Need advice. Blurry vision since cataract surgery 5 months ago.

That's great information. Thank you Ron. I'm in the US. I have all of my medical files because I requested them in writing from their outside records company. However, they neglected to include lens information that the doctor used to decide upon my prescription. And other pieces of info that were not in my records.

And yes, i did get a card AFTER my surgery telling me which model lens was inserted, serial number etc. It would have been preferable to have had that BEFORE my surgery. I went in blindly (no pun intended) for this surgery without any detailed information. Thanks for your help!

You're very kind thank you Lynda. I am in the USA and did get my records (or at least the ones I know about) however there is missing information that I believe the surgeon doesn't want to disclose. I am not too far (albeit several hours driving) from top eye medical facilities but I am going to fly to see a doctor next week who previously worked at the Mayo Clinic and has his own practice now. Thank you for your help!

Yes that's correct David. No, I didn't see an optometrist. I was supposed to have a 1 month follow up with my cataract surgeon but they dropped the ball and didn't schedule me. Then I couldn't get in until 5 weeks post surgery.

I went to a different ophthalmologist at another clinic a few days ago and he said my cornea and retina looked fine although I have inflammation. Then he patronizingly said there's nothing wrong that I can see. And since he didn't do my surgery he couldn't comment.

I'm pretty sure my vision can be corrected, however I want to know what is going on with my eye before I correct it. If there is an incorrect IOL in there I'm not real happy about it. It's totally irritating my eye and also making my chronic migraines even more frequent because I have blurry vision and a cataract in the other eye. Sorry, that's more information than you need 😃 Thank you for your input!

You really should go see an optometrist. Any place will do… Costco, a glasses place in the mall, whatever. You don't need a referral of course just to get a glasses prescription. This could tell you a lot. If the issue is simply a missed target and not something more serious they can figure that out.

Thanks Trilemma. I did do all of the compound eye drops pre and post surgery for 3 weeks. I am not going to a optometrist at this point unless my new 4th doctor recommends it. But I appreciate your suggestions.

Thanks Bookwoman. I am in the Southeast USA. I was going to go to Wills Eye in Philadelphia but decided it was easier to fly to a Mayo Clinic doctor in Florida.

It is best to get this refraction from an optometrist that is financially independent from the surgeon that put the lens in.

Yes. Lay out the $60 for a good cause.

thanks Ron --- The doctor/surgeon never discussed targeted vision with me or what he had hoped to achieve. He simply said my distance vision will be corrected with that monofocal lens and I will need to continue w/reading glasses. There was some vision test numbers from my pre-cataract appt with him but he never said what they meant. I just obtained them from my online portal account.

They only checked my vision the morning after my surgery and said your eye is healing well.

I am going to get all of this information when I see the Mayo doctor next week. He is objective and an excellent background. And he has all of my medical records.

Besides a current eyeglass prescription the next most important document you need to see is called the IOL Calculation sheet. It documents the eye measurements, the intended target and the expected outcome with the lens power they use. Your can find an example of this data sheet by googling this:

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IOLMaster 700 Quick Guide Printing Functions EN PDF

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See page 5 of this document for an example of an IOL Calculation sheet. If you look at the right hand side for the OS (left) eye, you will see a Target ref of "Plano". That means a target of 0.00 D, or in plain words, Distance, as you were told. Then near the bottom are some potential lens powers that could be used to achieve plano. Two different formulas are being used to calculate what each power would do. One is the commonly used Barrett Universal II formula and the other the Barrett TK formula. They give different results and the surgeon has to decide which formula to believe and use. If we stick with the Barrett Universal the eye in this example is predicted to achieve a refraction (Ref D) of -0.05 D with a +11.75 D. Most surgeons in this situation would likely choose the +12.00 D lens with a predicted outcome of -0.22 D, or very slight myopia. This is to reduce the risk of going positive or far sighted.

