Does anyone have experience with having astigmatism corrected after cataract surgery? Due to my surgeon's reluctance to recommend a toric lens to correct my astigmatism I am expecting to be left with higher than acceptable astigmatism after my upcoming surgery. And, in addition he tells me that it is irregular astigmatism with is harder to correct, and the reason for a reluctance to use a toric lens. These are the surgical reduction methods I am aware of: . LRI - Manual limbal relaxing incisions is a older technology and seems to be used less and less. My surgeon says he does not do it any longer due to his inability to get predictable results. He recommends a laser procedure instead. . Laser-assisted in-situ keratomileusis (LASIK) - This is the most common laser method and would seem to be suitable for reducing astigmatism only. . Photorefractive keratectomy (PRK) - This method is a little more invasive, requiring a longer recovery period, but seems also to be suitable. . Small-incision lenticule extraction (SMILE) - This is a newer version of the LASIK, but from my initial research may not be all that suitable for smaller amounts of astigmatism. I am expecting about 1 D. . Any thoughts you may have on these methods would be appreciated?
I am still considering doing laser surgery to optimize the outcome on my recently done left eye intended to give my closer vision with mini-monovision. It is pretty good the way it is, but I think it could be better. I am still seeing a drop down shadow like effect on letters, especially white on black. I'm pretty certain it is due to the residual astigmatism after cataract surgery with a non toric monofocal (Clareon). . Cataract Surgery Results: Expected Outcome: Sphere -1.25 D, Cylinder -1.0 D Actual Outcome: Sphere -1.0 D, Cylinder -0.75 D Ideal Desired Outcome: Sphere -1.5 D, Cylinder 0.00 . . I know that I am not going to get an outcome of 0.00 Cylinder, but I would like to get closer to it. Perhaps -0.25 D is possible...., and with that amount perhaps -1.40 D sphere is ideal to give me the best monovision. . In any case I think I will go to at least the first step of a Lasik or PRK consult to see what they think they can do. I have prepared a list of questions below. Any thoughts on other questions I should ask, if 16 is not enough!!! . 1. Can cylinder and sphere be corrected at the same time? 2. What is the accuracy when making small corrections to each? 3. Is there any problem in targeting -1.5 D for monovision instead of plano? 4. How is the target set when cylinder may not be reduced to 0.0 D? 5. Would PRK or Lasik be better? 6. What is the relative risk of developing dry eye? 7. Are there any complications in dealing with irregular astigmatism? 8. Is custom Lasik going to provide any advantage with irregular astigmatism? 9. Can custom wavefront be used with PRK? 10. With custom Lasik how is the eye measured and the results programmed into the laser? 11. Do the measurements only compensate for cornea topography or total eye refraction errors? 12. Are there any complications in doing surgery in an eye that already has an aspheric IOL? 13. What is the cost of custom Lasik vs standard Lasik? 14. Is Intralase used in both custom and standard? 15. Who would do my surgery? 16. Who would I see if there are post surgery issues?
I've read many of your previous posts Ron and just wanted to say thanks for all of your contributions.
There's also conductive keratoplasty to consider. I know very little about any of these treatments.
I saw a W5 documentary about a rare complication from Lasik. You can find it by Googling "W5 lasik". It's on Youtube. I doubt I'd take the risk myself and would instead correct with glasses if/when needed.
I have not heard of conductive keratoplasty, and the eye clinics I have been recommended do not seem to offer it. I will have to do some research on it. My cataract surgeon recommended Lasik for what I am trying to achieve which is a very modest increase in sphere (<0.5 D) and a reduction in a mild degree of astigmatism (0.75 D cylinder). He said that the risk would be low as the treatment would be very minor compared to correcting a large amount of sphere, like -10.0 D. I plan to ask about whether PRK would be safer than Lasik, to see what they say. I also plan to ask about custom Lasik which is said to be more controlled with fewer side effect issues. . I had a quick look at the W5 article. Yes, it does appear to be a risk, but it seems to be very remote. Again, I would hope that the minor amount I would need, would seem to further limit the risk. So far the only bit of a red flag I have gotten is my age (72). I currently have an appointment at one clinic, and am waiting for a referral to two other clinics. All were recommended by my surgeon. . Thanks for the comments. All good things to consider.
Sorry, I can't help you much with your questions in this post of yours, I hope you already got the information you were looking for! But maybe you've already researched a lot and can clear me a doubt?! Let's say the IOL should have been chosen at 19.5D, but was wrongly chosen at 19.0D, resulting in a residual refractive error of 0.5D. Can this error be corrected (LASIK, PRK, SMILE, etc.) and if you get a 0.0D result, would that work for both far and near vision? Exaggerating: Would it be like explanting the 19.0D lens and replacing it with the 19.5D? Or does the laser not have the same effect as an IOL with the correct power would?
