From Macular Hole to Retinal Detachment to Cataract

I am facing a cataract surgery in my right (bad) eye, but after my
visit with the cataract doc I am having serious doubts and concerns.

Brief history: About 8 months ago, while driving, I closed my left
eye for a moment and the school bus in front of me disappeared. I
realized that I had a problem and went to see an ophthalmologist,
expecting it to be a cataract. To my surprise I was diagnosed with a
macular hole instead. I went to get a second and third opinion, and
all agreed -- stage 3 mac hole, which was demonstrated to me with no
doubt in an OCT printed image. I had hard time making the decision to
operate, but was finally convinced to do it when considering the much
higher risk of same occuring in my other eye at some future time. I
must add that at that point my overall vision (with both eyes with
glasses) was good -- I had no problem functioning and I felt "whole".
My nyopia was mild and I had progressive glasses that enabled me to
drive or read with no difficulty.

The 40-minute surgery (vitrectomy and gas-fluid exchange) went well
and was almost painless, and the hole closed. My recovery was
spectacular, my vision returned as the gas bubble diminished, and I
thought that I was out of the woods. One month after the surgery I
already had a cataract in the operated eye but this was anticipated,
although not so soon (all articles that I had read stated a cataract
within 6-12 months, and I still have no clue of why I was so fast).
What little did I know then!

8 weeks after the surgery, again while driving, I suddenly noticed
very dark cloudy sky in front of me. I closed the "bad" eye and the
sky was blue! Further tests revealed to me that I had no vision above
my eyebrows line, as if a curtain was pulled down my right eye field
of vision, but no floaters or flashes of lights.

I saw my ophthalmologist the following day and BOOM! Retinal
detachment, emergency surgery, no time for preparation or information
gathering. I was rushed to the hospital for a 3-hour surgery (another
vitrectomy + laser + stitches + scleral buckle) and woke up with
another gas bubble and pain.

The recovery was slow and painful. I had a variety of strange
sensations in my eye -- prick, squeeze, sting, pinch, punch, itch,
tingle and plain deep pain. It's now 3 months after the second
surgery and I still have very mild pain. My vision in the bad eye
went from -3.5 to -7.75 and my cataract is HUGE. However, the retina
is still attached and the macula still closed. The recent OCT looks
absolutely perfect.

So here I am, needing a cataract removal. First, I don't like this
cat-doc. He seemed to me as a money-making machine, didn't give me a
chance to ask questions, and before I knew it I was presented with
consent forms to sign. But what was disturbing most was his "plan":
to install an IOL that would correct my distant vision, which will
require me to have reading glasses (and I presume also intermediate
distance glasses), and then do the same in the other eye, my one and
only GOOD EYE that has no cataract and so far no problem except mild
myopia.

This doesn't make sense to me. I would hate to take a risk of
possible retinal detachment and more complications and more
surgeries. I don't want to tamper with my good eye unnecessarily. I
also think that I'd rather have my vision corrected for intermediate
distance, which is what most of my activity is involved, and have
glasses for driving and another pair for reading. But he didn't allow
me to ask questions!

I still don't know what's the right plan for me. I understand that
it's not a good idea to create a big gap between the vision in both
eyes, although a small gap is OK. Maybe I should just wait? I am not
sure that my operated eye is fully healed and ready for another
trauma. I am functioning OK meanwhile, with the exception of glare
that makes night driving almost impossible.

What to do? Any advice, either from professionals or people who have
had similar experiences? I would appreciate any feedback. Thanks!

 

Wow. what an unfortunate series of events.

you seem quite intelligent and understand a lot about your situation
and what you want. i would encourage you to find another doctor who
will spend a little time with you to discuss your concerns, your
ideas, and give you a deeper explanation about why he/she proposes the
course of treatment that they do. sounds like you've been to a doc
who has poor bedside manner or is too busy to spend much time talking
to you. either way, i wouldn't feel comfortable either and would
pause to consider the situation further as you have done.

yes-- it is problematic when cataract surgery results in a large
prescription difference between both eyes. oftentimes this problem is
sufficient reason to have surgery in the "good eye" even if there is
no cataract. in such situations many surgeons simply implant a lens
that instead makes the operated eye have approximately the same
refractive error as the "good eye". in your case this approach makes
sense to me. why risk surgery on a healthy eye when it is pretty much
the only good eye that you have? actually i agree with you that
performing surgery on your good eye at all is something that is
questionable and possibly even not medically-advised in your
situation.