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If you had this sheet from your surgeon you can use the power on the card you got for the lens to see what was predicted as the outcome for that lens power. And, if you get an optometrist refraction (eyeglass prescription) you can compare what you got to what was predicted. If there was a significant miss, and that can happen, it would explain your less than crisp vision.

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If there was a miss, all of this information is very important as it would determine what adjustments may be necessary to get an accurate outcome with the second eye. The other use of this document would be for your new surgeon to compare the eye measurements in the upper half to what they get when they measure your eyes. Some reasons for a "miss":

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1. Incorrect eye measurement
2. Less than ideal formula used
3. Simple mix up where the wrong power was inadvertently used.

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   Keep in mind that this IOL Calculation sheet will be in your surgeon's computer, and may or may not be included in your "medical records". You may have to request it in writing to get it.

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   Hope that helps some,

You are so smart Ron. That is such helpful information. It really helps me understand everything a whole lot more. Now trying to get my doctor to release his sheet but I know he has to by law. So I guess I will first try going through their Health Portal. That should be interesting.

I thank you very much and will let you and everyone know how it goes. I really appreciate it.

One more thing, is that was is called a Manifest Refraction? My file has numbers in two areas. One says Manifest Refraction and the other Manifest Refraction #2 (Auto).

I'm just wondering if they do the IOL calculations manually and also with a computer program. Or just solely a computer?

I also don't understand how they determine approval for cataract surgery. The nurse told me they include glare testing and I believe keratometry. The glare testing brought my 20/20 vision in my left eye to 20/80. This was of course done prior to my surgery.

Manifest refraction is just your glasses prescription which is determined by looking through a phoropter and the optometrist says "1 or 2" etc. It can also be determined by that machine where you just look at an air balloon or barn or something (autorefractor). The word manifest just means the test was done without any drops or dilation that could affect the result.

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A refraction isn't how they determine IOL lens power choice though. IOL power is primarily determined by axial length (how long your eye is). A machine called an IOL Master measures this as well as a host of other variables (angle K, cornea thickness, etc.) and plugs all that (plus the a-constant of various lens options) into a computer which outputs a list of lens options and their predicted outcomes. Typically the surgeon will choose the predicted outcome that is closest to plano or one notch / minus below plano (20/20 uncorrected distance vision). For this machine you just look at a light and keep still and it only takes a second. It's not really possible to just guess at IOL power or do it manually by just looking at you or doing an eye exam. You need this scan and all surgeons do this scan.

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I'm not sure what you mean by approval for cataract surgery. It's such a low risk procedure now that you can pay to get it done even if you don't have cataracts at all. They call that refractive lens exchange but it's the same surgery. The decision to have surgery is 100% your own. The only difference would be who pays. If you don't have a cataract (or if you do but you want a fancy expensive multifocal lens) then insurance (or public health in Canada) won't pay for it. If you have a cataract that is affecting your vision then you can typically get a monofocal or eyhance for free (or a nominal fee) through insurance or public health.

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All of that aside I will say again, you should go to your local glasses store and get an eye exam for a glasses prescription. This will tell you if your issues are due to the IOL power or something else. You need an optometrist for that. It's not really something that surgeons do or would even necessarily be any good at doing. It's not their thing.

It's such a low risk procedure now that you can pay to get it done even if you don't have cataracts at all.

There is the rub. If you you wont pay $60 for an independent refraction, ....

One quick and dirty test that has a long history, but is still used today is called the pinhole test. The optometrist will hold a paddle with one or more small pinholes in it, in front of your eye while you are looking at the eye chart. If your vision improves when looking through the pinhole then your refraction is off. The pinhole improves your depth of focus and if the refraction is off then vision will correspondingly improve. If refraction is not the problem then there is no improvement. You could do this test at home with a hole in a piece of paper and an eye chart at 20 feet or so. The ideal hole size is about 1.2 mm. Google pinhole eye test for more information.

thank you RonAKA - they did the pinhole test on me the other day at the 3rd ophthalmologist -- and yes my vision did improve in that eye.