Yes, as far as I know Lasik, PRK, and SMILE can adjust the overall power of your vision. The IOL does it in the lens, while the laser methods do it by adjusting the shape of your cornea. In general a myopic eye is too long and steep. The laser is used to flatten the cornea shape out to make the correction. And if you have hyperopia then the laser cuts are made to make the cornea steeper. That would be my situation as the IOL left me with about 0.25 to 0.5 D less myopia than I wanted for my close eye. . However just like a monofocal IOL, these laser methods cannot restore both far and near vision. You have to pick one, the other, or something in between. Some Lasik places advertise that they can correct presbyopia but when you read the fine print, all they are doing is giving you monovision by correcting one eye for distance and the other for closer up. . I have a consult appointment with one Lasik place on Tuesday and will probably know a bit more about it after that. But, this is how I understand it from the research I have done to date. Hopefully they can answer some of my questions.
"However just like a monofocal IOL, these laser methods cannot restore both far and near vision. You have to pick one, the other, or something in between."
Now I realize that I didn't ask the question correctly. And if it's an MFIOL (EDOF or Trifocal), will the laser correct from far and close at the same time?
My best understanding of the EDOF and MF IOLs is that they still have an optimum distance power. That power has to be matched to your eye to give you hopefully 20/20 distance vision. If the power selected was wrong and you need for example a 1.0 D adjustment, then that could be done by removing the IOL and putting in the IOL with the 1.0 D change in power. I believe the same thing could be done with Lasik, but that is just my amateur opinion. My thoughts are that when the distance power is correct then the intermediate and close corrections built into the lens would follow. You would just ask to have a correction made to correct your distance vision to 20/20. But, that is something you would need to check with the Lasik specialists. . This said if your distance correction with the IOL is good, but you have issues, close or intermediate, then an overall correction with Lasik may not be possible.
You understand my question and, like me, you also believe that the laser will not be able to correct what only an IOL with the correct power would do. This is a little off-putting, when you think about doing a touch-up looking for something close to "perfect"...
I am not sure that is what I was trying to say. If you get a MF IOL and after it is implanted you do not get full 20/20 vision at distance due to the wrong power selection for the IOL, then I think it can be possible to correct that with Lasik. However, if your distance vision is correct and you get 20/20, but you do not like the reading or intermediate vision, then you have a problem. If you try to correct the intermediate or close, then you probably mess up the distance.
"If you get a MF IOL and after it is implanted you do not get full 20/20 vision at distance due to the wrong power selection for the IOL, then I think it can be possible to correct that with Lasik."
In this situation, will LASIK not only correct distance vision, but also change something in your near and intermediate vision?
Sorry for the silly questions, but I'm still trying to understand certain concepts.
I think it is similar to getting an eyeglass lens that is a trifocal. The top portion gives you the correction for distance, the middle intermediate, and the bottom closes. If the top portion is wrong for distance getting Lasik is like layering one big corrective lens over the whole lens. Yes it corrects the distance portion, but at the same time it makes an adjustment to the intermediate and close. The upside is that probably if the distance is off then the other three distances are off too, so they all may need correction. . At least that is my understanding of it.
I have a consult at the first Lasik clinic today and was very surprised with what they told me. Basically they said that they could not accurately use Lasik to increase my myopia by even as little as -0.25 D. They were happy to reduce it to zero and my cylinder to zero, but then of course it would be useless for reading. It is pretty good now, and I certainly do not want to make it worse. It was clear that this clinic is set up to correct young people to emmetropia so they can go without glasses. They are not used to dealing with someone that has already had cataract surgery. At one point I heard one of the two technicians tell the other when they were having trouble getting a good Lenstar LS900 reading that it was probably due to a cataract..... No, that is not possible. I was not at all impressed by this instrument. It seems you have to hold your eye still without blinking forever. . In any case I hope I get a different story from the other two places I expect to go to.
Thanks for the update! I'm very interested in your posts, but my thoughts are that LASIK cannot correct a residual refractive error the way an IOL with the correct potency would! I will keep following...
