Explant IOL because of Wrong power?

Discussion in 'Optometry Archives' started by George, Jul 7, 2005.

  1. George

    George Guest

    Hi All,

    My cataract surgery went okay, slight edema that cleared up. But now,
    after 2 weeks, I noticed that I appear to be hyperopic by about 0.5
    diopter in right eye. When I looked at the laser IOLMaster measurement
    report taken two years prior to surgery (Doc said I didn't need a newer
    one), it reported possible choices of a 15.5D for Ref(D) of -0.38 or a
    15.0D for Ref(D) of -0.03. He chose the 15.0 which in my opinion was
    wrong choice since I have been myopic in right eye for most of my 66
    years. For reference, I had the left eye done two years ago and he went
    for 16.0D to get a target of -0.34.

    I was very surprised that he inserted a 15.0 in the eye instead of the
    15.5 which would have matched both eyes and made them both slightly
    myopic. When I brought this up with him, he was very defensive and said
    it would be okay and that a 0.5D difference was negligible. Well it is
    not negligible to me and I can see that right eye is not as sharp as the
    left eye. Also nothing seems to be in focus in right eye now unless it
    is very far away. He said to use both eyes and not compare vision from
    each other. That seems like good advice, but with large floaters
    occasionally left eye is blocked and must revert to right eye which may
    be blurry.

    When I asked him about replacing the IOL he came up with a whole list of
    things, including possible detached retina, that could happen during the
    explant. I think he was trying to scare me. He recommended using
    glasses. I have only used glasses for 3 years of my life except for
    reading glasses, and dislike using them tremendously. I am also getting
    bad headaches when I read, drive or watch TV. The right eye will hurt
    when I drive a long distance for over an hour.

    I feel terrible that he screwed up the IOL power. So what should I do?
    Is an explant warranted? What are the real risks? Are there surgeons
    that do explants more often and have a good sucess rate? Thanks for any
    and all answers.

    Sincerely,

    George
     
    George, Jul 7, 2005
    #1
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  2. George

    LarryDoc Guest

    Based on your report, I'd say you're correct and he blew it, primarily
    by not paying attention to your desires. He was shooting for zero
    resultant optics and that is not at all unusual. But if you had asked
    so, he should have erred on the myopic side and now you need to deal
    with reality of where you are today.

    For one thing, it's only two weeks post-op and it is possible that there
    will be some changes in your resultant optics, so hang in there and wait
    and see. You might very well end up exactly where you want to be.

    If not, I'd say the risk vs. benefit profile considering explant-redo
    IOL and the use of a continuous wear silicone-hydrogel lens easily
    favors the contact lens scenario. There are indeed risks to a second
    operation and I would caution against that in your situation. Further,
    likely in a few months there will be multifocal silicone hydrogel
    contacts lenses that will be able to address your residual optical
    correction and provide you with some help with near vision at the same
    time.

    Best of luck with your choices and final outcome.

    --LB, O.D.
     
    LarryDoc, Jul 7, 2005
    #2
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  3. George

    Guest

    When an IOL is explanted the replacement lens is almost always put in
    the anterior chamber. You would not necessarily solve your problem by
    replacing the IOL. After you are done healing, you can consider a mild
    refractive surgery procedure on the hyperopic eye to make it slightly
    myopic. Until then, the contact lens option sounds best.
     
    , Jul 7, 2005
    #3
  4. George

    Dr Judy Guest

    With only 2 weeks since surgery, you may well find that the +0.50 is not
    your final Rx. Also, some of the blur, discomfort etc you are noticing may
    be related to healing. Wait at least 6 months before deciding on explant.

    Explants do carry the risks your surgeon mentioned; more risk than
    correcting a 0.50D refractive error warrants. The other thing to consider
    is that, even with the other IOL power, you may end up with refraction of
    +/- 1.00 due to positioning, healing, and so on. Not to mention that you
    could end up with a small amount of astigmatism.

    No surgeon can promise to deliver a particular post op refraction100% of the
    time. If you were expecting plano refraction, you had unrealistic
    expectations.

    Dr Judy
     
    Dr Judy, Jul 7, 2005
    #4
  5. I too think he blew it and do not think you will end up with less
    hyperopia in a few weeks.

    Unfortunately, it is too small an error to think seriously about
    explantation, due to the risk/benefit considerations. Also, the longer
    you wait the more difficult explantation would become. So just count
    your blessings and get some good glasses.

    w.stacy, o.d.
     