BTW - I just received the IOL calculation sheets from my doctor . Shocked it was so fast. He used Lenstar. I haven't looked at the numbers yet.

This is very good information thank you David. I have learned so much from kind folks like you in this forum -- a lot more than from my doctors -- (or my extensive online research ). If I had had this information from the start I wouldn't have so many questions. My doctor never discussed targeted distance vision, etc. etc.

I thought I had read somewhere that the doctor should do a manual ( by hand) IOL formula as well as a computer / automatic generated formula. What did doctors do before all of these fancy computer programs?

My ophthalmologists are also cataract surgeons -- so yes they can do these tests but also their nurses/techs do them. Which I've often wondered if the numbers were off because the tech was SO rushed.

Yes of course I will go to an optometrist in the near future. Right now I have to see what will happen next week with the Mayo doc.

My question about cataract surgery approval meant --- how do they determine if you need it? I know I needed it but I was confused because my vision was 20/20 . And I know there must be more factors involved or no insurance company is going to approve 20/20 vision for cataract surgery. So I assume the glare testing made it obvious because then my vision was 20/80. I'm just trying to understand the components in the mix.

Thank you for your help....

I have no problem paying for an independent refraction from an optometrist and will do that next after I see the doctor at Mayo Clinic next week. I have inflammation which is also causing non stop burning in my eye. So medically speaking I need his thoughts on that as well. My doctors are ophthalmologists as well as surgeons. Thank you trilemma.

The Lenstar instrument if it is the LS-900 is a credible device. The data sheet should still have the important data which would include the target, the IOL used, the formula used, and the list of lens powers along with the one actually used, and the predicted refraction. This information should be of interest to your new ophthalmologist. If they take the same measurements they can compare the methods, data, and predicted outcome for the eye to the actual outcome (assuming they also do the phoropter refraction test).

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If you look at the line on the data sheet that has the lens power (from your card) there should be a predicted refraction outcome. This is the number to compare to an actual refraction test on the eye done now.

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The improvement when you look through the pinhole confirms there was a miss in the power of the lens, but until you have a phoropter test you don't know by how much and in what direction (too near or too far sighted).

"What did doctors do before all of these fancy computer programs?"

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If you go way back, I think they simply removed the cataract lens in the eye, and did not replace it with an IOL. Then you had to wear very very thick glasses to correct the vision.

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From the Dr. Hill site on IOL Power Calculations, he says that in 1977 when IOLs were available the state of the art method for calculating the IOL power was to add 1.25 times your eye refraction prior to cataracts to +18.0 D. So for example if you were near sighted and needed glasses with a -3.0 D correction the calculated IOL power would be +18 +(-3.0x1.25) or +14.25 D. This is a pretty crude method compared to today's many formulas.

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The method that Dr. Hill has derived is called the Hill RBF 3.0 and is based on artificial intelligence where the outcomes of thousands of cataract surgeries (and growing) are used to derive the formula.

Great info thanks --- I did read that pre-IOL they used non-corrective lenses to replace the cataract. I guess the corrective glasses used depended on the patient's vision pre-surgery. The glasses you describe sound like Mr Magoo's. 😉

Years ago in the late 1960s, my grandmother had cataract surgery. Back then they did BOTH eyes at the same time. And they used sandbags on either side of the head to prevent movement. That would be movement of anything - including the whole body. It was done at a hospital. My grandmother was in her early 80's and died the day after surgery from a blood clot. Really sad and totally unexpected. So yes we've come a long way in spite of the risks today. I was just glad my surgeon didn't kill me. (bad joke).

PS - I'm in my early 60's.

My mother went to the Mayo Clinic for her cataract surgery years ago due to her concern about what happened with her mother. They did an excellent job -- one at a time -- she was thrilled with the outcome. In more ways than one.

