Second-guessing the optometrist

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Dave Bell - 04 Dec 2007 02:54 GMT

Before paying for a second opinion, I thought I'd take hat in hand and
throw this out to the group for some thoughts.

Left eye has undergone multiple surgeries for a retinal detachment, loss
of lens and lens capsule, months of profound hypotony that's slowly
resolving to near normal, but has left me with a significant macular fold.

Vision in that eye is extremely poor, of course, and the retinal
specialist doesn't foresee an implant in my near future. Pretty much
told me, "What you see is about as good as it's going to get."

What I see: Distorted, blurred images, small sources expanded somewhat
vertically, and drawn out 5 or so diameters horizontally. I can count
fingers at ~2 feet, if they're horizontal, but not if vertical, for
example. From this, I infer some significant sphere is needed, and a lot
of cylinder on a vertical axis.

So, since I needed a new scrip for the other, good, eye, I asked the
optometrist to do what she could to refract the left, as well.

After using the binocular refractometer (semi-automated: she hits keys
on the PC, instead of rotating lens wheels, but still "Better 1 or
better 2?"), she comes up with +10 sphere (believable, for no lens), and
"about 1 diopter" cylinder.

Huh?!? This evening, on the drive home, I experimented at traffic
lights. If I create a vertical slit, I reduce the error to only slightly
enlarged, round spots. A horizontal slit reduces the vertical extent
even more, while not improving the horizontal.

As for filling the prescription, she said I should forget a spectacle
lens for the left, "It would drive your head crazy!", but suggested that
if I really wanted to try it, to get fitted for a contact on that side.

Any thoughts?

Dave

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Dan Abel - 04 Dec 2007 05:18 GMT

> Before paying for a second opinion, I thought I'd take hat in hand and
> throw this out to the group for some thoughts.

> As for filling the prescription, she said I should forget a spectacle
> lens for the left, "It would drive your head crazy!", but suggested that
> if I really wanted to try it, to get fitted for a contact on that side.
>
> Any thoughts?

Yes. Both my wife and I only have one good eye. Unfortunately, we are
both right handed and the left eye is the good one. Still, we get by
just fine. You really only need one eye.

Still, the money for those surgeries was major. The cost for a contact
just isn't. If you make a choice about surgery, you most often have to
live with it. If the contact doesn't help, you just stop using it. I
don't think it has a big chance of working, but if you want to put in
the effort, why not try it? I don't see paying for a second opinion.
If you want it, just do it. If it doesn't work, just stop.

Signature

Dan Abel
Petaluma, California USA
dabel@sonic.net

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Dave Bell - 04 Dec 2007 05:35 GMT

>> Before paying for a second opinion, I thought I'd take hat in hand and
>> throw this out to the group for some thoughts.
[quoted text clipped - 15 lines]
> the effort, why not try it? I don't see paying for a second opinion.
> If you want it, just do it. If it doesn't work, just stop.

Well, the real issue is whether a +10 diopter sphere and very little
cylinder is even close to correct.

What I fear is that the semi-automatic refraction may have been like
trying to find the minimum of a complex curve, and catching local min,
not a global min. Think of a "W" shaped curve, where one 'v' is lower
than the other. If you traverse the curve from one end, you'll find a
low spot, and "1 or 2" back and forth around that. But the other low may
actually be much lower. Perhaps she should have tried to optimize for
astigmatism first, then look for the best sphere afterwards. Doing that,
I could end up with maybe a +8 cylinder (compensating for the fold) and
only a +2 or 3 sphere. Totally different prescription, and effect!

Fortunately, the surgeries were all under HMO care (good care, for
that), so all I had was a butt-load of copays, and a lot of experience.
Pretty interesting, lying there chatting with the surgeons and listening
to the chief's Chicago blues for 2 to 3 hours...

Dave

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Dan Abel - 04 Dec 2007 22:15 GMT

> Well, the real issue is whether a +10 diopter sphere and very little
> cylinder is even close to correct.

If the OD can't figure it out, then maybe there is just no "correct".
Maybe you are just screwed.

> What I fear is that the semi-automatic refraction may have been like

If it was an autorefractor, that means you can't see.

> only a +2 or 3 sphere. Totally different prescription, and effect!

Might be worth talking to the doctor, to give it a try. Still, if it is
a problem with the macula, no OD can fix that. I have scar tissue over
one macula. No lens correction will fix that. I can live with it (my
current choice), or go back under the knife.

> Fortunately, the surgeries were all under HMO care (good care, for
> that), so all I had was a butt-load of copays, and a lot of experience.

Been there, done that. I've been pretty happy with my HMO (Kaiser).
The copays were pretty nominal, considering what surgery costs elsewhere.

Signature

Dan Abel
Petaluma, California USA
dabel@sonic.net

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Dave Bell - 05 Dec 2007 01:32 GMT

> If it was an autorefractor, that means you can't see.

Not the full-auto autorefractor, this was a motorized phoropter.
Still the same old drill...

> Might be worth talking to the doctor, to give it a try. Still, if it is
> a problem with the macula, no OD can fix that. I have scar tissue over
> one macula. No lens correction will fix that. I can live with it (my
> current choice), or go back under the knife.