and your idea of implanting a lens to focus at intermediate distance
is quite reasonable. actually i suggest to many of my patients to
have their cataract surgery set them at approximately -0.50 to -0.75
afterwards. that type of refractive error is quite small and gives a
person reasonably good distance vision (~20/30) while also providing
reasonable vision for computers, reading larger to standard sized
print, etc.

i also think that your concern about having another operation on your
affected eye so soon is a reasonable concern. i don't think there is
any downside to waiting for awhile and it would give that eye a little
more time to heal and basically "settle down" after scleral buckle
surgery. there is a risk of re-detachment and that risk diminishes
the longer that an operated eye heals. in some situations retinal
surgeons will "weld" the peripheral edges of a suspicious-looking
retina down firmly to the sclera before cataract surgery using either
a laser or freezing so as to reduce the risk of detachment. i am not
sure if that is appropriate in your case but a good cataract surgeon
actually likes that to be done so that it minimizes the risk that the
surgery they are performing might turn out badly and that they could
be held accountable.

i don't know what your relationship with your retinal surgeon is but
you should consider discussing your cataract surgery with them. they
will know who the best cataract surgeons are for people in your
circumstances and they will also know whether preparative retinal
procedures (laser, freezing) is advised for you.

good luck.

 

I would not have surgery in the good eye if at all possible. My
experience was a cataract in only one eye, had surgery, had the YAG
laser, and then had a retinal detachment. The difference in the two
eyes was such that glasses did not work, but by wearing contacts, that
solved the problem of the two eyes having a big gap in vision. The
retina specialist recommended not having any surgery in the good eye as
long as possible if I could get good vision with the contacts. I
followed that advise but in my case the contacts solved the problem of
the gap. Any surgery is risky and the past history is something that
should be taken into consideration.

Ten years after the cataract and the detachment the good eye did start
developing a cataract. Soon I will probably have to have cataract
surgery in the second eye soon as it has been getting worse but it is
not something I look forward to because of the past experience, but I
got by with 12 year good years of good vision by waiting. And with the
advances in cataract surgery in the years since, smaller incisions,
hopefully a detachment won't follow.

 

Thanks for the responses. I am to see my retina specialist in a
couple of days and will discuss the situation with him, but alas, this
will be my last meeting with him because he is leaving the state to
relocate elsewhere by the end of the month. I really like him and
trust his experties, and his departure is a great loss for me.

You all advised me to get another opinion(s) and look for another
cataract sergeant, which is what I intend to do anyway. FYI, I chose
the ophthalmology department of my local University Medical Center
(which is on the list of the 5 best hospitals in the U.S.) to take
care of me, and both the retina and cataract specialists are in the
same group. However, there is a huge difference between their
personalities and the way they relate to their patients, or at least
to me. So it seems that I am now forced to find somebody outside the
UMC, and hopefully I will. There are many options available where I
live, and communication with my doctor + REAL consultation is
essential, in addition to his/her skills, qualifications, experience,
etc.

I was informed about the possibility of multifocal intraocular lens,
but my cat-doc said it would not be the right thing for me. Why? I
don't know, and when I asked he scolded me and ordered me not to
interrupt his lecture. When he finished he filled out some forms (I
was not allowed to interrupt this activity either), and then left the
room and submitted me to his assistant for some procedural tasks. I
think I deserve better than this.

Hopefully I will be able to get information from my retina specialist
as much as I can, but when I inquired in the past about cataract
surgery he referred me to the cat-doc, so this is where I am stuck.

 

multifocal implants do not give optically-sharp images. in order to
gain some near vision, there is some blurring of distance vision and
vice versa (i.e. "ghosting"). many patients do not find multifocal
implants to be satisfactory. however there are now "accommodating"
implants that have more recently been introduced (eg. Crystalens) that
seem promising. these implants can allow some patients to restore a
portion of their ability to focus at near. results vary, and it is a
relatively new development. this is something to discuss with your
new doctor.

PS - oftentimes the best doctors are not associated with a university
medical center. you are not giving up anything by going with someone
who is fully private nor are you gaining anything by going with a
university-affiliated group.