I have no problem paying for an independent refraction from an optometrist and will do that next after I see the doctor at Mayo Clinic next week. I have inflammation which is also causing non stop burning in my eye. So medically speaking I need his thoughts on that as well.

I don't see how the data sheets will help.

RonAKA suspects they can, but a refraction will be more to the point-- is your IOL correct, and how much is it off? I don't read the datasheets, but it seems to me that the datasheets would be more about figuring out what happened happened. The datasheets at this point would be useless in my hands.

In your Mayo clinic, I think you should bring a note with some simple facts, and the fact that I would include is that plano (distance) was supposed to be the target (IIRC).

I understand that irritation and infection concerns are your higher-priority things to address.

I think the more information/facts that he has the better. He can figure out the whole mess. I sent him my records with a cover letter highlighting my issues.

The datasheets are helpful in determining what was intended to be the outcome, and also diagnose what was the reason for the miss if there was one. What did the surgeon actually target? 0.00 D, -0.25 D, or -0.50 D? There may have been more than one formula used. With your refraction outcome you will be able to determine which formula was the most accurate in the prediction compared to what you got. And, even that formula may need to be adjusted for the second eye to get the most accurate result.

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And with the eye measurements you can even dive into the deep end and recheck the calculations used by the surgeon. The Barrett Universal II, Hill RBF 3.0, and Kane formulas have on line calculators which will accept the measurement data from the datasheet. Then you will have more formula predictions to compare to what was the actual outcome.

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If the overall objective is distance vision without glasses and reading vision with readers, it is not a disaster if there is a miss on the first eye. You just use that information to refine the target/formula for the second eye. If there was a significant miss then it is very important to determine the reason so it does not happen again on the second eye.

Hey Ron -- I finally had a chance to look at the IOL Calculation sheet you referenced and then looked at my doctor's IOL Calculation. So he chose the Hill RBF w/target refraction of -0.08D with a 22.00 D. It says 22.00D on my lens card and a couple other T and B mm numbers on the right side (not sure what they are).

Regarding this info you wrote in above reply:

*If we stick with the Barrett Universal the eye in this example is predicted to achieve a refraction (Ref D) of -0.05 D with a +11.75 D. Most surgeons in this situation would likely choose the +12.00 D lens with a predicted outcome of -0.22 D, or very slight myopia. *

Where did you come up with the -0.22D number?

The Hill-RBF formula is probably as good as it gets, especially if it was the 3.0 version of it. However, I would suggest the surgeon made a mistake by selecting the 22.0 D lens with a predicted outcome of -0.08D. that is just very slightly myopic, and the more conservative choice would have been the 22.5 D lens which should have given you something like -0.30 D. The problem with shooting for plano as he did, is that if you miss to the plus side you could come out hyperopic or far sighted. That reduces both distance vision and near vision some.

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In that example from the IOL Calculation sheet there are two columns side by side. One is the IOL Power used, and the column to the right is the corresponding predicted outcome for each power Ref (D). The predicted outcome for the +11.75 D lens is -0.05 D. Right above that the predicted outcome for the +12.0 D lens is -0.22.

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Your situation is very similar to the example on a relative basis. Selecting a very slight negative is risky. Your eye refraction test when you get it done, will tell you where you actually ended up. This Ref (D) number is a spherical equivalent. That is the sum of the sphere plus 50% of the cylinder if you have any (astigmatism).

Thank you Professor RonAKA -- I wouldn't be surprised if you were a doctor or an optometrist. Your information is invaluable and I really appreciate it.

Thank you. The real test is what your eyeglass prescription is for the eye. That will determine if the power is off, or if there is something else wrong.

Exactly. I had hoped to get there this week but something urgent took priority so next week hopefully. Thank you!

These are the results from my Pre-Cataract Surgeon's IOL Calculation - in May 2023 and My Post Cataract 2nd Opinion Exam from Mayo Doctor November 2023.

