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Medical Forum / General / Vision / July 2006Tell me about accomodation after cataract surgery
I'm a 33yo male with OD -3.75, -2.50 @ 115, OS -4.00, -1.00 @ 120 which have been like that for over 25 years. I'm accustomed to wearing glasses or soft contacts full time. Since mid-March of this year, I rapidly developed a cataract in my left eye which is now quite advanced. I've had a consultation for lens replacement surgery with a well experienced doctor who presented both IQ and ReSTOR options for my consideration. Since I have young, otherwise healthy eyes, I'm uncomfortable with the prospect of losing the ability to accomodate due to surgery. Is this a given (is the ciliary muscle severed during the procedure)? I want to avoid needing bifocals if possible. Does the ReSTOR simply work as an implanted bifocal, requiring me to tilt up and down to look out of the proper region? Is correcting the left for excellent distance vision while keeping the right myopic a good idea? I have also begun reading about multifocal and accomodative IOCs, but they seem like they are still in the experimental stage. Would I be better off preserving my ciliary muscle intact for a few more years until a truly accomodative solution is perfected, rather than damaging it now and denying that option in the future? Any thoughts or insights you can offer are greatly appreciated. >I'm a 33yo male with > OD -3.75, -2.50 @ 115, [quoted text clipped - 10 lines] >prospect of losing the ability to accomodate due to surgery. Is this a >given Yes. > (is the ciliary muscle severed during the procedure)? No. >I want to avoid needing bifocals if possible. Does the ReSTOR simply >work as an implanted bifocal, requiring me to tilt up and down to look >out of the proper region? No. See <http://www.acrysofrestor.com/apodization-diffraction/restor-lens.asp>. Your eye doctor should explain how the various multifocal IOLs work so you are well informed and can make a rational, informed decision. >Is correcting the left for excellent distance vision while keeping the >right myopic a good idea? It may be. That is something you should discuss with your eye doctor(s). You need your eye doctor(s) to explain the pros/cons of the various post-operative vision goals such as clear distance vision in the left eye (may be spectacle intolerant due to anisekonia), clear near vision in the left eye (require spectacles or contacts to see clearly in the distance) or somewhere in between. [snip] >Would I be better off preserving my ciliary muscle intact for a few >more years until a truly accomodative solution is perfected, rather >than damaging it now and denying that option in the future? It depends on how much your cataract bothers you. Cataracts are typically removed for two reasons: 1. It bothers the patient -- i.e., you can't see as well as you want to and the risk:benefit ratio is acceptable to you and your eye surgeon. 2. It bothers the eye doctor -- e.g., doctor is unable to adequately view fundus details, waiting much longer will risk making cataract "rock hard" which makes surgery more difficult/risk of complications, waiting much longer incurs risk of catarct becoming hyperacute/Morgagnian, etc. If both (1) and (2) do not apply, then you can probably wait. >Any thoughts or insights you can offer are greatly appreciated. >I'm a 33yo male with > OD -3.75, -2.50 @ 115, [quoted text clipped - 10 lines] >prospect of losing the ability to accomodate due to surgery. Is this a >given (is the ciliary muscle severed during the procedure)? No, but the artificial lens will have no focusing ability, as it will be a rigid lens. Your ciliary muscle will continue to constrict, but it will have no effect on the iol shape/power (or little or no effect if it is a hinged/moveable lens). I'm not a fan of the Restor or any multifocal iols at this point, but you will get differing opinions. The main problem with the Restor is the add is over 3.00 so the near focus is much closer than necessary for most people. I'd opt for a prolate aspheric single vision lens set for distance, and you might need some readers to balance you at near. You might not. If and when they perfect a multiofcal or a focusing lens, you might be a candidate for exchanges later. Important to get a VERY GOOD surgeon. w.stacy, o.d. >>I'm a 33yo male with >> OD -3.75, -2.50 @ 115, [quoted text clipped - 15 lines] >will have no effect on the iol shape/power (or little or no effect if it >is a hinged/moveable lens). So ... Doctor Bill ... If you said what I think you just said, then you answered my $64,000 question. The *only* place I found data was in Clyde Oyster's book, "The Human Eye: Structure and Function" (1999) where he said, in effect, that the ciliary ennervation never stops in presbyopia; only the accommodation itself. Intuitively, even before seeing that, I thought this was right. Otherwise, something would have to "go dark" and "re-ignite" when AIOLs were implanted. My doc *still pushes* for me to get RLE + (preferably monofocal) IOL's, under the premise that my accommodative mechanism will eventually give up, thus permanently ending the spasm. *I* think that--based on my history--giving up is *not in the lexicon of MY* accommodative system and that putting a brick wall in front