Finally reporting back after 16 months - Part 1 "the positives"

[nh_user_1261018]

Hi All,

It’s been 16 months since my first cataract surgery. I’ve been meaning to follow up with the group as promised, but “waiting until things got stable” took a lot longer than I anticipated. Rather than give a long(er) narrative, I’ll just give the highlights in three parts: cataract specific, complications, and lessons learned.

Short background: in my early 50’s I was diagnosed with cataracts in both eyes. These didn’t manifest themselves as haze, but as double and triple vision. (Really annoying.) I had worn glasses since I was around 9, and my latest prescription before the cataracts started was between -9 and -10 diopters.

After much consultation and investigation (a lot of related info coming from this group - much thanks!), as well as considering what was available in the US at the time, I went ahead and had the Symfony IOLs implanted. Against the practice’s standard procedure of 2 weeks, but due to recommendations here, I spaced the two procedures apart by 5 weeks. I ended up with the toric version for both eyes, and both lenses ended up being exactly the same prescription (which is something that my doc, who does a lot of these, says that he never sees for someone coming in with a previous prescription at over -9 diopter.)

The lens replacement procedures themselves went smoothly, and my vision was far better than before with glasses, essentially right after the bandages came off. Fast forward to today, and I have 20/15 in both eyes without glasses at distance and intermediate, with really good reading vision only occasionally requiring reading glasses for protracted reading sessions - this near-range result doesn’t happen as frequently with this IOL or EDOF lenses in general.

There are indeed nighttime effects - halos and “spiderwebs” around lights - even after a year. I do indeed still see them, but frankly they don’t bother me all that much. There also is a bit of contrast reduction, which you’ll get with any multifocal - it’s just physics - which manifests itself with needing a bit more light for reading stuff in low light or “dark gray on black” print scenarios. Given the previous amount of chromatic distortion at the periphery, as well as significant problems with small text, I’ll take all of this “distortion” over what I used to have with glasses. (As my doctor said, with IOLs at my relatively-young age, it’s usually a matter of “what you’re willing to give up”.)

On to Part 2…

[nh_user_1261018]

Part 2: “yeah, however…”

That’s the “easy part”. Unfortunately, there were complications. Due to my age (which meant that the vitreous was only in the process of breaking down), my stronger myopia, and (as it turns out) my relatively-thin eye walls, I proceeded to have two retinal detachments: first one at around 8 weeks after the first eye, and the second one about 5 months after the second eye (and right at the start of the Big COVID Medical Shutdown - huzzah!). These detachments were basically around the entire periphery of both eyes, with some additional tearing with my left (second) eye just inward of my left peripheral vision. Both of these were caused by vitreous traction on the retina, exacerbated by the ultrasonic lens removal during the cataract procedure.

Retinal detachment and the reattachment and vitrectomy surgery are a whole different level of stress and complexity compared with IOL implants. Nothing was bad-enough for immediate hospitalization, but watching the “gray curtain” slowly creep toward your center of vision over the course of a couple of days is nerve wracking. Afterwards, I got the whole “keep your head facing the floor for 45 minutes each hour and all night, for up to 2 weeks” deal for each eye.

I had a different retinal surgeon work on each eye, so it’s not completely apples-to-apples: the right eye is basically as it was before, with any effects of the laser and vitrectomy being outside of my peripheral vision. The left has a bit of peripheral vision loss, but oddly-enough it’s “getting better” … mainly due to the affected area becoming more quickly responsive to changes in light levels. My pupils are slightly larger than before, and they don’t dilate or contract quite as quickly as before, but all things considered these are relatively minor.

Also due to my relatively-young age, I was warned that PCO was almost a guarantee, likely within a year. I made it to 15 months before needing the YAG followup, which restored my 20/15 in both eyes at the expense of a tiny bit more nighttime effects in the periphery. Getting the capsulectomy basically makes a lens replacement way more difficult at this point (although my doc is one of the minority who can do these), but given the overall results I’m pretty satisfied with where I am now, correction-wise.

Part 3…

[nh_user_1261018]

Part 3: “lessons learned”

So … yeah. 16 months and six procedures later, and here I am. On balance, I’m still ahead, in many ways with better vision than I’ve ever had, minus some loss of left peripheral that frankly I didn’t really have anyway when I had to wear glasses.

In retrospect, the biggest things that I’d suggest for someone in my shoes - under 60, strong myopia: first, understand that the risk of detachment is much higher with you than with others who are older or have weaker prescriptions. I got lucky, and had a referral to a very strong retinal practice - the doctor who did my IOLs is also one of the strongest in his area regionally, so this played into it. It might not be a bad thing to do some upfront legwork looking into retinal surgeons before the IOL procedure, just in case.