 

With the economics as they are, if he's a money making machine doing
cataracts, he's probably pretty doggone good at it.

One of the most important things about choosing a surgeon is: How many
do they do in a day? If the answer is 1 or 2, run away. If it's 10 or
12, you've found someone who has the technique down.

I especially like that he dismisses multifocal IOLs, which are in my
opinion garbage optically. I would not shoot for perfect distance
vision in the bad eye, but a little myopia. There's always some slop in
the calcs, and the buckle surgery has added more slopt to the mix, so do
yourself a favor and err a bit on the myopic side.

If he's suggesting you do the good eye as well, it most probably has a
cataract under development. But I agree with getting the bad eye done,
take a break, then decide.

 

I have no doubt about his skill or experience. He apparently does
hundreds if not thousands of them every year. The UMC records
indicate that he has made $325K last year. But consultation with the
patient and consideration of the patient's special needs and wishes
are equally important. For instance, I doubt very much my ability to
endure the surgery with topical or local anesthesia only, which my
retinal doc detected without me even telling him. My 2 previous
surgeries were done under general anesthesia, although this is not the
standard.

Because of my eye history, and the fact that my vitreous is gone
forever and my retina is somewhat flimsy, there are more risks and the
cataract surgery will be longer and more complicated than usual.
However, he didn't want to hear about general, and I don't think I can
agree to such a procedure otherwise. This is, of course, in addition
to the considerations of what will be inplanted in my eye(s) and how
it will fit my lifestyle and needs.

Interesting. I have a glossy brochure issued by HIM, recommending
this wonderbar as the best thing since indoor plumbing.

Yes, I agree with this, but this is not HIS "plan", which I have had
no opportunity to even discuss or express my concerns. Most of my
daily activity does not involve long distance vision.

No, there is no cataract in the good eye, not even a beginning. My
cataract did not develop "naturally", but was rather caused by the
vitrectomy. And this is my main concern. It seems (from my own
experience and from reading the numerous messages on this site) that
once tampering with an eye begins, there is more and more to come.

Actually, I did the first surgery (the macular hole) for the purpose
of securing a spare eye in the event the other eye gets bad in the
future. As I said, I was "whole" prior to the first surgery and the
loss of central vision in one eye was not noticeable when I used both
eyes. But I was afraid of future problems in the good eye, which
could leave me legally blind. So I went ahead.

Now, here is MY "plan": To wait another 3 months for further healing,
then do the bad eye with a lens to match the other eye, which has been
stable for quite a few years, and leave the good eye untouched. I
will need progressive glasses for various distances, which is fine
with me. BTW, being myopic I can read (even small print) without any
glasses, but have to be closer to the print.

What's your opinion?

 

Well, topical anethesia only is kind of a misnomer, as they actually put
an IV line in and dope you up pretty well with Versed or something
similar, which will make you pretty much not care what they do. I'm a
big chicken and had it done with no problems, well almost no problems.
My second eye I did feel some discomfort, almost to the point of asking
for a little more in the IV, but I braved it through and was fine. This
is MUCH safer than having a general, which can kill you, or make you
wish you were dead.

Just make sure you get a Valium or 2 before they put in the IV and make
sure you tell them you want no pain. You'll do fine. Forget the general.

Yes, unfortunately market forces are strongly at work here. They are
garbage optics.

Stick with single vision and ask for prolate optics if possible.

Tell him you want a little myopia post op. If he still balks, go
elsewhere which is what it sounds like you want to do anyway. Tell the
same thing to the next surgeon candidate.

Actually, I'm a big proponent of refractive lens exchanges, which is
what it sounds like he's recommending. If so, I'm amazed because I'm
having trouble finding a gutsy enough surgeon who's also competent to
send people to. I'm still against it in your case because the myopia
makes you at risk for another retinal detachment. Small risk, but
real. I'd probably wait, unless it gets worse. (I'm sure there is
"some" loss of clarity in that lens if you've been around more than 40
or 50 years, which may not be technically a cataract, but in reality is
the beginning).

As above, and I mostly agree with your ideas. Most importantly, do NOT
let anyone talk you into a multifocal IOL or a "focusing" (hinged
type). Good luck, and report back the results.

w.stacy, o.d.

 

What is "Versed"?