of it will only pi$$ it off ;-) Do you have any reference for your statement?? Very curious ... and very interested. I looked at a 5/05 thread about this and didn't see where you said the same thing: http://tinyurl.com/nrzuf TIA, Neil >>>I'm a 33yo male with >>> OD -3.75, -2.50 @ 115, [quoted text clipped - 46 lines] >TIA, >Neil I found this: seems to lend support to my/your theory: http://www.pubmedcentral.gov/picrender.fcgi?artid=1353417&blobtype=pdf OR: http://tinyurl.com/jhvzs > > I found this: seems to lend support to my/your theory: > > http://www.pubmedcentral.gov/picrender.fcgi?artid=1353417&blobtype=pdf > > OR: http://tinyurl.com/jhvzs Pretty heady stuff, and kind of macabre what with getting all those eyes so fresh and whatnot, but I think the theory really belongs to Helmholtz. I tend to think classically, and have thought for many years that accommodation drives convergence. Now I'm not so sure. It may be the other way around, and it even just might be that it's a 2 way street, so some of each is working... w.stacy, o.d. > > >> I found this: seems to lend support to my/your theory: [quoted text clipped - 6 lines] > eyes so fresh and whatnot, but I think the theory really belongs to > Helmholtz. If you're referring to the equatorial growth of the lens, that's Schachar's theory > I tend to think classically, and have thought for many years that > accommodation drives convergence. Now I'm not so sure. It may be the > other way around, and it even just might be that it's a 2 way street, > so some of each is working... > > w.stacy, o.d. Often things like this work out to "a little of each". If I recall correctly, though, convergence, which is slower than most eye movements, is still a faster than accommodation. They might both be under the control of some "premotor" area, though. Now, all we need is someone to advocate that pupil size drives both ;)  SignatureScott Reverse name to reply > > >> I found this: seems to lend support to my/your theory: [quoted text clipped - 10 lines] >other way around, and it even just might be that it's a 2 way street, so >some of each is working... But ... in either case ... you're of the opinion (at least) that the drive for accommodation (ciliary innervation) doesn't cease simply because of presbyopia? Again, I'm trying to get as knowledgeable as possible about the chances that rigid IOLs might induce my accommodative mechanism to declare an Unconditional Surrender. > But ... in either case ... you're of the opinion (at least) that the > drive for accommodation (ciliary innervation) doesn't cease simply > because of presbyopia? I do think it continues, and in fact I think I can "feel" my ciliary muscle working to focus my iol, which it can't of course. It's an especially strong sensation when I "cross my eyes", as I did as a child (and in optometry school). I also think it happens less involuntarily now, but is very strong when I push it hard. > Again, I'm trying to get as knowledgeable as possible about the > chances that rigid IOLs might induce my accommodative mechanism to > declare an Unconditional Surrender. I think and hope it will, but there is a psychological component to this as well. You can force yourself to relax, or not, and your comfort may depend on how well you can use this force. Anyway, you have already got my advice. Go for the procedure in one eye (the worse one first), then decide on the other based on what you learn. But then I have the comforting bias of a successful outcome, and, as always, your mileage may vary. w.stacy, o.d. >>>I'm a 33yo male with >>> OD -3.75, -2.50 @ 115, [quoted text clipped - 46 lines] > TIA, > Neil There are two current ideas for presbyopia. One, we all have heard of, is that the lens loses elasticity. The other, which surprised me, is that the lens grows too big for the cilliary and zonules to be effective. SignatureScott Reverse name to reply >>>>I'm a 33yo male with >>>> OD -3.75, -2.50 @ 115, [quoted text clipped - 55 lines] >is that the lens loses elasticity. The other, which surprised me, is >that the lens grows too big for the cilliary and zonules to be effective. Thanks, Scott. Given that, though, NEITHER would seem to imply that the ciliaries retire, move to Palm Beach, and take up golf, would you agree?? > Given that, though, NEITHER would seem to imply that the ciliaries > retire, move to Palm Beach, and take up golf, would you agree?? So far. We'll see if the scleral expansion band trials work or not. Even if they don't work, we should find out if the ciliaries are still working. I'd be curious to find out if the accomodation/vergence ratios are adaptive enough to function accurately. In any case, some is probably better than none! SignatureScott Reverse name to reply >> Given that, though, NEITHER would seem to imply that the ciliaries >> retire, move to Palm Beach, and take up golf, would you agree?? [quoted text clipped - 4 lines] >enough to function accurately. In any case, some is probably better than >none! ... which brings up yet another question for me: I'm heading exo- after a lifetime of eso- and 3 surgeries to correct. Fairly stable alignment at distant, but only because of accommodative control. Breaks down to 6-8d of exo. In either of these theories, do you have a guess as to whether the accommodative amplitudes--even