“I had cataract surgery 6 months ago but I’m still having blurry vision.” I see patients here at Miami Eye Center who come to see me for a second opinion totally distraught over the issue and in many instances their degree of concern is unwarranted. This could be you, if so there are several things to consider. Firstly, what is the cause of the blurriness and secondly, can it be fixed?”
We can start analyzing the problem from the front of the eye (cornea) and working to the back (retina). Some of the issues are simple yet overlooked while others are complex. If you have had a multifocal lens implant there is no margin of error as these lenses are unforgiving. If your tear film is not good you could be losing vision. I have many patients complain of poor acuity only to find that by putting a drop of artificial tears on their eye they recover substantial vision. A long term program of tear film enhancement leads to continued excellent vision.
There could be residual nearsightedness, farsightedness and or astigmatism. If this is the case and you have had a multifocal lens implant it is incumbent upon the surgeon to correct this. If you have opted for a generic lens implant, eyeglasses is the answer. However, with multifocals you should be offered LASIK correction which has the potential to completely correct the blurry vision.
The intraocular lens is placed into the eye on a clear membrane (like Saran wrap) called the posterior capsule. On occassion this clear membrane becomes cloudy and impacts the vision potential. This is easily treated with a Nd:YAG laser procedure which vaporizes the membrane and thus clears the vision.
Moving to the back of the eye there is the retina. If there is a problem with the retina it is the same as taking a photograph with bad film in the camera. In a small percentage of surgeries there could be swelling of the retina known as cystoid macular edema. This has a profound effect in reducing the vision. Fortunately, it is self limited to several weeks to months and often responds to therapeutic eye drops.
While the point of this discussion is to inform the reader that all is not lost if at first glance the outcome of cataract surgery appears to be less than optimum, however, there are a number of complications which require extensive evaluation and complex repair. One must keep in mind that if you lump all of the possible complications of cataract surgery into one, the risk is about 3%, one of the safest major surgical procedures performed today.
Here at Miami Eye Center I am seeing a gradual trickle of RK alumni who had their surgery in the 80’s now coming back for cataract surgery. While the outcome from cataract surgery following prior RK can be excellent, there are a number of important issues that should be understood by the patient. The cornea is a very complex tissue that is perfectly designed to help focus light on the retina and the result of making radial incisions vastly alters the optical properties. Most importantly is that the cornea loses its stability. As the years have past since the RK, the cornea has flattened. In addition, within any given day the cornea shape changes from flat in the morning to steep in the evening. This often makes people farsighted in the morning and nearsighted later in the day. When we make the preoperative calculations for the intraocular lens we are in effect shooting at a moving target. When the calculation is off, the patient will be either nearsighted or farsighted following the surgery. In addition, the algorithms applied to normal corneas are impacted by the flatness of the RK cornea further making the calculations difficult. While I have a pathway of making the appropriate calculation adjustments I still warn patients about the above possibilities. Also that one can not be certain of the outcome until several months following the surgery as the cornea continues to flatten. If the power of the eye is not satisfactory there are several options for improving the outcome. Eyeglasses are easiest but perhaps not the first choice. Contact lenses might be worn. Lastly, it is possible to insert a second intraocular lens into the eye to add or subtract the power necessary to yield good vision without glasses. I have done this on a number of occasions at which time the calculation of the “piggyback lens” is straight forward. I would recommend against a multifocal lens implantation because the multifocals don’t perform well if there is any significant power error. A second reason is that there could be too much glare as a result of the optical properties of the RK cornea combining with the optics of the multifocal lens. In many instances the Toric Lens has been helpful in managing astigmatism that is often seen after RK surgery. It is important that the surgeon understand the type of astigmatism since the lens is not optimally effect in irregular astigmatism. My advice to any post-RK cataract surgery candidate is to be certain that their visual loss is due to cataract and not a cornea related issue and find a surgeon who has been there, done it and has a T-shirt.
