Vision worsening and improper focus distance after cataract surgery

I would get to the bottom of what the issue is before going ahead with the second eye. I would hope the problem could be avoided in the second eye once there is an understanding of the issue in the first eye.

Thank you Night - Hawk. It's helpful to know that. From the beginning I wasn't in 1m-inf, more like 2m-inf, but with very good far sight. Now I am more like in 3m-inf and with bad far sight. I'll speak to the doctor, it helps me to get all this information before hand

Good idea to get all this clear before doing the right eye, RonAKA

If your objective is to be free of glasses after getting both eyes done and you ended up far sighted in the + range, that is not good. About the only options are to get the lens removed and the correct power lens put in. Or, you could get Lasik to correct the error. Neither of those are great options though.

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If you planned to use progressive glasses to see close and far, and perhaps correct some residual astigmatism then it is no big deal. You just correct all the residual errors with glasses as well as get reading with progressives.

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I think I would first determine if there is something wrong with the lens position, or it has tilted. Could it be moved back into place? That is what I would ask about first.

Thanks RonAKA, I already assumed I'll have to use glasses for short distance, no problem with that although I would have liked to be ok 1m-infinitum. Using progressive glasses would be a very sensible option, my brother has a pair of those and he is very happy.

About the potential lens movement, I feel like my vision has been worsening over time after surgery, not just suddenly, not sure whether that fits with the lens having moved. I would expect that to happen in a precise moment.

I forgot to say something: two weeks ago I started having some negative dysphotopsia. Perhaps that's because the lens moved?

Yes, the negative dysphotopsia if it was not present from the beginning is possibly an indicator of lens movement. Was it a toric lens to correct for astigmatism? If so the other possibility is that it has rotated out of angular position. However, that does not account for loss of closer vision, or the dysphotopsia.

They were standard lenses I think, model PCB00, diopter +22.5 D, øT 13mm, øB 6mm

Yes, that looks like the standard Tecnis 1 piece monofocal lens. The lens is 6 mm in diameter and the overall diameter is 13 mm with the flexible "legs" that keep the lens centered in the eye. When the lens is inserted in the capsule in the eye these legs bend and serve to center and stabilize the position. One issue can be that one of the legs if not positioned properly can poke back out through the hole made to insert the lens. Then the lens can tilt or go off center. An optometrist or surgeon will be able to easily see that if that is the case.

Thanks very much, RonAKA. That's both interesting and helpful. As a scientist I like to understand things.

I have an appointment with the ophthalmologist on Thursday. Today I went to the optician to get a prescription so I have something objective to share with the ophthalmologist. The optician said the lens is in place, but I will need glasses both for near and far sight, getting 20/20 vision out of them. He said I have a tiny cataract on the right eye and I need to think whether is worth or not to operate. The benefit would be to have both eyes balanced, the disadvantage would be to lose my ability to focus with that eye.

This is my prescription:

Right eye:

Sph: Distance 0.00, near 1.50;

Cyl: -1.00

Axis: 105

Left eye (the one operated):

Sph: Distance +0.75, near 2.25

Cyl: -0.50

Axis: 100

My questions for the ophthalmologist are:

-What do you think of this prescription? Should we change the plans for the right eye?

-Why I had perfect vision right after surgery but now it keeps worsening, with some fluctuations?

-What do you think I should do with the right eye? Balance with the left eye or wait until the cataract develops more?

-I've caught myself a couple times rubbing my eye while asleep. Is that ok after 1 month or should I wear some protection?

Although I want to understand and get the best out of this, I would be happy if I am just told "stop worrying, be grateful and enjoy your new sight"

So that new prescription from the optician verifies that indeed your left eye did end up significantly far-sighted with the +0.75D value. That would indeed make your near and intermediate vision worse while still giving you good far vision.

If you have the right eye cataract operation you should probably target it for a little nearsighted like -0.50D or even more to give you a mini monovision to help with intermediate/near vision while the left eye handles shart far vision.

Rubbing the eye is not recommended, but probably has little effect after one month - its mostly critical early on like the first week or so after the operation. Also its more critical to avoid rubbing if you got a toric IOL like I did since that could cause rotation.

I would have your eye prescription checked again after a couple more months - the eye should be fully stable by then hopefully but probably if the Rx changes it will only be slight from this point on.

Thank you, Night - Hawk!

