Positive Dysphotopsia after Cataract Surgery

Last year in March at the well established Pepose Vision Institute here in St. Louis. I had a $6,000.00 RX Sight LAL (Light Adjustable Lens) 20.0 D implanted be Dr. Pepose, in my left eye and immediately developed ND.

The following procedures have been done to my poor butchered left eye since then. : /

- a Reverse Optic Capture was performed at WashU. This diminished the shadow and transformed it to a blurry area of light non focused by the IOL. It’s like the frame on an eyeglass lens effect only it moves with the eye.

- Next a YAG capsulotomy (bad idea) that Dr. Pepose stopped mid procedure to reexamine the eye with slit lamp and then finished, subsequently the posterior capsule was not opened enough, confirmed by Dr. Gira at Ophthalmology consultants, inducing glaring light streaks.

- another YAG capsulotomy at Washington University in St. Louis to open up posterior capsule more and more evenly to correct the light streaks created by not making a good opening that was large enough - that had been done by the brilliant Dr. Jay Pepose who again, originally convinced me I needed cataract surgery in the first place, even though my real issue was vitreous opacities, aka floaters.

- Next Vitrectomy, to clear up the floaters and clouds in the eye - which it had to begin with, before cataract surgery with a crystalline natural lens that was not very clouded, in an eye with >= 20/20 acuity - but was told the vitreous opacity (floater cloud) was cataract. Post YAG’s I developed PVD (vitreous detachment) which increased the floaters. I also have right eye with cloud floaters. But the acuity is 20/15. Both eyes had LASIK 12 years ago.

- Next YAG pitting of the edge to ostensibly diffuse light from edge of the silicone RX Sight lens was tried twice with some minor improvement the first time and the second time made it worse than before producing arcs across from oblique light sources.

- Next and lastly on March 22 this year the RX Sight LAL was now explanted and a new Lucia 602 was implanted in the sulcus, behind the iris - as I was assured that would most likely be the final solution for the peripheral photopsia.

- Post last surgery developed corneal edema that went on for 3 weeks. That finally cleared up which brings the photopsia back into front stage.

The eye is now in worse shape than before surgery. The lens power was dropped from 20.0 Diopter to 19.0 because it was moved to sulcus. I have lost distance, and central acuity. Back to glasses for good distance vision and depth perception. I'm an avid tournament ballplayer that has now struggled mightily for the last two seasons to stay off the bench.

I now have floaters in the eye again, some pitch black ones that are most annoying. Worst of all I still have left peripheral blur/blob from left sourced peripheral light hitting my nasal retina.

All of the solutions they try seem to be hacks, yes hacks, that do not address the core issue, that of replacement lenses at 5-6.5 mm diameter that simply are not nearly the same diameter as the natural lens which is 9-9.5 mm. Current replacement lens optics in use are smaller in diameter than the natural lens. There are many light ray tracing studies that clearly model the issue of oblique peripheral light crossing the eye to the nasal retina, passing across the lens and emanating either from the edge of the lens light or bypassing the edge of the lens and hitting the nasal retina. The current state of FDA approved lense in the United States seem to be way behind. There are perhaps better lenses that perform better available outside the US. I'm going to see at least one or two more doctors, perhaps Dr. Safran in New Jersey, before I decide whether or not to go abroad for help. It's extremely disheartening to feel like I'm living in the third world of ophthalmology.

Mine is not an “apples to apples” comparison to anyone else’s, but below are my comments:
- I’ve had 2 FOVs (Floaters Only Vitrectomies) to cure/remedy an intolerable degree of floaters in each eye. Surgeon claimed I would have “zero” floaters and would “never have floaters again.”

The post surgical results:
- Left eye (done 2.5 years ago), had (and, has retained) a few spec floaters right after surgery AND has more recently developed 5+- larger, darker floaters that are frequent and discouraging. I spoke to other ophthalmologists since that surgery and they say it is common to develop post FOV floaters because the vitrector only removes 95% of vitreous material and a “flaking off” often occurs and causes new floaters..
- Right eye (done 4 months ago), I continue to have 5+- spec floaters that are frequent and a temporal group of floaters that bounce up and down with eye movement. With 4 months having passed, doesn’t seem they will dissolve or disappear via neuradaptation.

