Complications with replacement IOL in sulcus

[B1ackd0ug1as]

I had surgery to remove a Tecnis DCB00 from my right eye this past Tuesday.  (The surgeon had erroneously put in a lens that gave me clear vision only from 6"-18" although I had specifically said I did not want to wear glasses inside the house for normal activities.  He told me he had done replacement surgery hundreds of times with excellent results).  The plan was to replace that lens with the same model and a different power.  However, the surgeon ran into trouble removing the Tecnis and was forced to replace it with a Acrysof MA60AC in the sulcus. I asked if the capsular bag was torn and he said no, but I don't know the particulars as he is not very forthcoming with technical information.

Post-op I had crazy, roiling visual images in this eye.  Now, the 4th day after surgery, I still cannot see with my right eye (it's like looking through frosted glass).  By this time after my two previous surgeries my vision had improved considerably.  I've read about sulcus placement and am really worried about possible complications of this placement, of the difficult explantation, or both..

I am seeing a "Best Doctor" in a well-known teaching facility.  He strongly urged getting the Eyhance lens for my first cataract surgery (LE) last fall.  I paid $2900 out of pocket for that.  As a whole, I am pleased with the result.  I can read and distance vision is about 20/30, which approximates my nearsightedness before cataracts.

Has anybody here had a lens exchange with complications?  Is this extended period without vision WNL?

Thanks for any info you can share.

[B1ackd0ug1as]

More support here for Ron_AKA's suggestion that anyone preparing for cataract surgery should get target diopters and a copy of the IOL Calculation sheet before proceeding with surgery.

It has been a year since my RE cataract surgery and my vision is worse than it ever was before surgery due to 1) the wrong lens power being selected and inserted for my initial surgery and 2) a promised easy replacement of that lens  that led to considerable corneal edema and lasting surgically-induced astigmatism.  (I had no astigmatism pre-surgery.)

My ophthalmologist seems to think I should be satisfied with wearing glasses at all times to correct this astigmatism.  He has referred me to a contact specialist for a consultation.  My astigmatism has decreased from 3.65 to 3.03 over the past several months, but, obviously, that astigmatism is sufficient to guarantee blurry vision at all distances.

Additional surgery carries risks, no matter how confident your surgeon tells you he is is of a successful outcome.  Had I done what Ron _AKA suggested in the first place, all this grief and additional expense could have been avoided.

[MrPresley]

The “promised easy replacement” of the lens was a big issue in my opinion. I have never considered replacing my plain-jane monofocal IOL in my LE. It works just as my cataract surgeon said it would, and going through any sort of eye surgery with the likelihood of redoing it would give me serious pause from ever doing it at such a practice in the first place.

[B1ackd0ug1as]

Yes, absolutely.  But I was in an unworkable situation when the plain Jane lens the doc put in at first gave me clear vision only for plucking eyebrows.  I could not read with that eye then, either.  (I asked for a lens that would allow me not to have to wear glasses inside, only for distance.)  The whole thing resulted from not doing what Ron-AKA suggested.

[MrPresley]

I get what you’re saying now. I was myopic before cataract surgery, wore primarily contact for distance. Was myopic after cataract surgery (IOL in LE only) and still use contacts for distance only. Close-up vision without any correction is good, with both the surgical and non-surgical eye relatively equal in terms of myopia. Not ever intending to have cataract surgery on my RE if it’s not necessary.

[Ron_AKA]

Not an answer to your current question, but when people are preparing for cataract surgery I always try to encourage them to get an understanding of diopters and that the target be set in diopters, not vague terms like near, intermediate, or distance. And, to ensure there is no misunderstanding you should ask for a copy of the IOL Calculation sheet, and agree with the surgeon what lens power is being used. It goes a long ways to prevent any confusion as to what is being targeted.

[B1ackd0ug1as]

Agree 100%.  I tried to gt this info, but was rebuffed.  I had the devil even to get the name of the Eyhance (or Tecnis) lens.  Very frustrating.

[Ron_AKA]

To me, this is a red flag suggesting that one should find another surgeon. Medical data belongs to the patient not to the doctor, as determined by the supreme court. They should never refuse to give a patient medical data like the eye measurements.

[MrPresley]

This was one of the many benefits I realized by joining this forum in 2015. The potential pitfalls of multi focal IOLs were reported by many posters. I went with a monofocal IOL in my LE set in approximate parity to my non-operative RE, since there was no compelling reason (and still is not) for cataract removal from my RE.

[John C Hagan III, MD, FACS, FAAO]

Of all the modifications and new technology to come out in the last 15-20 years I think the Light Adjusted Lens (LAL) is associated with the hightest patient satisfaction. If I were having cataract surgery, which I as yet don't need, at this time 9/4/23 that is what I would choose. Corrects astigmatism, its a monofocal but adjustable for up to 6 weeks post surgery.

[John C Hagan III, MD, FACS, FAAO]

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[B1ackd0ug1as]

Checking back here to report my vision in the right eye is still poor.  I am in the middle of another prednisolone taper (4-3-2-1 with two weeks at each level).  I only did one week each previously, and the cornea person wanted me to start all over again.  Ditto with hypertonic sodium chloride drops in AM and ointment before bed.