At some point I was considering that trick of the monovision and asked the ophthalmologist. But he didn't seem very convinced. Isn't it better to have both eyes balanced? and easier to use later progressive glasses if both eyes have the same "problems"? At present I'm using the right eye for near vision and the left one (+right too) for far sight. For near vision I can say this doesn't feel very well. I guess it's difficult to know what's best for each person. Anyways, I'll bring this possibility again with the ophthalmologist, thank you!

You should have very good vision in your right eye, unless it is starting to get hazy due to a cataract. There is no need to let the cataract get "ripe", nor is there a need to rush it. I think if I could see well with it, then I would hold off for a year or two, unless it becomes an issue. It might benefit from a toric lens. It will depend on how much of the cylinder error is in the cornea and how much is in the natural lens.

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Your left eye now appears to be a miss in the bad direction - hyperopia. That messes up your near vision. The puzzling part is why was it good and then it changed. I would still worry about the lens position not being correct. I would ask the surgeon why it is so far off and why did it change. You may need to get an independent second opinion from another surgeon.

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I think I mentioned before that getting Lasik may be an option to correct the error. I just went for a Lasik consultation today and got a bit of a surprise. They are telling me, and I am not sure how well qualified this person was, that they cannot correct a hyperopia eye caused by an IOL lens that is the wrong power. I have not heard that before. So Lasik may be an option or it may not. The other option is to have the lens replaced with one of the right power. Your cylinder at -0.5 is quite low, so it would not have to be a toric lens, just the basic monofocal.

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So now I am doing a bit of research on how to correct error post cataract surgery. I found this one article, which is a bit dated, but you might find of interest. Hopefully this is enough that you can find it with Google Scholar.

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"Surgical options for correction of refractive error following cataract surgery

Ahmed A Abdelghany & Jorge L Alio"

Which eye is your dominant eye? Ideally you want your distance eye to be dominant. I have monovision, but it is called crossed monovision because my near eye is dominant. I think it has some minor issues, but still works.

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FWIW this is where I stand:

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Right Eye (non dominant): 0.00 D Sphere, -0.50 D Cylinder 20/20+ distance vision

Left Eye (dominant) -1.0 to -1.25 D Sphere, -0.75 D Cylinder

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I have two different readings on my left eye for Sphere, so I assume it is between those two numbers. What I would like to have is -1.5 D Sphere, 0.00 Cylinder, but I was told today they could not go in that direction. I am not sure I believe them, and I have two other places to get a consult to see what they say.

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This said I am happy with monovision even with my slight error. I have not really worn glasses since my second cataract surgery. In fact I don't have a pair with the correct prescription to use. I very occasionally use some OTC +1.25 D readers. It is worth looking at, but if your surgeon is not cooperative it could be an issue. Accuracy on the near eye is quite critical. You need someone that will do everything they can to make sure they come as close as they can on the lens power.

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If you want to consider monovision the best approach would be to simulate it with a contact lens. Considering your prescription, I would try a +1.5 D sphere, and -1.0 D cylinder toric lens as a trial to see if you like it. I did that for about a year and a half before I got my second eye done.

When I asked my doctor about monovision he replied asking which eye was my dominant eye. I have no idea, perhaps because I've been 2 years with an useless left eye I forgot I had a dominant eye... Do we all have a dominant eye?

In that paper you sent they mention LASIK : "However, in spite of all these advances, residual refractive error still occasionally occurs after cataract surgery and laser in situ keratomileusis (LASIK) can be considered the most accurate method for its correction." You may want to ask again.

I would love not to need glasses but I am not comfortable having two eyes working differently. Difficult decision...

Thanks so much for all the tips and information. If you are not an ophthalmologist it is impressive how much you learnt about it!

It may be difficult to tell which eye is dominant when you have little vision from one eye. Normally a right handed person has a dominant right eye, but not always. The quick test if you have vision in both eyes is to just point at an object across the room. Then close your right eye. If you are no longer pointing at it, then that indicates right eye dominance. If you are still pointing at it after you close the right eye then you are left eye dominant.

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It is usually better to have your distance eye as the dominant eye, but it is not essential. My close eye is the dominant eye (left one and I am right handed), and it still works.

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The normal target for distance vision is -0.25 D because you do not want to go over into the + side. That hurts near vision. And although there are varying opinions, I think having the close eye at -1.5 D is ideal. That means if all turns out well there is 1.25 D difference between the two eyes which is not much. I don't really notice it.