Second, you’ll hear the “showers of floaters” and “sudden hazy vision” symptoms of retinal detachment. I had those in both eyes. When that happens, that’s due to blood leakage caused by tearing, and it’s time to get to that retinal surgeon, pronto. However, in my case there were some visual signs that in hindsight should have been warning signs, but unusual-enough that neither the IOL surgeon nor the retinal surgeon interpreted them as such. For me, particularly in my left (second) eye, it looked like gray strands that would sway into and out of my vision, attached to a point above my vision. I expect, although I don’t have any medical confirmation here, that these were part of the vitreous that had become partially detached and was causing the retinal traction on the periphery. In any case, if you see things like that, definitely bring it up with your retinal specialist as cause for concern: these aren’t likely just “increased floaters”.

Last, even though your IOL surgeon may be very talented, there’s a reason why retinal surgery is a separate specialization. For my first detachment, I had one of the practice’s “normal” doctors say that everything seemed fine … but that I should get a second opinion from their retinal specialist. The second opinion was “no, everything is not fine, you need surgery in short order”. When in doubt, if your vision seems hazy and “off”, getting that referral may not be a bad idea.

All said and done, my vision seems (finally) pretty stable at this point, and I’m hoping to (again, finally) get on with life. If folks have questions, I’ll probably monitor the group for a week or so.

[nh_user_1293490]

High Myope like you (over -19 glasses prescription in right eye now) also in early 50s. I’m curious about your cataract symptoms. I too am having double vision, but only with both eyes open at the same time. Was yours the same? You also mentioned at the end the chromatic distortions with your IOL are less than what you had with your cataract, what were you experiencing? If I have a bright light, like the group above the bathroom mirror, directly overhead, I get somewhat of a whiteout affect with my right eye (this doesn’t happen with my other eye). Block the light or turn it down and things are almost ok, except for colors. Switching back and forth between eyes, it’s as if someone has adjusted the contrast badly on the tv. Darks are a little darker, gray and black may merge, and a very slight yellowish tint, but so slight it’s not always noticeable, more noticeable in brighter environments switching between eyes. If you take away the whiteout affect, the color difference is minimal and the image from that eye isn’t bad, the double vision is the biggest problem. Is this similar to what you were experiencing?

[Sue.An]

haven’t read your 2nd or 3rd part but sounds line all went extremely well. Was similar age as you when I made this decision - giving something up but ended up with these same results with Symfony.

[Sue.An]

Thanks for sharing your story. Glad there was a happy ending for you.

[nh_user_1261018]

Hi Scott,

Keep in mind that, as always, all of this is coming from someone who is not medically trained (although, wow, do I now know more about eyeballs than I ever thought that I’d know).

“I too am having double vision, but only with both eyes open at the same time. Was yours the same?”

Not the same as mine was, so I suspect that this is something else. I had double vision in one eye by itself, and triple in the other eye by itself (can’t remember which was which). It was uncommon-enough that the medical assistant performing the initial evaluation thought that I was cracking some sort of annoying joke. Had to explain to her afterwards that, no, I actually saw three copies of that big “E” in one eye: one dark and fuzzy, one clearer and thin, and one kind of a shadow image to the lower left of both.

“You also mentioned at the end the chromatic distortions with your IOL are less than what you had with your cataract, what were you experiencing?”

Sorry, what I meant was that I had chromatic distortions toward the edges of my old glasses. High index prescription lenses will often do that. I don’t have any such problems with my IOLs. What I have noticed is that colors are a lot more blue / lot less yellow with the IOLs than before. (I compared the treated eye with the untreated a day or two after implantation.) That’s apparently a very common side-effect of cataracts and aging of the natural lens in general.

The “whiteout effect” with loss of contrast that you’re describing is a common side-effect of cataracts when you’re presented with a strong light source from the side. I had that, particularly badly in my right eye. From memory of the intake test, the resulting glare dropped my corrected vision in that eye (pre-IOLs) from around 20/30 down to around 20/400. Note that in my experience one can also get glare from corneal issues as well (e.g. dry cornea), and there may be other causes that I don’t know, but it’s definitely common with cataracts. I can’t speak to the changes in color perception, except as related to my IOLs being less yellow than my natural lenses were at the time. (Note that some IOLs are slightly yellow tinted as well, reportedly to filter blue light. Mine aren’t, and there are plusses and minuses to yellow-tinted IOLs IIRC - on balance, I preferred the non-yellow tinted lenses, although I didn’t have a ton of EDOF options.)

