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Medical Forum / General / Vision / March 2006Part of my current cataract-LRI-astigmatism problem explained
Note please: This is a repost of part of an ongoing discussion in alt.lasik-eyes. If refers to the tripling of OD astigmatism incident to a misplaced LRI to relieve astigmatism during cataract surgery. ----------------------------------------------- Had 2nd second opinion yesterday from cornea specialist. I am no 3 months out from the cataract surgery. I have a written report coming, but here are some of the highlights as I wrote them down; We are talking about the affected right eye here: 1. I now suffer from posterior capsular opicification (PCO) aka secondary cataract. Any correction of the astigmatism must be proceeded by the by correction of this problem (i.e. YAG capsulotomy) since it affects vision and the astigmatism, 2. Probably wait to do anything until about 6 months, so that we're not trying to hit a moving target. 3. WRT to Lasik/PRK he suggested that which one would depend on how bad the existing dry eye is and the actual shape of the cornea. He said that since it is an irregular astigmatism, Wave Front, Custom Cornea, or some such should be used to correct it. 4. He thought an offsetting LRI was a possability and that any resultant nearsightedness could be refracted away. His goal would be to get the astigmatism as low as possible, but below 2.00 if the remainder is also to be refracted away. 4. He brought up CK - conductive keratoplasty - saying that some research is beginning to show that it has some application in astigmatism, though no what it was "designed" for. Sounds a bit experimental to me, and while "statistics are for populations, nor for individuals" I'm getting a bit weary of coming out on the wrong side of the statistics. ------------------------------------- I see the original surgeon in about 2 weeks. Anything he does is free, but I'm a bit gun shy at this point. Medicare will pay anyone for the secondary cataract surgery, but any follow on corrective events will be out of pocket---probably about $2000. Money is not a real big problembut always relevent to anyone.. Who does what will be based on my gut after lot of research. So, if anyone has any suggestions for further exploration, etc., which would help me rule in/out which way to go with this, I would appreciate it. TIA Down but not out I don't think it's a good idea to mess with your corneas at this point. Glasses should provide excellent vision after you get that capsulotomy done. Do you have a problem with wearing glasses? w.stacy, o.d. > Note please: This is a repost of part of an ongoing discussion in > alt.lasik-eyes. If refers to the tripling of OD astigmatism incident [quoted text clipped - 37 lines] > TIA > Down but not out >I don't think it's a good idea to mess with your corneas at this point. >Glasses should provide excellent vision after you get that capsulotomy >done. Do you have a problem with wearing glasses? > >w.stacy, o.d. Absolutely no problem with wearing glasses, up through trifocals. Neither my cataract surgery (nor any now follow on) were specified by me to make me glasses free. Can, do and expect to continue to wear glasses, up through trifocals PRN, when this is all over - in a year or so. But, since this is your department, I repeat what this latest second opinion eyedoc (I don't do glasses, I don't do contacts, I do eyes) said, i.e. that he doesn't believe that astigmatism above 2.00 can be corrected effectively with glasses. As a result of the LRI, mine is now 3.00 or 2.75, depending on who takes it when. Second question has arisen, and this is slightly out of your end of the business, but I know you have broad experience (or someone else reading this might have some information) I came across some data that reflected that the getting it done sooner might be better, rather than later, because the smaller the opacification, the smaller the hole and the less the chance for complications. Any thoughts. BTW, I found this document to really describe the whole process quite well: http://www.surgeryencyclopedia.com/La-Pa/Laser-Posterior-Capsulotomy.html In fact, the basic document seems to have good info on many surgical procedures > But, since this is your department, I repeat what this latest second > opinion eyedoc (I don't do glasses, I don't do contacts, I do eyes) > said, i.e. that he doesn't believe that astigmatism above 2.00 can be > corrected effectively with glasses. I completely disagree with that. Maybe HE can't do it, but most of us o.d.s do it every day of the week. I personally wore about a 3 cyl in one eye with 20/15 for about 40 years. I commonly correct 5 and 6 cyls with glasses and contacts, and have corrected well above that. Refractive surgery for astigmatism is still kind of dicey by comparison. As a result of the LRI, mine is > now 3.00 or 2.75, depending on who takes it when. > Second question has arisen, and this is slightly out of your end of [quoted text clipped - 3 lines] > than later, because the smaller the opacification, the smaller the > hole and the less the chance for complications. That might be true, but most of the emphasis these days is on preventing the PCO in the first place, esp. by intra-operative polishing of the capsule and judicious choice of iol lens edge design (fairly sharp being better than rounded). I wish surgeons were paying more attention to thse things than they are to the multifocals/focusing iols. w.stacy, o.d. >> But, since this is your department, I repeat what this latest second >> opinion eyedoc (I don't do glasses, I don't do contacts, I do eyes) [quoted text clipped - 5 lines] >one eye with 20/15 for about 40 years. I commonly correct 5 and 6 cyls >with glasses and contacts, and have corrected well above that. Maybe I am not stating what I think I understand properly re: correction. I guess I need the term defined better. Depending on what day it is, my OD sees 20/20-20/25. Up until the PCO reared its ugly cloud, I was seeing with clarity. Now the OD sees with just a bit of fuzzy. That is not the problem. The problem is the loss of much depth perception and the tilting left and away problem ( As I sit here the left side of my 40" wide desk is lower than the right side, even though a level says it isn't)(If I view the segmented circular CH-VOL setter on my remote, it is elongated along the axis of sight) Both of these problems go away if I remove my glasses) It is this feature/problem that both consultants (as I understand