    William Stacy, Jul 7, 2005
    #5
  6. George

    George Guest

    Dr Judy wrote:
    ..>
    ..> ..> > Hi All,
    ..> >
    ..> > My cataract surgery went okay, slight edema that cleared up. But
    now,
    ..> > after 2 weeks, I noticed that I appear to be hyperopic by about 0.5
    ..> > diopter in right eye. When I looked at the laser IOLMaster
    measurement
    ..> > report taken two years prior to surgery (Doc said I didn't need a
    newer
    ..> > one), it reported possible choices of a 15.5D for Ref(D) of -0.38
    or a
    ..> > 15.0D for Ref(D) of -0.03. He chose the 15.0 which in my opinion
    was
    ..> > wrong choice since I have been myopic in right eye for most of my
    66
    ..> > years. For reference, I had the left eye done two years ago and he
    went
    ..> > for 16.0D to get a target of -0.34.
    ..> >
    ..> > I was very surprised that he inserted a 15.0 in the eye instead of
    the
    ..> > 15.5 which would have matched both eyes and made them both slightly
    ..> > myopic. When I brought this up with him, he was very defensive and
    said
    ..> > it would be okay and that a 0.5D difference was negligible. Well it
    is
    ..> > not negligible to me and I can see that right eye is not as sharp
    as the
    ..> > left eye. Also nothing seems to be in focus in right eye now unless
    it
    ..> > is very far away. He said to use both eyes and not compare vision
    from
    ..> > each other. That seems like good advice, but with large floaters
    ..> > occasionally left eye is blocked and must revert to right eye which
    may
    ..> > be blurry.
    ..> >
    ..> > When I asked him about replacing the IOL he came up with a whole
    list of
    ..> > things, including possible detached retina, that could happen
    during the
    ..> > explant. I think he was trying to scare me. He recommended using
    ..> > glasses. I have only used glasses for 3 years of my life except
    for
    Thanks for the comments so far.

    My surgeon admitted to me that the 15.5D IOL could have been used. He
    couldn't explain/justify to me why he chose the 15.0D instead of the
    15.5D IOL. So I think he made an error. My feeling is that he was so
    busy in our interview that he didn't spend enough time asking me the
    right questions and I was too timid to suggest a lens power for him,
    although I knew the 15.5D would be best based on the Zeiss IOLMaster
    data I had reviewed. I do sometimes kick myself for not being agressive
    enough... but I'm a layman and he is the surgeon and I thought he knew
    what he was doing!

    Dr. Judy, he did promise me perfect vision in the right eye; so why were
    my expectations unrealistic? Afterall he did a perfect job on the left
    eye. How would you feel if you had to resort to contact lenses,
    bifocals, or progressive lenses if you didn't have to? Granted, for
    people who need them they are great. And how would you feel if you had
    to walk around the rest of your life knowing that your OD goofed and
    cheated you out of a nice result? Its a terrible feeling!

    George
     
    George, Jul 7, 2005
    #6
  7. George

    Dan Abel Guest

    I was very surprised that he inserted a 15.0 in the eye instead of the
    15.5 which would have matched both eyes and made them both slightly
    myopic. When I brought this up with him, he was very defensive and said[/QUOTE]


    It's too bad that you weren't able to communicate your desires to him.
    Although many people would be quite happy with your present situation,
    it's obvious that you aren't.

    Most people would consider .5D as negligible. Again, you just aren't
    "most people".


    I'm sure he was trying to scare you. There are risks in doing eye
    surgery. It's pretty clear that the choice between those risks and going
    blind due to cataract is for surgery. The choice isn't so clear when the
    sole purpose of the surgery is to correct a .5D hyperopia.

    Wait!!! It is too soon to know what your vision will really be. It is
    also too soon to know how you may or may not adapt to a possible less than
    perfect vision.

    I feel more and more lucky that they got both of mine right on. I knew
    there was some risk, but it didn't happen to me.
     
    Dan Abel, Jul 7, 2005
    #7
  8. George

    The Real Bev Guest

    Yeah, especially if you're too nice to complain about it.