I am trying to line up two more Lasik clinics to see what they say. I was not impressed by the one I went to yesterday. I would not have even gone there in the first place, but my surgeon recommended it. I hope the other two are more professional. . I am getting conflicting information on what can be done. Some sources say corrections can be made over a wide range of myopia and hyperopia with accuracy in the 0.1 D range, and that it is the most accurate way of doing a post cataract surgery "touch up". A replacement IOL was said to be the least accurate way, a piggyback lens better, and Lasik the best.... It will be interesting to see what the other two clinics say. . The only good news I got from my consult yesterday was that I was correct in that I have irregular astigmatism in this eye, and a toric lens would not have been suitable to correct it well. They claimed that Lasik could correct the irregular astigmatism very well. So, my problem is the sphere correction. . I had a choice of a 18.5 D IOL and a 19.0 D IOL. The surgeon talked me into the 18.5 D which corrected a bit more of the myopia. Now, I'm certain I would be better with the 19.0 D IOL which would have left me close to -1.5 D sphere. And then if they could correct the astigmatism without messing up the sphere I would be good. But, I am not prepared to do an IOL exchange.
"I had the option of an 18.5D IOL and a 19.0D IOL. The surgeon convinced me to use the 18.5D IOL"
I'm still not sure, I think in my case the surgeon was between 19.0D and 19.5D and ended up choosing 19.0D, taking away some of my near and far vision, but I will only be able to confirm this if I do exams with another surgeon and in another clinic, as my surgeon insists that the refraction is 0.0D. If my suspicion is confirmed, I will also need LASIK.
The lower the IOL power the more correction of myopia it provides.
Inversely, The higher the IOL power the more correction of hyperopia it provides. If my surgeon chose 19.5D would it have given me better near vision, or am I wrong?
I got a call back today from the clinic that did the in person consult with detailed measurements. They basically said they cannot predictably increase myopia with laser. This seems to be at odds with many claims that up to +5 D hyperopia can be corrected with Lasik. To correct +5 D you would have to go 5 D in the myopic direction. Perhaps the key is "predictably". I guess if someone is at +5 D and you are targeting 0.0 D and miss by 1 D they may be still happy. I am at -1.0 to -1.25 D and want to accurately go to -1.5 D, which requires a lot of precision. I remember asking my cataract surgeon about the ability to make small changes and his response was that it was much easier to make small changes than to make big ones. But, he is not a laser specialist. He only does cataract surgery. . I found one article that does acknowledge that correction of hyperopia (movement in myopic direction) is more difficult. A quote: . "...the treatment of hyperopia continues to pose a challenge to many surgeons due to reports of unfavorable outcomes, including refractive regression, undercorrection, and loss of corrected distance visual acuity (CDVA) [1, 2]. The correction of hyperopia is considered more difficult because excimer laser photoablation must induce flattening in the corneal periphery with concomitant steepening of the central optical zone, in comparison to direct flattening in the center of the cornea for myopic patients. The technique requires larger ablation zones and accurate centration for uniform delivery of energy onto the cornea." . It can be found when searching for this: . Comparison of Visual Outcome After Hyperopic LASIK Using a Wavefront-Optimized Platform Versus Other Excimer Lasers in the Past Two Decades Published: 19 May 2021 . The clinic I went to is kind of like a McDonalds chain so you are not sure what surgeon you will get, or what laser they will use. They list that they have a Alcon WaveLight Allegretto EX500 wavefront guided excimer laser but I did not get far enough with them to know if they even have it at this clinic or considered using it. In any case there is not a chance in the world that I am going to push them to do a procedure with a laser on my eye that they are not confident in doing. So it is the end of the road with them. . I have one hope left and that is at a locally owned and operated laser clinic that has the owner doctor and one associate. I am waiting for my surgeon to transfer them my eye data before they will give a preliminary opinion. They have a excimer laser that based on my research is perhaps a bit better than the Allegretto model. It is the Ocular wavefront (IRX 3) imaging technology paired with the SCHWIND AMARIS® 750S laser. It will be interesting to see what they say. It appears the surgeon has at least looked at what I am trying to do, and has not rejected it outright. If it is a no go with them too, then it is probably the end of the road for this option. The up side is that I have very good reading vision, just not excellent... And, I would not want to drop a few thousand and go from very good to needing reading glasses! . I thought I have had is that if one is considering the use of Lasik as a touch up after cataract surgery, it would appear to be much better to end up more myopic compared to your optimum target. It seems it is easier to to correct myopia than hyperopia.
I got a bit of promising information today. The surgeon at the clinic which I had evaluated to be the best in our city to do this kind of Lasik has reviewed my file and is willing to do a consult. I had sent them information making it clear I wanted to correct the astigmatism while increasing the myopia to -1.5 D sphere. They did not dismiss my request outright and I have an initial consult now in August. I guess I will see at that consult what the risks are and how likely I am to achieve my objective of getting to -1.5 D sphere and as close as possible to 0.0 D cylinder in my near eye. Fingers crossed that they will be able to confidently do it.