[nh_user_1291666]

I would agree with Ivan in that I don’t think double vision with two eyes, but not individual eyes, is a result of cataracts. I had a cataract in one eye and it certainly caused me to have double vision in that eye only. In fact that was the first symptom that alerted me to having a cataract and made me go to have my eyes checked. However, if you only have double vision with both eyes open, I would wonder about the possibility of prism. Your eyeglass prescription should tell you if you have prism issues. As I understand it, IOLs cannot correct prism, although there may be some eye muscle surgery that could reduce the prism effect. Normally eyeglasses are required even after cataract surgery to correct prism.

[nh_user_1261018]

Hi Sue An,

Yep, it’s shaping up to be an “alls well that ends well”, minus some residual corneal dryness that I’m working through in my left eye (that retinal surgery was rougher than the first).

Was still pretty nerve-wracking at times, especially when all one can do is sit (face down) and think about stuff.

[nh_user_1074331]

thanks for sharing. u were prone to retina detachment because you were a high myope. it would have been better to get YAG before the retina detachment as the capsule fragments would have been removed with the vitrectomy. what visual signs should have been warning signs? what doctor does the lens exchanges on a regular basis? how did PCO affect your vision?

[nh_user_1261018]

“u were prone to retina detachment because you were a high myope.”

Yeah, and the thin eyewalls (diagnosed by the second retinal surgeon) were apparently the icing on the cake.

“it would have been better to get YAG before the retina detachment as the capsule fragments would have been removed with the vitrectomy.”

Given all that was going on - both onset of PCO and visual distortions that in hindsight were due to vitreal issues rather than floaters - there was a bit of back-and-forth between the IOL surgeon and the first retinal surgeon about which to do first: YAG or floaterectomy. By the time that the retinal detachments hit, there was no real time to quickly slip in a YAG. Past that, having the capsules intact IMO increased the chances that the IOLs wouldn’t be shifted by the retina surgeries, which is a risk … although how much this helped I don’t know. Given the otherwise amazing correction results, I really wanted to avoid lens displacement.

Frankly, the only way that all of this would have been avoided would have been for me to get a pre-emptive double vitrectomy prior to cataract surgery. However, I’m not sure how anyone would have been able to medically rationalize that, all things considered.

As it turns out, the YAG only added a floater or two in each eye. I rarely see them in my right eye. The left eye (courtesy of the second retina doctor having a less OCD personality than the first, as well as the entire medical profession kind of freaking out about patient contact when COVID first hit) had a few floaters present after the retina surgery, and the YAG produced one or two extras that I would otherwise likely not notice much, if my right eye is any indication.

“what visual signs should have been warning signs?”

If you’re talking about warning signs of an impending detachment, I’d say that a LOT of additional floaters and haze starting a couple of weeks after the IOL surgery would be the biggest ones. I previously had quite a few floaters in each eye (way more than I have today), so I wasn’t really able to judge what would be considered “excessive”. The “swinging, stringy curtains” should definitely be of concern, although at the time it wasn’t identified as one.

One of the biggest problems here is that cataract patients - and retina patients - younger than mid-60s or so are a small fraction of what these doctors typically see. Add to that patients that are at a higher risk due to eyeball shape, as well as patients that are willing to effectively educate themselves about the procedures and side effects, and you’re talking about a fraction of a fraction of a fraction. True, they can and do make predictions based upon known risks added together, but I suspect that the associated in-person experience with all of these combined is still kind of sparse.

“what doctor does the lens exchanges on a regular basis?”

My cataract surgeon has done quite a few intact capsule lens exchanges, mainly swapping out multifocals / EDOFs for single-vision lenses for those who couldn’t tolerate the side-effects of the former. He does not encourage doing so, which is why one has to kind of convince him to go with multifocals and EDOFs in the first place: his conservative preference is monovision with single-vision lenses. He, like most surgeons who will swap, basically will entertain one exchange per eye: the risk of complications with more than one is just too high.

He is also one of the roughly 10 - 15% in the US who can successfully replace IOLs with a non-intact capsule. He really, really doesn’t want to do this outside of medical emergency, however: this takes a 15 minute procedure and turns it into a few hours, and the outcome of the results is far more uncertain.