The formula/lens chosen by my surgeon was the Tecnis Eyhance DIB00

Target 22.00/-0.08

Pre-Cataract

Not sure if this exam includes my prescription for eyeglasses.

Post Cataract - Left Eye - I still have a cataract in my right eye.

It appears you had an autorefraction test for visual acuity with the results displayed in positive cylinder format (ophthalmologist style). Your predicted outcome for the Left Eye was

Spherical Equivalent:-0.08 D

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The outcome measured with the autorefractor and converted to negative cylinder optometrist format is:

Sphere +0.25 D, Cylinder -0.75 D, Axis 41 deg

Spherical Equivalent: -0.125 D (sphere plus 50% of cylinder)

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So, the Hill-RBF prediction was extremely accurate. If the +22.5 D lens has been used you would have ended up in the range of -0.40 D, and your vision would not likely be as good as what you have. I think the right choice was make for lens power. The issue, if I am reading these numbers properly is that you ended up with 20/40 visual acuity which is not great. The pinhole test improved it to 20/25 which would suggest if the sphere and astigmatism were corrected vision would improve. It is puzzling why you are only getting 20/40 with your spherical equivalent of -0.125 D refraction. This may be suggesting that the lens is not properly positioned in the eye. Don't know.

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One thing however to keep in mind is that I believe there are some known issues with testing vision with an autorefractor when the IOL is an Eyhance. More accurate results would be achieved with a phoropter instrument (which is better, one or two?). Getting a full eye test is still worthwhile. But the bottom line is that if things don't look sharp to you, that is what really counts.

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It is possible that you may have benefited from a low power toric lens to correct the astigmatism (cylinder). The lowest power available in the Eyhance (-1.50 D) may have been too much to use. However, the AcrySof IQ is available with a -1.0 D cylinder correction, and I recall the enVista comes with a -1.25 D cylinder option. Once you get the detailed eye measurements done for your right eye, the use of a low power toric should be discussed with the surgeon. Being left with -0.75 D cylinder is right on the margin as to whether it should be corrected or not. That said I have -0.75 D cylinder in my distance eye, and still get 20/20 vision with it.

If I interpret correctly, your left eye refraction from your Mayo report (2nd image) was sph -0.50 cyl +0.75. Seems acceptable. In spherical equiv numbers, I would say excellent. I am thinking that was similar to what RonAKA ended up with. I think I feel more of a desire for close to zero cyl (astigmatism) than most. But certainly not the big miss that we had suspected. But somehow your visual acuity in the left eye is 20/40. That is pretty marginal. That has to be something other than the lens choice. Your eye pressure was below average, and it make me wonder if you have been taking drops to prevent advancement of glaucoma.

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Ron, I interpreted the refraction numbers to be "Snellen" done by phoropter. Of course I am taking inference, and maybe it was not justified.

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It seems to say that your right eye prescription was sph +0.50 cyl+0.75

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Trix317, what symptoms remain for you on your left eye?

Hi, well my eye still has very blurry vision all around --- at least I can wear reading glasses to correct it. But since I was told by my surgeon that the lens would give me good distance and I would only need reading glasses like before I'm not thrilled. Plus I had 20/20 vision before the surgery and just used reading glasses. But the pre-surgery glare eye test said that eye was 20/40.

The Mayo doc didn't seem to believe this was an incorrect IOL calculation, but he said 10-15% of the time, the intraocular lens heals in a position that results in a residual refractive error. The surgeon tries to calculate the effective lens position (ELP) but there can be some variance in healing.

Okay so translation is? I have no idea other than I'm in the 10-15% category and my visual outcome was not good. It could be the way the lens is sitting. Or not. But I will get my answers one of these days from the optometrist in town who is wonderful and totally unrelated to my ophthalmology group.

So the target was essentially plano (spherical equivalent) and the autorefactor measured you at essentially plano… so on paper everything looks great but your line chart is 20/40. It's odd. It will be interesting to see if the optometrist can get you to 20/20 distance with glasses.