Yeah, and I have plenty of scar tissue there, too. I don't mind going
back under the knife, I just don't want anyone screwing around inside
the eye any more! I suppose some day, he'll have to remove the oil and
replace it with saline or whatever they use, but as long as it's not
irritating my cornea, I'll leave it alone.

>> Fortunately, the surgeries were all under HMO care (good care, for
>> that), so all I had was a butt-load of copays, and a lot of experience.
>
> Been there, done that. I've been pretty happy with my HMO (Kaiser).
> The copays were pretty nominal, considering what surgery costs elsewhere.

Yeah, Kaiser (Santa Clara) for me, too.

Dave

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Dan Abel - 05 Dec 2007 02:53 GMT

> > If it was an autorefractor, that means you can't see.
>
> Not the full-auto autorefractor, this was a motorized phoropter.
> Still the same old drill...

I had a bad experience with one of those. I won't ever go back to that
OD. Maybe he's figured out how to work it. I won't give it another try.

> Yeah, and I have plenty of scar tissue there, too. I don't mind going
> back under the knife, I just don't want anyone screwing around inside
> the eye any more!

If it's an eye doc, and they have a knife, it goes in the eye.

Signature

Dan Abel
Petaluma, California USA
dabel@sonic.net

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Mike Tyner - 04 Dec 2007 07:20 GMT

> What I see: Distorted, blurred images, small sources expanded somewhat
> vertically, and drawn out 5 or so diameters horizontally. I can count
> fingers at ~2 feet, if they're horizontal, but not if vertical, for
> example. From this, I infer some significant sphere is needed, and a lot
> of cylinder on a vertical axis.

Maybe, but your OD didn't "come up with +10 sphere." You did. The PC and the
phoropter just made it easy for you to choose efficiently.

> Huh?!? This evening, on the drive home, I experimented at traffic lights.
> If I create a vertical slit, I reduce the error to only slightly enlarged,
> round spots. A horizontal slit reduces the vertical extent even more,
> while not improving the horizontal.

You might be right - you have some good evidence there, but it's still too
easy to pop on a contact and overrefract. If your refraction truly is
+1000-100, then re-measuring over a +10 or +10.50 contact will give better
real-world results. Thick (hi plus) contacts can mask a lot of astigmatism,
especially stiff lenses like Focus N&D. Also, if your cataract surgery
created 4 or 5 diopters of astigmatism, it's likely that a "relaxing
incision" could bring you into spherical range.

You really deserve to find out what you could get with something like a
+10.00 sphere. The only other reasonable course is to leave it alone.

The caveat is with your retinal fold, you might not like the sharper image.
It may confuse, or compete with the other eye.

-MT

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Dave Bell - 04 Dec 2007 16:12 GMT

>> What I see: Distorted, blurred images, small sources expanded somewhat
>> vertically, and drawn out 5 or so diameters horizontally. I can count
[quoted text clipped - 4 lines]
> Maybe, but your OD didn't "come up with +10 sphere." You did. The PC and the
> phoropter just made it easy for you to choose efficiently.

True, as far as that goes, but see my comments last night, regarding
finding a local minimum of a complex function.

>> Huh?!? This evening, on the drive home, I experimented at traffic lights.
>> If I create a vertical slit, I reduce the error to only slightly enlarged,
[quoted text clipped - 5 lines]
> +1000-100, then re-measuring over a +10 or +10.50 contact will give better
> real-world results.

Makes a lot of sense.

> Thick (hi plus) contacts can mask a lot of astigmatism,
> especially stiff lenses like Focus N&D. Also, if your cataract surgery
> created 4 or 5 diopters of astigmatism, it's likely that a "relaxing
> incision" could bring you into spherical range.

What's a "relaxing incision"? In this case, the astigmatism appears to
be from the macular fold, not anything to do with my cornea or anything
around the pars plana.

The cataract surgery was a sidebar during my second(?) retinal surgery.
Doc pointed out that there was a very early cataract forming, and he
felt the silicone oil fill I opted for would quickly exacerbate it. We
discussed it, and I agreed. Never was quite certain why he pulled the
capsule, though. Unfortunately, that ruled out a posterior chamber
implant, *and* left the iris open for the oil to migrate forward. At one
time, the oil was creating band keratopathy and had to be removed for a
while. It was later re-introduced after my retina re-detached and was
trimmed and sutured. (It's been a long 18 months!)

> You really deserve to find out what you could get with something like a
> +10.00 sphere. The only other reasonable course is to leave it alone.

I did try a +10 hand lens. It helped, but I could still easily see the
lateral stretching and "ripple" distortion from the fold. I also have
some significant prism now, probably due to muscle trauma from all the
surgeries.

> The caveat is with your retinal fold, you might not like the sharper image.
> It may confuse, or compete with the other eye.

Understood! When I used the hand lens, it did add to the confusion, but
over all, I really want to regain some left-field peripheral vision.
After a year and a half, I still haven't learned to "see" well with one
eye. I'm still knocking things over, tripping on objects that are
clearly in view, and (even more than usual) can look all over a scene,
and not see what I'm looking for.

As for competition, if I relax and let my eyes fixate on a point for a
few seconds, the left eye's image, blurred, distorted, and carrying a
complex permanent abstract afterimage, starts to come to the foreground,
even now. Something I'll probably have to learn to live with. Even if I
lost all sight, I suspect "phantom eye" effects would stay with me.

Thanks for the input!

Dave

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