    My mom's quack (a) was perhaps the last doc on earth to do stitchful cataract
    surgery; (b) chose to make my mom myopic when she had been hyperopic all her
    life -- had she known she had a choice she would have chosen hyperopia; (c)
    allowed a macular hole to develop in one eye and a macular swelling to develop
    in the other (even though he was giving her quarterly eye exams for 10 years)
    resulting in deteriorated vision such that she had to give up driving and is
    unable to read the newspaper without a 7x magnifying glass; (d) treated her
    for glaucoma for 2 years, although her IOP has not increased during the last
    year when she stopped using the drops (advice of new ophthalmologist).

    No, she won't complain. When the new opthalmologist learned I was thinking of
    complaining to the medical board he spent half an hour on the phone trying to
    convince me that the old doc was a great guy and knew his stuff and shit
    happens and it's nobody's fault. What he did convince me of was that I hadn't
    a hope in hell of finding an ophthalmologist to back me up. I thought of
    picketing the quack's office, but my mom got really angry about that.

    At the very least, your doc's services ought to be free from now on. The
    question is, of course, would you trust him to touch your eyes again?
     
    The Real Bev, Jul 9, 2005
    #8
  9. Actually, within the first couple of months, a lens is explanted by blowing
    up and separating the bag around the implant, and usually placing the
    implant back in the bag. Is does not fuse permanently this early. If it
    does, the second choice is to place the lens in the sulcus, only slightly
    less preferable than in-the-bag. Only if this cannot be done is an anterior
    chamber lens used.

    So, the "almost always put in the anterior chamber" statement is really not
    accurate.


    David Robins, MD
    Board certified Ophthalmologist
     
    David Robins, MD, Jul 9, 2005
    #9
  10. I don't see any mention of the final refraction in the previously operated
    eye, where the expected target power was -0.34. Did it end up accurate at
    about -0.34, or was it more hyperopic than that, and ended up around plano?
    That prior "track record" would have helped in deciding the power needed for
    the other eye.

    Another factor, though, is if someone has been always myopic (ie 1-4D
    range), I never aim for near plano. I go for somewhere between -0.50 and
    -1.25, after discussing where they want , visually, after surgery. However,
    I also warn that the equations cannot predict precisely where the implant
    heals in the eye, so despite aiming for a certain power, there is a "bell
    curve" outcome, with powers on either side of intended being possible, with
    a standard deviation of about +/- 0.50.


    David Robins, MD
    Board certified Ophthalmologist
     
    David Robins, MD, Jul 9, 2005
    #10

  11. Wow! Promised perfect vision!!!

    a) What is "perfect vision" ?

    b) How can one possibly "promise" something that is unpredictable, based on
    the vagarities of the implant power prediction limitations?

    C) How can he promise, in addition, that you will not have a complication
    like endophthalmitis, and lose all vision, or something like cystoid macular
    edema, and have compromised vision? These are the usual and expected risks,
    albeit small risks. But you can never promise these won't happen. It is in
    the informed consent discussion and the surgical signed consent in every
    case I have ever seen. Our informed consent specifically mentions possible
    need for glasses (or other refractive help) after surgery.

    Frankly, being a third of a diopter hyperopic is usually still a very good
    result.

    Just out of curiosity, do you happen to be an engineer?
     
    David Robins, MD, Jul 9, 2005
    #11

  12. By the way, one can easily have glaucoma WITHOUT increased pressure. This is
    common, and know as "normal tension glaucoma". Diagnosis is based on
    cup/disk assymetry, as well as abnormal visual fields. A common
    misconception, that your story supports, is the glaucoma requires elevated
    pressure, which is not true in about 10 of glaucoma cases.

    Just as common a treatment issue is people being treated for glaucoma for
    years because they had one slightly elevated pressure. Some people have
    ocular hypertension (elevated pressure) without any damage, so there is
    really no "glaucoma", but are being treated as such. Or, some people get
    high reading leaning forward into the instrument, and really don't have high
    pressure when measured in the upright peosition, so they are getting treated
    for a measurement artifact.

    Just some more information for folks out there.

    Now, I'm not saying your mom actually had glaucoma, or that the new doctor
    was wrong - just more info.
     
    David Robins, MD, Jul 9, 2005
    #12
  13. I think you mean emmetropia. Nobody in their right mind would choose
    hyperopia post cataract. If she ended up -.25 to -1.50 myopic, that was
    a reasonable outcome; if more than that, then I'd agree that an error
    was made.

    w.stacy, o.d.
     