I guess back in 1983, Mrs. S. asked the same question. That was the year that she had her first cataract removed here at Miami Eye Center. She followed with the second eye a year later. Ten years after that, in 1993, she had a corneal transplant in the right eye. Here she is pictured during this week’s exam with vision of 20/30 in each eye without glasses. She is a healthy and active 93 year old.
There are several messages here: (1) If you are in your 60’s and worried about impending cataract surgery know that you and your surgery outcome may well be around for a good long time to come (2) intraocular lenses are composed of a highly refined acrylic which does not appear to degrade over time. (3) don’t let your quality of life suffer due to poor vision from cataracts.
I have operated well over 15,000 cataract surgeries, evolving my surgical technique as the technology has improved. I can offer you the latest multifocal intraocular lenses designed to eliminate the need for reading and distance glasses, toric lenses which correct astigmatism or traditional generic lenses. I can help you choose the best approach for your visual needs; one size does not fit all. So give the office a call and we can discuss your situation. I must admit that I will not predict what you will be doing at 93.
Vision is a critical part of sports performance.At the elite level of sports, the athletes tested have been found to have above normal visual acuity.It is not only acuity but the entire visual system including association areas in the brain dealing with the visual response which are special.When a pitcher delivers a pitch at 90 miles an hour, the batter must react almost immediately.The interesting factor is that once the eye sees the release of the pitch, it takes two-tenths of a second for that visual information to arrive at the visual cortex at the back of the brain.By the time the brain perceives the pitch, the ball has already traveled 25 feet toward the batter. Ofcoarse, the same considerations apply to reaction time on the tennis court. There is no doubt that there are numerous immeasurable clues that the batter or tennis player processes in order to get to the ball.One physical finding that is readily measurable is the visual acuity of the professional baseball player.Many of the outstanding batters have acuity which is far better than 20/20.A batter with 20/10 acuity can see the stitches on the baseball as it is released by the pitcher.This enables him to predict the type of pitch (curveball, slider) that is coming his way.
If there is an athlete in your family, he or she should have their visual acuity measured and the examiner should not stop at correcting the vision to 20/20 but should attempt to correct the vision to the very best that is possible.A nearsighted baseball player might require the smallest amount of additional power in the eyeglasses or contacts to get to 20/15 and this could make all the difference at the bat or on the tennis court.Of coarse here in Miami where the glare is so intense, any residual refractive error can enhance the glare as well.
I take this same approach with the senior sportsman/sportswoman who are coming to cataract surgery at Miami Eye Center.Whether they are avid golfers, tennis players, sports anglers or pilots, these folks need an optimum visual outcome.This means selecting the best intraocular lens for that individual, meticulously obtaining the most accurate preoperative measurements on that person’s eye and delivering an outcome which exceeds the patient’s expectations.
A professional fishing guide needs optimum contrast sensitivity and minimum glare.While it would be nice to offer a multifocal lens in order to eliminate glasses, this would not be the best choice; rather an aspheric lens would fulfill the guides requirements.And if there is any astigmatism, that must be addressed.
If you are an up and coming athlete or a more seasoned veteran, have your visual acuity optimized, it will make more of a difference than you might think.
Now that you have a visually significant cataract, that is, a cataract that is interfering with activities that you enjoy doing or those that you must do, the choice is no longer “should you do the surgery,” rather “how should the surgery be done.” Needless to say, this decision must be made during a consultation with an ophthalmologist with whom you feel comfortable. Keep in mind that this is the last and best opportunity to not only remove your cataract but to correct other problems such as nearsightedness, farsightedness presbyopia and astigmatism.
To help with the discussion, the lens options fall into several classes; MONOFOCAL LENSES will deliver good vision at a single point in space, ie, distance or near. A modern variation on this lens is the ASPHERIC LENS which has a curvature which neutralizes the curvature of the cornea and thus reduces glare and other types of distortion. A TORIC LENS will correct astigmatism at the same time that it corrects nearsightedness or farsightedness and it has recently been manufactured in an aspheric form. Then there are the MULTIFOCAL LENSES which are in many instances, aspheric as well. These lenses correct for distance and near vision. There is the Restor lens from Alcon Labs, the ReZoom lens and more recently the Tecnis lens from AMO. In addition, the Crystalens from Bausch and Lomb which is somewhat different from the other lenses but ultimately yields a similar outcome.