Astigmatism remains to the degree that I can only rarely see clear enough to read or watch TV.  No debridement was done as the bullae had resolved by the time of my last visit to the cornea specialist on Dec. 8.  It's going on 5 months since the surgery and I'm more or less despairing of getting decent vision in this eye again.

[John C Hagan III, MD, FACS, FAAO]

At this point I cannot offer much useful information.  If the problem was just astigmatism or under/over correction of post op refractive goal you should be able to see clearly when they do a glasses test and put those lens before the eye. Given you are seeing a cornea consult, on sterods and hypertonic saline likely your cornea is still swollen. Prognosis would have to come from your ophthalmologist and consultants.  I wish you the best of luck.

[John C Hagan III, MD, FACS, FAAO]

Situations like yours do not  track the general post op course. Because of that we can offer other information because it would just be a guess and we don't do that. You will need to get that information from your surgeon

[B1ackd0ug1as]

Understood.  I was only seeking reassurance (or not) from someone (patient or doc) who had had the experience of blurry vision taking this long (or longer) to resolve.  I saw the surgeon on the day after surgery and he said the lens was properly centered.  He upped my prednisolone to a 4-3-2-1 taper, and I'm not scheduled to see him again until next Friday (a week away), so I am anxious.

[John C Hagan III, MD, FACS, FAAO]

Realistically no reassurance can be given. Some people see well after surgery but develop problems, some surgical related, some coincidental, in the weeks and months after surgery. Other people are quite blurry for the first week, especially if elevation intraocular pressure, or complications at surgery.  Your are best advised to call the office early Monday and ask to be see that or next day.   I practice in a huge group of surgeons and optometrists working for the good of our patients. Our phone bank may receive 600-800 calls/day. If a post op patient calss complaining of pain, major change of vision, or just needs an extra visit for reassurance, we will always accommodate them. With your concerns your sugeon, or another in that office should see you Monday.

[B1ackd0ug1as]

Thank you.  I did call the surgeon and saw him the following week.  He says it is corneal edema and 85% is clear, but not the central part which, of course, is what I need to see clearly.  He clarified there was some fibrosis in the capsule which made removal of the prior IOL difficult.  He said he was able to put the new IOL in the bag, but the haptics are in the sulcus.  He put me on a prednisone taper and recommended the Muro 128 drops.  I've been taking them for close to a week and see very little improvement, e.g. I cannot read the text of this webpage on my laptop and the although I can finally see the letters of the keypad, they are all blurry at any distance.  Ocular pressure is 16/17.

[John C Hagan III, MD, FACS, FAAO]

The general impression is cataract surgery is always successful and complication free, even though everyone (in most countries) signs a informed conscent that lists blinkness as a possible complication. An IOL exchange has more risks, in most cases, than a routine cataract removal and insertion of the first IOL.  In most instances a healthy cornea can recover from trauma during surgery.  The chance of your vision improving over the next 2-6 weeks is generally good. I think your expectations for your uncorrected vision are likely unrealistically high and your vision without glasses may not live up to what you were hoping for. Good luck

[B1ackd0ug1as]

Thank you for your response, Dr. Hagan.  Please understand that my expectations for my uncorrected vision after this surgery came exclusively from what the surgeon told me ahead of time.  I did not have a "general impression" of no-risk.  I was extremely concerned about potential risks and he assured me he did this sort of surgery routinely with complete success.  Yes, the consent form lists generic possible outcomes from IOL surgery, but, practically speaking we must rely on what our doctors tell us, or we would do nothing that entailed risks.  He did not even discuss the fact that recovery after this procedure would likely take longer than the first cataract replacement!  I was given the exact same post-op info and instruction sheet as I received after cataract surgery.  I wish there were universal standards for what surgeons had to disclose before surgery.  It seems unfair to me to put the burden on the patient for understanding what questions to ask and with what precision when the patient has little or no familiarity with the territory.

[Cocobean2]

"I wish there were universal standards for what surgeons had to disclose before surgery.  It seems unfair to me to put the burden on the patient for understanding what questions to ask and with what precision when the patient has little or no familiarity with the territory."--B1ackd0ug1as Sep 04

AMEN, B1ackd0ug1as! Thank you for your VERY TRUE words! More than fifty percent of the cataract surgery questions on this forum would not be necessary if the surgeons themselves would speak to their patients as if there was actually a brain behind the lenses they are removing. Why are we crowd sourcing cataract surgery information? Why don't they provide appropriate information? I get a better explanation about parts, procedures and what to expect from my auto mechanic!  We, the patients, are living with the results. The surgeon should share their plans for the surgery, the recovery and the expected outcome. The surgeons are smart. They know stuff. They should learn to communicate as well.