Indeed, there is a risk in general anasthesia, but the occurrance of
not waking up is rare. I am generally healthy and my 2 recent
experiences with general were wonderful and very smooth.

What is "prolate optics"?

What is "refractive lens exchanges"? Does it mean replacing the
already replaced lens in the future as the ever changing situation
dictates?

If you are correct in this speculation, I should have been informed
about it. I have no reason to assume a beginning of a non-technical
cataract in my good eye. I had none in the bad eye either prior to
the first surgery, which included vitrectomy and 2 months with a gas
bubble. The second surgery (retinal detachment) repeated the
vitrectomy and the bubble, which helped the cataract to grow.

What is "focusing - hinged type"?
Thanks for your response. I have learned a lot, and will certainly
keep you updated.

 

What's the advatage of contacts over glasses? How are they different
in this context?

 

Do you have any additional information on this? any website? link?

 

I can't wear glasses because the difference in diopters between my two
eyes is so large it is uncomfortable. The glass causes a magnification.
That does not happen with a contact lens which is on the cornea. One of
the Opticians or Optometrist can explain it better. If I could not wear
a contact lens then I probably would have had an implant in what was
then a good eye.

 

It's Midazolam Premedicant - Sedative - Anesthetic
commonly used in minor surgical procdeures. Also has an amnesic action
so you can't remember if it hurt or not.

What is your age?

It's used in some IOLs to reduce/eliminate spherical aberration. Gives
superior clarity and contrast sensitivity. May or may not be indicated
for some Rxs, but for most, works great and also apparently allows for
some decentration of the IOL without loss of vision.

No it means removing a human lens that has no (or minimal) cataract, and
replacing it with an IOL for refractive reasons (such as strong
hyperopic Rx). Also pre-empts the cataract which will eventually come
anyway. You don't want to do it more than once on an eye.

That's why I want to know your age. If you're over 50 you have some
cataractous changes for sure, even if sub-clinical (not diagnosable for
insurance persons as "cataract"). It's like if you're over 50 you have
some atherosclerosis, even if not clinically significant. Wear and tear
on the body is not completely preventable.

The Crystalens for example is an IOL which is designed to move forward
during accommodative (reading) effort. It doesn't work very well, in my
experience, and even if and when it does work, it only works a little
bit, never enough to really focus well up close. Not worth the effort
and added risk (larger incision, longer operation, etc).

 

We've had this discussion before and I have no problem with your
opinion, only that I personally like having less myopia than when I
started. Gives me freedom to not wear glasses when watching TV mostly.
Since I wear glasses the rest of the time, it wouldn't matter if they
were -3 instead of -.75, although I also like having such thin lenses.
I also ended up with .75 aniso which I find handy when shaving and not a
problem with the glasses. In the above case, I'd probably have the
surgeon target -1.00, knowing that the end result could be between 0 and
-2.00 and I would have a hard time justifying more than -2.00 unless the
person insists on it. The aniso will be an issue, but one that can be
dealt with easily with contacts, glasses, and/or refractive lens
exchange. For sure, nothing is perfect and everything is a compromise...

 

I did some research before my first cataract surgery. Once my surgeon
realized that I wasn't "up in the clouds", he discussed my options. It
was totally up to me. It was some years between the initial diagnose
and the actual surgery, so I had time.

 

Many thanks to all of you for the thoughtful input. You certainly
have been very helpful, and I mean all of you.

Update: I saw my retina doc yesterday, who said that my macula looks
"beautiful". Only an ophthalmologist could make such a statement! He
recomended another cataract specialist, to whom he said he would send
his parents if they need a cat surgery. I already set an appointment
with the cat doc for Friday.

I had a very good and informative discussion with my wonderful retina
doc, who is now leaving town. He said my eye is healed and ready for
a cat surgery, and he agreed that operating at this stage on my good
eye unnecessarily is not advisable. His suggestion is to aim to -2.00
in the operated (bad) eye, and then aim to zero for the other (good)
eye when the time arrives, i.e. when a cataract is formed there. THIS
MAKES SENSE. He also stated that the risk of another retinal
detachment in the operated eye has been DIMINISHED due to the scleral
buckle, and in fact my good eye has a greater risk of detachment as a
result of future lens replacement.

I will keep you informed you later about the continuation of my saga
in a new thread.