappointed with the outcome and may defer the second eye surgery. My wife's doctor is saying he will learn on the first eye and do the second better... I just just different philosophies on how to get through the whole process, but really no technical difference in the order.
Sue.An2 RonAKA
Edited
Your poor wife - sounds like such a hard choice. Wish her the best.
My opinion for what it is worth would be to correct the astigmatism with a toric lens. Yes sounds like a lot of money but will be worth it. In 2017 paid $900 per Symfony lens. We are fortunate Canada covers cost of surgery regardless. Others pay so much more.
Just saw my optometrist this week and my RE (the one without the Epiretinal membrane) now sees 20/15. And I read well in good lighting conditions without using readers. Perhaps brain compensating for LE. since cataract surgeries my vision was 20/20 so not sure why after 3 + years I gained a line.
RonAKA Sue.An2
Edited
Yes, it is a difficult choice. If the Clareon lens is available in a toric it will be easier. Then it will be a toric in both eyes, regardless of the cost. Still lots of things to clarify with the surgeon. We have a more precise number on the amblyopia eye at 7.3 D which is extreme and merits a toric if there is any hope of vision. The better eye is only listed as a range of 0.5 to 1.25 D. 0.5 D isn't worth a toric in my opinion, but 1.25 D is.
RonAKA
Posted
As an update we got to talk to the surgeon today. He confirmed that the Clareon was not available as a toric currently in Canada, and he is not sure when it will be. He also recommended that if cost is not an issue that he would recommend the toric lens in both eyes, and do the amblyopia eye first. As it turns out he can do the AcrySof IQ Toric in the outside clinic as well. She now has appointments for Nov 9th and December 1. It is a little disappointing that she could not get the Clareon lenses, but I really do not think they are significantly better optically, and since both eyes need astigmatism correction a non toric Clareon would not be nearly as good. I had initially thought the Clareon lenses were the ticket to avoid the long wait time for surgery, but as it turns out he will do the toric in the outside clinic as well. Total cost will be $2,100 for both eyes, plus the eye drop prescriptions which will be about another $100. They will write a prescription and we will get it filled at Costco.
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The surgeon says it is really hard to predict the outcome with the amblyopia eye as he says in some cases it makes a big difference, and in others not so much. So we will spend the $1,050 and hope for the best. If she was ever to lose the vision in her current good eye, at least the optical components would be in place to allow vision if her brain could neuroadapt to a much better possible image. In addition to the 7.3 D astigmatism, she is also very short sighted in the amblyopia eye.
soks RonAKA
Posted
ron, your last line is very important in my opinion. my daughter has an amblyopic eye and that eye is near sighted. i have been thinking about it and wonder if it makes sense to put iol in that amblyopic eye for near vision. that way she could get near vision from the amblyopic eye along with the light for pupil dilation. the other eye could get the distance monofocal. good luck and keep us posted.
RonAKA soks
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We did not actually talk about what kind of correction he would target, but I assumed he will go for distance vision in the amblyopic eye. Perfect vision is not going to be theoretically possible with the IOL as the highest power toric is still not enough to correct the astigmatism she has. He did not mention any issue with the spherical power, but did say she was very near sighted.
soks RonAKA
Posted
higher the astigmatism better the near vision.
RonAKA
Edited
As an update my wife got her cataract surgery done for the amblyopic eye on Tuesday this week. It went well, and she feels she is seeing better. Colours and sharpness are improved, which is likely the result of getting rid of the cataract. Too early to tell if overall acuity will improve. She says she can read a couple of lines on the eye chart, but not much below that. She feels like that eye is now contributing to her eyesight and she has more depth perception to park the car in the garage. That is good as I have had to repair the door frame of the garage on more than one occasion! I guess time will tell if the improvement will continue. The second eye is now scheduled for December 3. She will likely see a large improvement from having that one done. Both eyes are getting a toric lens. The surgeon says that the toric will provide the best chance of restoring some vision from the eye with amblyopia.
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Interestingly after all these year of having many different optometrists look at her eye condition this surgeon mentioned that he sees what looks like a tear in the membrane under the cornea of this eye. This has never been raised as an issue before. He says that can be the result of a forceps delivery at childbirth, although the direction of the tear is not consistent with ones incurred from forceps delivery. So perhaps that is the reason for the overall issue and high astigmatism (-7.3 D) in this eye. I presume there will be scar tissue from this tear that may be interfering with vision, so that part is not going to be improved with the toric IOL. Her mother and father have both passed some years ago, and have never told her about issues at childbirth. So I guess that part will remain unknown.
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Edit: I did a little more research on this issue, and found this interesting article:
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Forceps-induced birth injury to the cornea Ruba Alobaidy and Sathish Srinivasan
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Her condition is not perfectly matched to what is reported here for a forceps damaged cornea, as it is her right eye, not left (but that is just a matter of most common baby position), and the tear is horizontal not the typical vertical for forceps damage. It appears the only really good treatment is a cornea transplant. I suspect with our public healthcare system that is not going to happen. The other cause mentioned which is more consistent with a horizontal tear and not vertical is congenital glaucoma. She currently has normal pressure in her eye, so that is kind of contradicted too...
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It is interesting that this surgeon says he only saw this condition during the surgery. Not sure why, but perhaps the tools used during surgery provides a better view of the cornea.
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In any case something to consider if you have amblyopia.
Bookwoman RonAKA
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Thanks for the report Ron, and I hope everything continues to go smoothly for your wife. She's lucky to have an inquisitive husband who now knows so much about cataract surgery!
RonAKA Bookwoman
Posted
Thank you for the encouraging words. We are hoping the vision improves over time.
RonAKA
Edited
My wife had her second eye done today. All seems to have gone well. They used a 19.5 D SN6AT2 AcrySof Toric. This lens only has a cylinder power of 1 D, which I didn't realize was available. I think most other IOL's start at 1.5 D cylinder minimum. Because it was a Friday the post operation exam was done only 7 hours later in the afternoon. She tested at 20/30 so that seems pretty good that early in the recovery. The other (lazy) eye was checked and tested, and there has been no miracle there. It looks like she is going to be stuck with very minimal vision out of that eye. In any case it is good to have it over with.