    William Stacy, Jul 9, 2005
    #13
  14. George

    George Guest

    Dr. Robins and others,

    The left eye was refracted several times over last two years and always
    came up "pl" on the prescription. I assume that means "plano". So he
    went for a target of -0.34 and ended up plano in the left eye. Okay
    good. Now for the right eye, which had always been myopic, he went for
    an IOL of 15.0D and REF(D) of -0.03. He can't tell me why he did this
    except to say it won't make any difference and is within normal range.
    Never-the-less I do not understand why he did not use the 15.5D IOL and
    shoot for -0.38. Yes, I had reviewed the Zeiss IOLMaster data myself at
    home prior to operation, but it seemed obvious to me that based on the
    previous surgery on left eye, that he would choose the 15.5D IOL. I
    never mentioned it to him as I thought it was a "no brainer" Boy was I
    wrong!! And was I shocked when I looked at the IOL card that night and
    saw 15.0D on it.

    Dr. Robins, you guessed it. I am an engineering professor (Ph.D) with
    nearly 40 years of teaching and industrial experience. My eyes are very
    important to me and I need them very much in my work. Perhaps this may
    explain why I am so confounded by this fiasco. I see errors in
    engineering all the time, but I am not tolerant of them. If a person
    can't do the job they are trained to do then it is time to get another
    line of work! On some ocassions where life, limb or property have been
    lost or damaged, I have been asked to evaluate the situation. In most
    cases it has been human error often based on laxness. I just never
    thought it would happen to me at a respected eye institute.

    My feeling is that some surgeons get overly used to cataract surgery
    because of the volume of patients and don't get much feedback from their
    older patients (See Bev's comments) and they consequently become lazy.
    My surgeon's first comment after I pointed out this error was "don't
    worry we can fix it with a little lense correction". "But I don't want
    glasses" said I. " He looked at me strangely. "Why not?". I guess he
    doesn't get it.

    Dr Robins, if a patient came into your office and explained the
    situation as I have, what would be your advice? My feeling right now,
    since I am understandably miffed, is that I want the wrong IOL pulled
    out and the correct one inserted. I don't care about the risk! How
    significant is the risk...really?? I'm a 66 year old male in excellent
    physical condition..according the physical I took before the surgery.
    Are there surgeons who specialize in IOL replacement? How does one find
    one. I am willing to travel almost anywhere.

    George Steber, Emeritus Professor Ph.D


    ..> > Hi All,
    ..> >
    ..> > My cataract surgery went okay, slight edema that cleared up. But
    now,
    ..> > after 2 weeks, I noticed that I appear to be hyperopic by about 0.5
    ..> > diopter in right eye. When I looked at the laser IOLMaster
    measurement
    ..> > report taken two years prior to surgery (Doc said I didn't need a
    newer
    ..> > one), it reported possible choices of a 15.5D for Ref(D) of -0.38
    or a
    ..> > 15.0D for Ref(D) of -0.03. He chose the 15.0 which in my opinion
    was
    ..> > wrong choice since I have been myopic in right eye for most of my
    66
    ..> > years. For reference, I had the left eye done two years ago and he
    went
    ..> > for 16.0D to get a target of -0.34.
    ..> >
    ..> > I was very surprised that he inserted a 15.0 in the eye instead of
    the
    ..> > 15.5 which would have matched both eyes and made them both slightly
    ..> > myopic. When I brought this up with him, he was very defensive and
    said
    ..> > it would be okay and that a 0.5D difference was negligible. Well it
    is
    ..> > not negligible to me and I can see that right eye is not as sharp
    as the
    ..> > left eye. Also nothing seems to be in focus in right eye now unless
    it
    ..> > is very far away. He said to use both eyes and not compare vision
    from
    ..> > each other. That seems like good advice, but with large floaters
    ..> > occasionally left eye is blocked and must revert to right eye which
    may
    ..> > be blurry.
     
    George, Jul 9, 2005
    #14
  15. George wrote:

    My feeling right now,
    I think it's not worth the risk. There is a significant chance you will
    end up WORSE than you are now. It's a guess, but I'll say on the order
    of 20%. There is also a slim chance, probably less than 5%, that you
    will have a devastating result (endophthalmitis, capsule rupture,
    retinal detachment, etc) and could end up with a blind eye.

    I would send you to David Chang in the SF bay area, but I think he would
    probably tell you the same thing, and I doubt he would do it.

    I also don't understand your aversion to glasses. Even with mild
    myopia, your best vision would be with glasses. And they are protective
    in case of a vehicle accident.

    w.stacy, o.d.
     