it) believe will be corrented by reducing the astigmatism through some form of surgery, and then refracting PRN any residual away. Again, I may be "seeing" the if-you-only-tool-is-a-hammer approach What kind of correction are we (you and I) talking about? >The problem is the loss of much depth perception and the tilting left >and away problem ( As I sit here the left side of my 40" wide desk is [quoted text clipped - 8 lines] >What kind of correction are we (you and I) talking about? > It is true that astigmatic spectacle corrections can induce such problems, but usually they can be mitigated or even eliminated by a more careful refraction, combined sometimes with a slight undercorrection, and a few hours or a day of adaptive wearing. I would not be against limbal relaxing incisions, except in your case you already had them, they were done wrong, and to try to fix that is dicey. Glasses should work, so I recommend trying them again, perhaps from a doc who is better at refracting and fitting such cases. If you do succumb to the surgeon, let us know what happens. w.stacy, o.d. >It is true that astigmatic spectacle corrections can induce such >problems, but usually they can be mitigated or even eliminated by a more >careful refraction, Sounds like I need to find the best OD around, rather than another EYEMD >combined sometimes with a slight undercorrection, Question here. My original glasses were made (at my demand) based on an exam done slightly less 4 weeks after the cataract surgery/LRI. That yielded a 3.00 CYL. Because of my continued complaints, the Refactory Factory's OD did it again 3 weeks later and specifically said "I have reduced it a bit below that called for to 2.75 to see if that helps" It did. Since then, subsequent refractions have called for 2.75, so maybe the eye is settling out where it wants to be. Of course, this will be mitigated a bit by the emergent PCO problem and the need to correct that, and let the eye settle out again Question: Nothing comes w/o payback. Wherever the eye stabilizes, what is the tradeoff in reducing the CYL to slightly below that called for, e.g. if the eye stabilizes "needing" a 2.75 CYL,, what do I lose elsewhere in vision if we go with 2.50? I realize the proof is in the wearing, but I would like to know what the theoretical tradeoffs are >and a few hours or a day of adaptive wearing. You mentioned once that ODs could make up an sort of wearable office pair of glasses with the lens prescription fitted in to try it out. I agree that it will need more than a few minutes in the office. However, Is this something an OD is likely to let me take home to wear 'til the next day to see if it "better or worse"? Thanks for your help Roy > Question: Nothing comes w/o payback. Wherever the eye stabilizes, > what is the tradeoff in reducing the CYL to slightly below that called > for, e.g. if the eye stabilizes "needing" a 2.75 CYL,, what do I lose > elsewhere in vision if we go with 2.50? I realize the proof is in the > wearing, but I would like to know what the theoretical tradeoffs are You lose very little. Even a .5 or .75 undercorrection of the cyl is often feasable with very little loss of acuity. I tend to automatically undercorrect cyls as I refract, so rarely go more than .25 under my finding. > You mentioned once that ODs could make up an sort of wearable office > pair of glasses with the lens prescription fitted in to try it out. I > agree that it will need more than a few minutes in the office. > However, Is this something an OD is likely to let me take home to wear > 'til the next day to see if it "better or worse"? The choices here are in office only trial frame/lens setup, which I don't care for in this situation, as the trial lenses don't have a "best form" shape. I'd go with a cheap trial run in a spare or cheap frame, that you could try and use as a spare later, or order from a lab that offers free remakes in the lens type you want. w.stacy, o.d. Your second opinion ophthalmologist is a moron. Virtually any amount of astigmatism can be corrected with glasses or contact lenses. It is unwise to try to correct very much astigmatism surgically, and IMHO any type of keratotomy is a bad idea; the incisions never totally heal and the eye can rupture given any trauma. Medicare will pay for correction of refractive error if it is a surgically induced problem; after cataract surgery, surgical astigmatic correction is a covered procedure. CK has a tightening affect as opposed to a loosening affect of a keratotomy and would therefore be useful for correcting astigmatism, off label of course. However, CK has a relatively small affect and is not stable, it regresses. But it does not destroy the structural integrity of the eye. There is just as much effort expended in trying to avoid posterior capsular opacification as there is in developing multifocal lenses. However, treatment of posterior capsular opacification is safe and effective and relatively inexpensive. Ted >Your second opinion ophthalmologist is a moron. Virtually any amount >of astigmatism can be corrected with glasses or contact lenses. It is >unwise to try to correct very much astigmatism surgically, and IMHO any >type of keratotomy is a bad idea; the incisions never totally heal and >the eye can rupture given any trauma. Please see my reply to Dr. Stacy re the definition of correction. Are we all in the same boat re: "correction"? >Medicare will pay for correction of refractive error if it is a >surgically induced problem; after cataract surgery, surgical astigmatic >correction is a covered procedure. I really appreciate you input on this. Whoever does what, when (if ever) will file Medicare. I am prepared to cover whatever they don't. Again, my understanding of correction may be what is screwing things up. I spoke with the insurance person at the first consultant about this. She said that as long as I am seeing 20/20-20/25, Medicare doesn't care about the visual side-effects I am experiencing. (Again please see my reply to Dr. Stacy which provides a couple of examples of these aberrations.) BTW. the OS is fine. But my goal is to have the same kind of vision with OD as with OS, or both combined, correctable to 20/20 or thereabouts with glasses, but w/o visual aberrations. How do you see me getting here from here, please >CK has a tightening affect as opposed to a loosening affect of a >keratotomy and would therefore be useful for correcting astigmatism, [quoted text clipped - 8 lines] > >Ted |
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