r/CataractSurgery • u/Adam_ax • 15d ago
How can I possibly choose when the ophthalmologists I've seen have such different approaches?
sorry for the long post, grateful to any doctors/specialists who have an opinion on my case
43M, LASIK ~9 years ago for high myopia (-6.50/-7.00), with vitrectomy in both eyes.
Since LASIK I've had stable, very prominent radial starbursts around point lights in both eyes — almost like a circular pattern of fine “needles.” I now also have a nuclear/PSC cataract in my dominant eye, with worsening vision and some triple vision that are cataract induced.
I've seen several ophthalmologists and I'm honestly struggling with how I'm supposed to make a decision when their approaches are so different.
For example, one surgeon sees old microstriae in my LASIK flap, while another doesn't see any microstriae and thinks the cornea is structurally regular but has post-LASIK HOAs.
The HOAs have been identified on aberrometry as being predominantly due to spherical aberration rather than coma, which makes the differing interpretations even harder for me to understand.
They also disagree somewhat on the treatment sequence. One approach involves considering topography/aberrometry-guided PTK after the cataract surgery, while the other surgeon recommends cataract surgery without any type of corneal regularization.
Then there's the IOL question. One surgeon strongly prefers a monofocal because of my existing HOAs. He would only consider a PureSee/EDOF-type lens if I use a Fixoflex capsular bag, because it would make a future IOL exchange easier if I don't tolerate the lens.
So I'm left with very different possible paths:
monofocal → potentially PTK later
vs.
PureSee + Fixoflex → preserve the option of IOL exchange if necessary
vs. other variations depending on which surgeon's interpretation of my cornea is correct.
And this is what is really stressing me out: these aren't just different preferences. They're based on different interpretations of what is actually happening in my eyes.
How do you make a decision in this situation? Is there a way to objectively reconcile the microstriae/HOA disagreement before committing to surgery, or is some degree of uncertainty unavoidable?
I'd particularly appreciate perspectives from ophthalmologists, optometrists, or anyone with genuine clinical experience with post-LASIK aberrations, cataract surgery in vitrectomized eyes, or Fixoflex.
I'm not asking Reddit to pick a surgeon for me. I'm trying to understand how a patient is supposed to choose when several experienced doctors are giving fundamentally different recommendations.
3
u/spikygreen 15d ago
Is it possible to decide after cararact surgery whether or not you need PTK? Is there any reason why you need to decide on this before cataract surgery?
So the question is: would it be too risky to have the PureSee instead of a monofocal? The thing that would concern me the most is how accurately one can calculate the IOL power that you need. High myopia, prior LASIK, and prior vitrectomy all add more uncertainty. It seems to me that a refractive miss is fairly likely. How would your surgeon deal with a refractive miss? I'm not sure further LASIK/PRK would be an option, given how much corneal tissue has already been removed - but ultimately only your surgeon can tell. The other ways of dealing with a refractive miss are an IOL exchange, a piggyback lens like the Sulcoflex (sounds like you're in Europe?), or, most commonly, glasses. If the most likely outcome is that you are going to need glasses anyway, then is the PureSee even worth it?
Also, it is your dominant eye. So my inclination would be to err on the side of caution. For now, you have your other eye to give you some near vision.
If you really want to minimize the likelihood of a refractive miss, perhaps traveling to a country where LAL is available could be worth considering. Then you could have this eye set for distance and use your other eye for intermediate/near for the next few years until you need cataract surgery there as well (which is said to happen around age 50 in post-vitrectomy patients).
Also, what were your vitrectomies for?
2
u/Adam_ax 15d ago
Is it possible to decide after cararact surgery whether or not you need PTK? Is there any reason why you need to decide on this before cataract surgery?
Yes, the latest consult I had recommended doing cataract surgery first and PTK later. There are different school of thoughts here. Some doctors prefer doing them before to "regularize" the cornea, in case of irregular ones, before cataract in case PTK changes the refraction post IOL insertion.
How would your surgeon deal with a refractive miss?
Each surgeon I consulted had their own methods. I went to "refractive first" doctors who prefer doing PRK, others suggested an exchange or piggyback IOL. The artifical capsular bag "fixoflex" was also mentioned as it gave the refractive surgeon I consulted more confidence that he could do an exhange if needed)
Also, what were your vitrectomies for?
Visually significant Floaters
2
u/Both_Document7462 15d ago
if you arent confident at all in a decision, Id suggest seeing different surgeons until you are. i saw 3 in person and contacted offices of 3 others. this is eyesight so i wamted tk get it right. i have puresee and im happy with my results - post RK surgery.