On dysphotopsia, both my eyes continue to have PD and it is unimproved. Light streaks temporally and from above. I see light arcs when many artificial lights are above (arenas, auditoriums, bars/restaurants). A newer symptom is a light (or, white) temporal, sporadic “bulge-in”. I think it’s from external lighting changes and kinda pops in, and quickly, out. Think it’s another PD symptom, but going to check back with surgeons that it’s not a retinal tear.

I guess that I’ve learned what I’ve learned because my cataract surgery and FOV results seem far less than optimal. Do some FOVs, REALLY, yield “zero floaters” for the rest of someone’s life? I think my vitreo-retinal surgeon is just supremely optimistic (unrealistic).

Did my much-experienced, 20-year cataract surgeon NEVER have a patient with long term, post surgical dysphotopsia (as he claimed). I think not.

At this point, I worry that further new surgeries or revisions will have diminishing returns. I continue to add what I can here and wish everyone improvement in their vision and ability to cope!

I had the YAG done on my right eye. It did eliminate the diagonal "Maddox rod" line but did nothing for the starbursts. I am holding off doing YAG on other eye for now.

Ok, I guess the lack of entries on post cataract dysphotopsias might show that they are, in fact, rare. That’s, certainly, good for the many people who have had cataract surgery, In reading online, seems that the data shows long term positive dysphotopsia occurs in about only 1.5% or so of patients. I’m thinking that this percentage is low as some post operative patients say, “well, my vision is fine except I can’t drive at night anymore because of the lights.” Also, when my surgeon tells me “dysphotopsias are very rare”, this gives me no solace since I am “1 for 1” (I had one eye done and got dysphotopsia 100 percent of the time).

With that, I’ll update what I’ve found out and done lately:
- I tried the photochromic contact lens in my eye in attempt to decrease the severe streaks and halos. The result was poor. I, actually, had worse halos/light glare and acuity was also worse
- Since, I have a very slight astigmatism, my optometrist gave me the very lowest power toric and it helps me a little to see street/highway signs. I’m, also, trying yellow glasses to try to calm the glare/halos/streaks at night driving with limited success.
- I explored the prospect of an lens exchange, but local doctors are strongly against it saying risks of a worse outcome are not worth it.

ALL of the above are related to my LEFT eye, the one on which I had cataract surgery in late 2019. As said previously, I put off surgery for RIGHT eye cataract this fall because of fear it will end up the same as my left. I continue to research surgeons in Pittsburgh area who know how to avoid the dysphotopsia problems of my first IOL implant. Thanks for any input.

I am beginning to think that patients get frustrated by replies from surgeons (second and third opinions) saying that most people just ignore the PD.
The surgeon I sought a second opinion from yesterday told me:
1) women were more sensitive to PD
2) my surgery was "perfect"
3) he would not do my Right eye cataract since he thought he couldn't meet my expectations
In other words, "old lady, you seem too picky, and you'll have to find someone else to do your right eye cataract."

I think anyone, whatever their age, would feel vision-impaired and disappointed with long term positive dysphotopsia. I, surely, empathize with you.

After my “perfect” first cataract surgery, with all the subsequent long term PD symptoms I’ve talked about, I asked surgeons many questions before going forward with the second eye surgery. They didn’t like it. One declined doing the surgery because I asked too many questions. The surgeon who, ultimately, did the 2nd eye reluctantly agreed to the more rounded edge IOL to make best attempt to avoid PD.

Yes, these doctors want compliant, “run-of-the-mill” cataract patients who say something like, “thank you doctor for saving my sight”.

I hope there’s a lot of life left and I’m trying to make the best decisions I can to maximize my sight. I guess most doctors don’t want to make enough effort to help those of us with atypical conditions and situations. That won’t dissuade me though; good sight is too important.

Since you got a more rounded edge IOL for your second cataract surgery, what was the lens used (manufacturer, and design #) and what was your result in terms of PD and also "coordination" between the two different lenses in your eyes?

Also, did you decide against an IOL exchange for the first eye?

Your reply would be most helpful to me as I am still seeking to know what questions to ask when I meet with my surgeon again.