[B1ackd0ug1as]

Yes, cocobean.  Or, at the least, the protocols for information that needs to be shared should be changed.  For instance the MyChart notes on my IOL replacement say,
"Status post IOL exchange OD (post-operative visit #1)
Patient is doing well POD #1
Intraocular pressure and incision checked.
Patient is pleased with procedure and facility.
Continue Post-op Medications per post op sheet.
Patient has been advised to call promptly if they experience significant reduction in vision, increasing pain, progressive redness, periocular swelling, or any concerning new symptoms or questions."
none of which, except for the bit about checking my ocular pressure is true!  The notes are boilerplate and the same as what was written after previous (successful) surgery.  

For the record, I am now approaching 4 weeks post-op and my vision is slightly worse than before the initial cataract replacement.  At least then I could still read with my right eye.  

[John C Hagan III, MD, FACS, FAAO]

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[B1ackd0ug1as]

Dr. Hagan, I'm posting here so as not to hijack Hailey's mom's query any further than I already have!

I saw the corneal specialist yesterday  and she said there was no evidence of descemet's detachment in vertical or horizontal cuts.  What she saw was irregular cylinder due to epithelial edema and bullae.  So she took me off the Lotemax and put me back on prednisolone in a 4-3-2-1 taper, added 4 Muro drops at 5 minute intervals first thing in the morning, and Muro ointment at night.  eye pressure was at 15.

Will see the surgeon again on Nov. 17 and the cornea specialist on Dec. 8.  She said if the edema does not resolve, she would consider debridement in hopes the cornea would heal without the deformation.

[B1ackd0ug1as]

P.S.  She also said there is no central edema, pachy is excellent (I don't know what pachy is), so it is hard to understand why my vision is so poor.  I cannot read at all with this eye.

[John C Hagan III, MD, FACS, FAAO]

Pachy is pachyometry  which is corneal thickness. Goes up with edema. Your prognosis is excellent. The Muro is very helpful. Symptoms are worse in the morning when awakening because during sleep the shut lids make less oxygen available. After you are awake and the eyes open the extra oxygen helps remove the edema as does the some evaporation.  Many many years ago this problem was treated by using a hair drying and gentlely blowing warm air over the cornea.  If all else fails scrabing the cornea and putting on a bandage contact lens for a week or so usually takes care of the problem.

[B1ackd0ug1as]

Thank you again for your kind attention.  For me, it's the lack of information that creates anxiety.  I think the cornea doctor knows her stuff and I hope I will see some improvement over the next month.

[John C Hagan III, MD, FACS, FAAO]

These cases are all somewhat unique and as you know people heal, or don't heal, at different rates. Best of luck

[B1ackd0ug1as]

Yes, thank you.  The cornea specialist mentioned debridement as the next step if edema and bullae don't resolve by next appointment on December 8.

[John C Hagan III, MD, FACS, FAAO]

It's been 8-9 days since you posted.  Have you been able to see some improvement.

[B1ackd0ug1as]

Only very, very slight improvement, I think a/o today.  Text on my laptop remains blurred with that eye and I can't make out words unless I squint and move my head just right.  I am now down to 2 drops of prednisolone daily.  Still doing the Muro first thing and the 5% sodium chloride ointment at night (which I have not figured out a good way to apply.  It want to stick to the tube or the outside of my eye and is the very devil to apply where it belongs).  Thank you for asking.  I'll report back after my Nov 17 appt with the surgeon.

[John C Hagan III, MD, FACS, FAAO]

Any improvement you see with squinting can usually be cleared with glasses

[B1ackd0ug1as]

That would be a disappointing outcome considering the whole reason for the revision surgery was so as not to need glasses inside the house.  If I was going to have to wear glasses, I would have been better off with the original, improperly selected lens and no additional surgery.  Vision is far worse now than it was then.  As you know, I only consented to surgery based on the surgeon's assurances that the revision surgery was routine with universally good outcomes.  Had he discussed desired outcomes in terms of diopters initially (as Ron _AKA suggested, above) the current situation could have been avoided.  I wish someone had advised me to ask for a copy of the IOL Calculation sheet, but I had no idea there even was such a thing to ask for.

[John C Hagan III, MD, FACS, FAAO]

In surgery there is NO type of surgery that has "universally good outcomes".  Crossing a busy street has "universally good outcomes"   That is why you sign a conscent form for every type of surgery including "routine".

[B1ackd0ug1as]

Of course not.  That's why you must rely on your surgeon's judgment.  This reminds me a little of the reason strict protocols were developed for airline pilots.  Without a clear mandatory checklist, accidents were more common.  Likewise with surgery like this, it seems to me.  I was not given information I needed to affect the outcome.  All the negative consequences have flowed from that, it seems to me.  The release alone does nothing to address the problem, just as having airline passengers sign a release would have no effect on crash frequency.  

[John C Hagan III, MD, FACS, FAAO]

I come from a family of pilots and I was in the USAF. However even with 'strict protocols"  pilots show up intoxicated, under the influence of drugs, to whit the pilot in the jump seat that tried to crash the commercial flight recently.  Nevertheless, it is not helpful for either one of us to belabor the point.  I don't think I can add any more useful information. Best of luck to your.

[John C Hagan III, MD, FACS, FAAO]

you