if they DO NOT result in dioptric changes of the lens (for either reason)--will still influence vergence (in my case: maintaining my alignment ... at least a little), or ... because of these issues of presbyopia ... do you think it's more likely that the exo- will increase as accommodative amplitudes decrease? Thanks! >>> Given that, though, NEITHER would seem to imply that the ciliaries >>> retire, move to Palm Beach, and take up golf, would you agree?? [quoted text clipped - 19 lines] > > Thanks! We're well beyond anything I can fake my way through now. I've always thought of the vergence driving accomodation, and not the other way around. My guess would be that any change in accomodative tone wouldn't hurt your vergence. It's fixation that allows you to maintain alignment. Right around the time laser surgeries really picked up in popularity, there seemed to be a spate of surgically corrected strabs developing diplopia, I seem to recall, as vision was impaired enough to impair the boost fixation could give to alignment. SignatureScott Reverse name to reply Right on both counts. The lenses grow thicker and larger and denser with time. The newborn has the capacity to focus ~20.00D. By the time you get to be about 40, the focusing drops to about ~5.00D. When it drops below that, your arms start getting too short for reading. The lens gains in size and mass while losing flexibility. There are several new "focusable" implant lenses availble, Restore being just one. Placement in the lens sulcus is such that when you focus, it pushes the lens forward letting you see at near, and when the muscle relaxes as you look away, the lens moves back for distance...IF I am thinking of the right lens. Previous posts are correct in that ou should explre all of your options. It sounds as though yuo are still young enough to focus the other eye somewhat. --Dr. Tom > >>>I'm a 33yo male with > >>> OD -3.75, -2.50 @ 115, [quoted text clipped - 55 lines] > is that the lens loses elasticity. The other, which surprised me, is > that the lens grows too big for the cilliary and zonules to be effective. > Right on both counts. The lenses grow thicker and larger and denser > with time. The newborn has the capacity to focus ~20.00D. By the time [quoted text clipped - 7 lines] > muscle relaxes as you look away, the lens moves back for distance...IF > I am thinking of the right lens. I believe you are thinking of the wrong lens. I have Restor implants and they are made of concentric circles with differing capabilities. Probably a poor description. > Previous posts are correct in that ou should explre all of your > options. It sounds as though yuo are still young enough to focus the [quoted text clipped - 61 lines] >> is that the lens loses elasticity. The other, which surprised me, is >> that the lens grows too big for the cilliary and zonules to be effective. >I believe you are thinking of the wrong lens. I have Restor implants and >they are made of concentric circles with differing capabilities. > >Probably a poor description. > Actually a very good description of the lens. How are they doing for you now? One thing I noticed on the Restor I saw a while back was they seemed to have pretty strong and unusual reflectance, so they are more noticeable to people looking at you. Did you notice that? w.stacy, o.d. >>I believe you are thinking of the wrong lens. I have Restor implants and >>they are made of concentric circles with differing capabilities. [quoted text clipped - 7 lines] > > w.stacy, o.d. I had the right eye implanted three weeks ago and the left eye last week. So far noone has commented on them being visible. The only comment has been how great by blue eyes look! Oh, I also get, where's your glasses from folks that don't know I've had the implants. I've looked carefully in a mirror and cannot see them. Maybe with a bright light behind my head shining into the mirrow would show them. I'll have to try that. So far I'm very pleased with the results. I feel that I'm 100% functional from driving to reading very fine print. That being said I do have a bit of the problem with the 19" LCD computer montior at three feet. I have the resolution set to 1280 X 1024. The "optimum" distance for reading is about 14", I wish that was a bit longer. I am using +1 drug store readers for the monitor and they are workable. I'll try some different powers and possibly a prescription set just for the monitor. I can live with that. The "star bursts" around bright lights is a little annoying but I'm getting used to it and not having to wear glassses is worth it to me. I have had no surprises and they live up to the doc's predictions. All distances are not as sharp as before the implants with good prescription bi-focals. I was told up front this would be the case. After 35 years of glasses it's really a pleasure to walk around without the extra hardware. Of course living in Florida I do wear sunglasses most of the time I'm partaking of outdoor activities. But then it's nice to walk into a store and just pick out the sunglasses I like, particularlly for fishing. I hope others that have had the Restor lenses installed are as pleased as I am. >So far I'm very pleased with the results. I feel that I'm 100% functional >from driving to reading very fine print. That being said I do have a