From Macular Hole to Retinal Detachment to Cataract

Discussion in 'Optometry Archives' started by Ms.Brainy, Mar 18, 2007.

  1. Ms.Brainy

    Ms.Brainy Guest

    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

    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!
    Ms.Brainy, Mar 18, 2007
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  2. Ms.Brainy

    p.clarkii Guest

    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

    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.
    p.clarkii, Mar 18, 2007
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  3. Ms.Brainy

    Charles O Guest

    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.
    Charles O, Mar 18, 2007
  4. Ms.Brainy

    Ms.Brainy Guest

    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,

    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.
    Ms.Brainy, Mar 18, 2007
  5. Ms.Brainy

    p.clarkii Guest

    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.
    p.clarkii, Mar 18, 2007
  6. 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.
    William Stacy, Mar 19, 2007
  7. Ms.Brainy

    Ms.Brainy Guest

    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

    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?
    Ms.Brainy, Mar 19, 2007
  8. 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.
    William Stacy, Mar 19, 2007
  9. Ms.Brainy

    Ms.Brainy Guest

    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
    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.
    Ms.Brainy, Mar 19, 2007
  10. Ms.Brainy

    Ms.Brainy Guest

    What's the advatage of contacts over glasses? How are they different
    in this context?
    Ms.Brainy, Mar 19, 2007
  11. Ms.Brainy

    Ms.Brainy Guest

    Do you have any additional information on this? any website? link?
    Ms.Brainy, Mar 19, 2007
  12. Ms.Brainy

    Charles O Guest

    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.
    Charles O, Mar 20, 2007
  13. 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).
    William Stacy, Mar 20, 2007
  14. 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...
    William Stacy, Mar 20, 2007
  15. Ms.Brainy

    Dan Abel Guest

    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.
    Dan Abel, Mar 20, 2007
  16. Ms.Brainy

    Ms.Brainy Guest

    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.
    Ms.Brainy, Mar 21, 2007
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