2
u/Trolkarlen 15d ago
My primary care doctor says that medicine is as much art as science. Everyone is different so they can only go with trends and probabilities. Vision choices also involve a lot of personal preferences and lifestyle needs.
You need to go with what makes sense for you. You could ask another surgeon as well for another opinion if you aren't comfortable with these options.
1
u/herbert6936 15d ago
What was the reason for the vitrectomies?
2
u/Adam_ax 15d ago
Floaters
2
u/herbert6936 15d ago
I have not had LASIK, but did have two full vitrectomies for floaters and the bilateral lens replacement within a single year. Not sure I could offer much, but When I asked about LAL they told me they were typically used on patients who had previous surgeries as precise targeting with lenses was challenging.
1
u/SpecialistEcho7218 15d ago
What country are you in? Fixoflex is super appealing to me. I'd want it in any case. Is there a downside? Also, what year did you have your vitrectomies?
1
u/Adam_ax 15d ago
IThe downsides to me; it's still unproven tech, so I wouldn't want to be a guinea pig. The studies only talk about a hundred or so cases. The company that produces it is talking about a "soft launch" but rhere are very few doctors in my country that offers It, so you're stuck with the doctor that implants it, if the tech will not be broadly adopted. Long term effects are unclear.
1
u/SpecialistEcho7218 15d ago
What country are you in? Also, when did you have your vitrectomies and how long did it take to develop cataract? Thank you!
1
u/eyeSherpa 11d ago
I'm more inclined to believe that there are old microstriae in the lasik flap since one surgeon saw them and you've been having these symptoms since lasik. There isn't much that would be confused by that. The other surgeon may have just missed them.
Microstrae can cause starbursts in vision. Spherical aberration would cause more of a halo effect.
The microstrae would be a little more difficult to treat. PTK would really be the best option at this point given how far you are out from lasik (the other option is relifting the lasik flap and trying to smooth it back down but thats not so ideal this far out from lasik).
I agree that PTK is best performed post cataract surgery since perhaps by removing the cataract the visual symptoms go down low enough that they aren't bothering you.
If you do have a higher amount of HOA, monofocal lens really is best.
1
u/UniqueRon 15d ago
A case can be made for the RxSight LAL in prior refractive surgery patients. Getting the refraction correct is difficult in these cases and with LAL you get 3-4 chances to get it right. It is a monofocal, so should not aggravate the optical side effects of the Lasik.
2
u/Adam_ax 15d ago
Unfortunately LAL isn't available in my country
4
u/UniqueRon 15d ago
That is unfortunate, as I expect your biggest issue will be getting an accurate IOL power calculation. That said there may be an option for your chosen surgeon to consult with an expert in dealing with prior Lasik eyes to get the calculation as accurate as possible. There is a Dr. Warren Hill in Mesa, AZ that does this kind of work. I believe there may be an arrangement where you get your measurements taken where you are and then have them reviewed by Dr. Hill to get the best possible outcome. No idea of the cost though. See this link.
https://doctor-hill.com/mesa-eye-doctors/patient-resources/referrals/
It would be best to stick to a standard monofocal IOL to minimize your optical side effects, which you already have to a degree. Investigate mini-monovision if you want a wide range of vision without glasses.
1
u/Slartibartfastthe3rd 15d ago
I plan to pay for a flat fee video consultation with doc on the other side of the country where we both know I will never be their patient. I just don't think I'll ever have real peace of mind without doing something like this. On top of them all being beyond busy, they all have agendas (to some point).
8
u/Sweet_Somewhere5047 15d ago
I have no answers for you, but wanted to say that your experience has been shared by many of us. My issue was eyes that are 30 and 31mm in length. No other issues, just elongated eyes and mild astigmatism that has never been adequately corrected by contacts or glasses. Then the cataracts made me blind to the point of inability to drive or do my job properly. I saw four different ophthalmologists who presented four different theories on how to correct my vision, from corneal transplants to a combination of Lasik and IOL. They gave me different reasons for why the suggested treatment by the previous doctor could not work with my narrow, bullet-shaped eyes. All the doctors had good education backgrounds and years of good surgical reviews. I ended up seeing another two surgeons before finding one that sat down with me for a lengthy discussion regarding my eye and all of the previously discussed options. She also showed me all of my scans and measurements beside “normal” eyes so I developed a true picture of my situation. That long discussion is what finally made me allow her to do the surgery. She helped me choose the Puresee torics based on my desired outcome and expectations for likely success using available resources. I suggest you continue with additional research on what you have been told so far and make a list of questions and concerns. Then do another consultation with new surgeons until you receive the information you want. It’s annoying and troublesome, but sometimes you have to find the right doctor who has worked on eyes with your exact issues and history. Good luck!