The issue is that there are numerous lenses to place in the eye at the time of surgery. The lens must be matched to the patient’s visual needs, not the other way around; one lens does not fit all. On the one hand, an 80 year old with macular degeneration and cataracts who does not mind wearing reading glasses would fair best with a lens that provides only distance vision and perhaps it should be an ASPHERIC LENS which minimizes glare and maximizes distant vision. The opposite situation might occur in a 50 year old who needs distance vision, computer vision and reading vision and would be willing to wear reading glasses occassionally. The latter case would call for a MULTIFOCAL LENS of which there are several.
It must be said that every style of lens has different advantages and disadvantages and these must be reconciled with the patient; that is my job. I must find out what you expect and want from the procedure. What are the tasks that you want to do without glasses and which are you willing to occassionally put the glasses on in order to perform.
Remember that cataracts come with having birthdays and perhaps this year’s present might be good vision and possibly no glasses to achieve that end.
Patients of all ages ask me what they must do to be free of eyeglasses. The answer lies in their age and their vision requirements.
The first group of folks are the younger aged. These are people who are nearsighted or farsighted with or without astigmatism and who when they have their contacts or glasses on, can read without the need for additional reading glasses. This group is “pre-presbyopic.” The approach to getting this group out of glasses or contacts is straight forward. We must correct the refractive error (nearsightedness, farsightedness or astigmatism) and they are set. In most cases this is done with LASIK or PRK in individuals who have a refractive error which has stopped changing with age and meet the other criteria for safe refractive surgery.
Eliminating the need for glasses gets a little more involved in the next group; the presbyopic group. These people need reading glasses in addition to their contacts or distance glasses correction; this is the group that wears bifocals. There are several theories as to the mechanism of this progressive need for reading glasses but the bottom line is that the lens of the eye losses its ability to focus at near. This inability is superimposed upon ones nearsighted or farsighted condition. This gets confusing because a 48 year old nearsighted individual can see well at near without glasses but once the glasses go on they no longer can see close. A younger nearsighted person will see well at near with the distance correction. So what must we do to eliminate glasses? In my surgical ophthalmology practice there are two ways to do this. The first is to do LASIK or PRK with the dominant eye corrected for distance and the non-dominant eye for near (monofocal). While this may sound “wild and crazy,” about 20%-30% of the population is capable of doing this. When patients inquire about this approach, we fit them with trial contact lenses for the day which simulates the monofocal condition. In general, people who are not suited for the monofocal correction know immediately after putting the lenses on. For those who are comfortable we go to LASIK or PRK and permanently correct the refractive error.
The other 80% used to have no option but to wear bifocals. Now there is an excellent second option; multifocal lenses. These are acrylic lenses which can be permanently placed inside the eye which give good distance and near vision in each eye. The lenses create two images at the retina, one for near and one for far. Depending upon which image your brain wants to see will determine which image it recognizes. This works similarly to being in a room where there are several conversations going on simultaneously. Your brain will direct your attention to one of these conversations and you will hear it at the exclusion of the others and in an instant you can switch to another conversation and not hear the first.
In multifocal lens surgery your clear lens is surgically removed and replaced with an acrylic lens which has been calculated to neutralize your refractive error and at the same time correct for near vision. I prefer the Restor Lens manufactured by Alcon Labs. The surgery takes about 15 minutes and one eye is operated at a time. The second eye is operated about 2 weeks later. There is very little down time as people feel good the next day.
This surgery is available for those of any age as long as they are presbyopic. In younger presbyopes we remove the clear lens and instill the multifocal lens. In those older presbyopes requiring cataract surgery, the same lens is placed with the same benefits.
I or one of the surgery counselors will be pleased to discuss these options with you. Give a call.