bit of >the problem with the 19" LCD computer montior at three feet. I have the >resolution set to 1280 X 1024. The "optimum" distance for reading is about >14", I wish that was a bit longer. > Excactly my thoughts. Why they set the "add" so high is a mystery to me. >I have had no surprises and they live up to the doc's predictions. All >distances are not as sharp as before the implants with good prescription >bi-focals. I was told up front this would be the case. > I would expect that to be the case, as some significant optical compromises have been made. Glad it worked out for you. [snip] >So far I'm very pleased with the results. I feel that I'm 100% functional >from driving to reading very fine print. That being said I do have a bit of >the problem with the 19" LCD computer montior at three feet. I have the >resolution set to 1280 X 1024. The "optimum" distance for reading is about >14", I wish that was a bit longer. That is a very commont complaint or comment. If a ReSTOR lens implantation turns out perfect, people generally get good distance and good near vision (but that near vision is about what you'd get with a +3.00D Add) [snip] >I have had no surprises and they live up to the doc's predictions. All >distances are not as sharp as before the implants with good prescription >bi-focals. I was told up front this would be the case. ReZOOM lenses typically provide better visual acuity than ReSTOR, but they have their own downsides also. Likewise, with CrystaLens people typically get better acuity and distance and intermediate, but not nearly the right up close vision of your ReSTOR. All the current IOLs have compromises, but they are certainly better than what we had to offer our patients, even 5 or 10 years ago. Glad you are enjoying your "new eyes". > I'm a 33yo male with > OD -3.75, -2.50 @ 115, [quoted text clipped - 22 lines] > > Any thoughts or insights you can offer are greatly appreciated. It sucks to develop cateract(s) at 33 but the IOLs will not only take care of that, itll bring you much closer to plano than where you stand now at -4. What do you use your eyes the most for? If you read for hours, consider a -2.5d undercorrection. If its surfing the internet, consider -1.5 to -2d undercorrect. If your life is spent outdoors seeing distance, you could go for plano but better hope not to get overcorrected or youll need progressive glasses. I know this lady in person who ended a bit overcorrected and cant see a thing from near. Her distance vision isnt bad but still blurry. When I develop cateracts, Ill choose to be set for near vision, this will keep me out of readers and protect me from overcorrection. Ill only need a thin pair of distance glasses occasionally. "Right on both counts. The lenses grow thicker and larger and denser with time. The newborn has the capacity to focus ~20.00D. By the time you get to be about 40, the focusing drops to about ~5.00D. When it drops below that, your arms start getting too short for reading. The lens gains in size and mass while losing flexibility." 20 diopters? wow! Thats about 2 inches! You however are wrong, a 40 year old has more like +2 diopters accomodation. He can focus no closer than half meter clearly. Someone with +5 diopters accomodation can focus down to 8 inches and ive never seen a 40 year old focus this close without him being myopic or using a magnifier. >20 diopters? wow! Thats about 2 inches! You however are wrong, a 40 >year old has more like +2 diopters accomodation. He can focus no closer >than half meter clearly. Someone with +5 diopters accomodation can >focus down to 8 inches and ive never seen a 40 year old focus this >close without him being myopic or using a magnifier. Ace, How many patients per day ARE you seeing in your practice these days? > >20 diopters? wow! Thats about 2 inches! You however are wrong, a 40 > >year old has more like +2 diopters accomodation. He can focus no closer [quoted text clipped - 5 lines] > > How many patients per day ARE you seeing in your practice these days? You must have confused me with another doctor, Dr. Brooks. >> >20 diopters? wow! Thats about 2 inches! You however are wrong, a 40 >> >year old has more like +2 diopters accomodation. He can focus no closer [quoted text clipped - 7 lines] > >You must have confused me with another doctor, Dr. Brooks. No ... I don't think so. Remember: I'm the guy who always lets people know that I'm NOT a doctor. See ... I'm not trying to feed some pathological insecurity by trying to get respect from Usenet doctors at the risk of harming patients. That's you ... or Otis. I try to add what I can, where I can, always prefacing it with "I'm not a doctor, but..." I thought I'd clued you in on that before. No? Hm. > >> >20 diopters? wow! Thats about 2 inches! You however are wrong, a 40 > >> >year old has more like +2 diopters accomodation. He can focus no closer [quoted text clipped - 22 lines] > > I thought I'd clued you in on that before. No? Hm. Arent you an optometrist in real life? I thought I heard somewhere that you were and is why you know so much about vision :) > Arent you an optometrist in real life? I thought I heard somewhere that > you were and is why you know so much about vision :) Ace, aren't you a retard in real life ? |
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