“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.

Firstly, let us not refer to the condition as “dry eyes” rather “tear film deficiency” or “dysfunctional tear syndrome.”  The change in terminology reflects the updated understanding that the problem involves the entire lacrimal functioning unit as a whole and emphasizes tear film quality rather than tear volume.  In the past, the dry eye has been treated with the application of artificial tear alone to replace the volume, now the condition is recognized as an inflammatory disease and treatment is directed at the inflammatory component.

Tear film deficiency is extremely common with the incidence anywhere from 4% to 15% of the population over the age of 45 years and it is more prevalent in woman. 

 What causes this tear problem?  The lacrimal functional unit consists of the lacrimal gland (tear gland), the surface of the eye itself and the nerve connections between the two which passes through the brain.  When the cornea is not happy with the quality of tears, it sends a message to the brain which tells the lacrimal gland to get busy.  The lacrimal gland produces the tears which contain growth factors and other proteins.  In addition, the surface of the eye contributes lipids which reduce evaporation and mucins which enhance the spread of the tears on the eye.  The currently available studies indicate that the symptoms are related to inflammation of the ocular surface and lacrimal gland which disrupts their function.

There are numerous conditions which influence the development and worsening of the dry eye such as LASIK surgery, glaucoma medications, inflammatory diseases such as rheumatoid arthritis and other systemic diseases such as diabetes and Parkinson’s Disease.  Antidepressants, diuretics, hormones and antihistamines among other drugs are implicated in worsening the condition.

Treatment is determined by the level of severity of the symptoms.  For those with mild, intermitent problems due to changes in the environment, the approach is to use over the counter artificial tear substitutes.  In general, I find that you get what you pay for when it comes to these products, that is, the inexpensive generic drops do not work.  Products such as Optive, Systane, Hypotears are most effective.  When the symptoms worsen where your activities are impacted then more aggressive treatment is indicated.  Firstly, you might consider taking omega-3 fatty acids for their anti-inflammatory effect.  If there is eyelid inflammation, you might require antibiotic eye drops.  Sometimes, in the short term, cortisone eyedrops for a limited period might break the cycle.  Eyedrops such as Restasis are effective in reducing the  inflammation of the lacrimal gland and ocular surface.  Silicone plugs (punctum plugs) placed in the tear drainage canal will allow the tears to remain on the eye for a longer time.  There are drugs which stimulate the lacrimal gland to produce more tears (secretogogues) which are sometimes helpful. 

If we think about tear film deficiency as an inflammatory disease we will be much more effective in treating the condition than in years past when we looked at it solely as a lack of tear volume.

If you would like to review your dry eye issues with me just give a call and I will be happy to give you my best opinion.