    William Stacy, Jul 10, 2005
    #15
  16. George

    Dr Judy Guest

    It is obvious that you are determined to have the explant, no matter what
    advice you are given. If your surgeon won't do it, he can refer you to
    someone who will.

    Just be aware:

    The risks are real and include loss of the eye.

    No one can guarantee a plano final refraction.

    Dr Judy
     
    Dr Judy, Jul 10, 2005
    #16
  17. George

    The Real Bev Guest

    That's me. At last check the ophthalmologist said come back in a year. Quack
    wanted me in quarterly.
    Quack said glaucoma. USC/Doheny instructors said no. Who would you believe?
    The quack watched her vision deteriorate for years, diagnosing MD with nothing
    to be done. Only at the very end when she told him about the SUDDEN turn for
    the worse did he think that hey, maybe we should get some photographs. Even
    then, it took over a month to get the results back, which I regard as
    absolutely irresponsible. The tech saw the macular hole a month before the
    doc did, but he went on vacation the next day and didn't get back to develop
    the pix for 2 weeks.

    If you need an ophthalmologist (or any other doc, for that matter), pick one
    where you can get essential diagnostic tests TODAY, not 2 months from today.
    If you have insurance, there's no reason to suffer with second (or fifth)
    best.
     
    The Real Bev, Jul 11, 2005
    #17
  18. George

    The Real Bev Guest

    Yeah, sorry.
    I don't know what her prescription is, but she needed trifocals right off the
    bat. She would much rather have been able to drive without glasses than read
    without glasses and was totally surprised when I told her she should have been
    given a choice. A little angry too, but not angry enough to beat the shit out
    of him, which he richly deserves.
     
    The Real Bev, Jul 11, 2005
    #18
  19. George

    The Real Bev Guest

    Engineers and physical scientists are used to working with things that follow
    rules. If they don't, either the rule changes or you don't understand the
    rule well enough. Medicine isn't like that, unfortunately. I have discovered
    this only recently, with the many illnesses and death of my MIL, the vision
    problems of my mom, and the various other illnesses of friends and relatives.
    Doctors **** up. They **** up a lot. If they're lucky they can repair the
    damage or bury their mistakes. Perhaps it would be better if suing for
    malpractice resulted in actual punishment. Nothing like the thought of jail
    time to clear the mind.

    They -- by definition -- can't be perfect. If the guy actually promised you
    "perfect" vision he clearly ought to be horsewhipped because he was promising
    something that was impossible for him to deliver. (Maybe this was like the
    "You're the poster boy for lasik" that lasik surgeons are reputed to tell 98%
    of their potential patients.)
    He probably doesn't. Some orthopedists think that being able to walk is great
    and can't understand that a 70-year-old might want to run.
    I've been reading this group for several years and so far the pros have given
    practical advice independent of what might be profitable for a practitioner.
    I think the risks involved in lasik (5% not-good outcome) to be WAY more than
    I'd be willing to tolerate, and the odds they've given you of improving your
    situation surgically are worse than that.

    Standard advice is to go to one of the teaching hospitals. In SoCal we have
    USC's Doheny Instutute and UCLA's Jules Styne <whatever>. I've been impressed
    by the Doheny retinologists my mom is seeing (less so the ones that took care
    of my MIL) and the orthopedists my husband just saw last week, and have no
    reason to believe that the UCLA guys would be worse.

    Glasses aren't all that bad. When I do yard work or something else where I
    might get poked in the eye I wear my glasses instead of my contacts.
    Got a med school there? What about Mayo?

    --
    Cheers,
    Bev
    ====================================================================
    "My parents just came back from a planet where the dominant lifeform
    had no bilateral symmetry, and all I got was this stupid F-Shirt."
     
    The Real Bev, Jul 11, 2005
    #19


  20. I know of no one who would replace an IOL for a 1/2 D difference.

    Yes, I agree, from your track record it would appear that you end up a
    little less myopic than the calculation assumes. So to end up similarly, I
    would aim for the same power as the other eye was originally intended, and
    hope it ended up equally less myopic. So, your logic is logical.

    PS: I always tell patients to expect to wear glasses - that is the norm,
    since the outcome is a bellcurve. If they end up at some distances not
    needing them, they are lucky ...

    PPS: I'm also an electrical engineer, myself.

    Good luck.
     
    David Robins, MD, Jul 11, 2005
    #20
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