Pre-COVID, he was doing about 20 or so IOL implants a week for years, so I suspect that he’s pretty aware of his capabilities in this area. In my case, with my results he basically said that swapping my lenses at this point would be stupid: everything ended up perfectly aligned, the resulting correction was way better than most outcomes especially given my previous prescription, and I’m not all that bothered by the accompanying Symfony night time effects. All things considered (including not wanting to risk any more retinal complications), I basically agree with him.

“how did PCO affect your vision?”

Just a gradual worsening of visual acuity. My near vision was the first to be impacted, which with these lenses is not surprising (since Symfony isn’t known for its near field results). Overall vision started getting impacted a month or three afterward (retinal surgeon said that I still had 20/20, but he suspected that it was a “hazy 20/20”), and side-light glare started to become a problem again. I could also tell which eye was getting more impacted by PCO due to the colors becoming slightly more yellow than the other eye - not tons, but noticeable if one did an “AB test” between both eyes and paid attention.

Frankly, the follow-up checkups for both the cataract and the retinal procedures indicated progressive PCO way before I noticed anything significant. Given what I was told upfront about my chances of PCO, I wasn’t surprised.

[nh_user_1074331]

thanks for the responses.

“Frankly, the only way that all of this would have been avoided would have been for me to get a pre-emptive double vitrectomy prior to cataract surgery.” - i think they only do that for diabetic patients with glaucoma.

[nh_user_1293490]

Thanks for the reply and information. Also sorry to hear you had to go through two retinal detachments and vitrectomy for both eyes after the cataract surgery. According to my surgeon’s notes, my left eye has had a posterior vitreous detachment, the right eye has already had a vitrectomy and they lasered the thin areas as a precaution as I am high risk and they were already in there. So not as concerned about my right eye.

Normally a vitrectomy causes increased myopia of a half a diopter or more (it did for me). As you had your IOLs already implanted, how did the vitrectomies affect your final visual acuity and prescription?

Due to the extra 3/4 diopter I received in my right eye from the vitrectomy, most likely I’ll ask to have the left eye targeted as less myopic anticipating a possible vitrectomy and myopic shift for it in the future; so mini/mono with my left eye better for distance.

Like many here I think I’ve researched this to death. I arrived at what I think are reasonable decisions, understanding there are many variables outside my control, quite some time ago. Time to stop researching and just wait for the appointment to discuss with the Dr. Only 2 and a half weeks.

[nh_user_1293490]

The double vision started about 2 and a half years ago, as the floaters in my right eye intensified. October of 2019 is when the distance between the two images increased substantially that it affected driving and I decided I had to get the vitrectomy. Post vitrectomy, the double vision greatly decreased. There was never any from 0 to 4 feet but it will happen randomly the further in the distance something away is. I suspect some of it is neurological, the floaters and bad vision in the right eye may have trained my brain to not rely on it (there are other less likely possibilities, like a stroke or some rare disorders affecting the optic nerve, but most of those are hereditary and don’t run in my family). I’m hoping it’s just Anisometropia, that the difference in between my two eyes is too large as the right eye, while improved after the floater removal, is still more than a diopter difference from the left. I did have an experience only two weeks ago, where for the first time in the two and a half years, the double vision was completely gone, at all distances. It was greatly decreased the second day, and slowly became like it always is, fairly random at a distance. That day it was gone I put in new contacts. It could have been coincidence as my contacts are 30 day disposables, and I’ve put new ones in many times and not had that result, but it gives me hope that there is a solution and it’s not serious. As I plan to be kept myopic, and this only affects me at distance, glasses to correct prism would be a good option.

[nh_user_1261018]

“Normally a vitrectomy causes increased myopia of a half a diopter or more (it did for me). As you had your IOLs already implanted, how did the vitrectomies affect your final visual acuity and prescription?”

Based upon my exams prior to all of the retina-related issues and post YAG, the vitrectromies didn’t impact my visual acuity at all: it was 20/15 and better-than-average near vision before the PCO and other stuff started to kick in, and it’s back to that after the YAG. I’m not sure how much of this is due to the inherently-greater “fore-aft final position tolerance” of the EDOF lenses (which is a big reason why I chose them), and how much is due to me again being lucky. (I had to talk the second retina surgeon out of adding a band as part of the retinal surgery - I think that he was being overly belt-and-suspenders, given the circumstances. Adding a band most definitely would have worsened my prescription.)

The only thing that I’m fighting a bit is some residual dryness in my left eye, due to the weather and humidity, airflow directed into my eyes due to wearing a mask, etc.. Eyedrops give some temporary relief, but realistically it will take eventual relocation to somewhere less arid to have a persistent effect.

Good luck with your decision and upcoming procedures.