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  #1  
Old 05-23-2011, 10:10 AM
Loved Loved is offline
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Cataract surgery ?

Just wondering if any of you who have experienced ON have undergone cataract surgery. I am relatively young for this surgery (56) but have severe myopia which seems to be consistent with earlier cataracts.

However I've had optic neuritis with significant vision loss in one eye. Have had pain off and on in the other eye and probably some loss of vision but not significant.

Does anyone know of any reason cataract surgery would be risky due to the potential of optic neuritis?
  #2  
Old 05-24-2011, 02:53 PM
Linda k Linda k is offline
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I just had my left eye done on the 10th, and mt right eye done on the 17th.
So far so good. I can see better distance already and I have to put eye drops in my eyes until june 6th.
It's really not a big thing. it is a out patient surgery.

Good luck if you reallt need it, do it.
  #3  
Old 05-24-2011, 07:01 PM
Loved Loved is offline
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Thanks, Oasis. I am just so very cautious and don't want to take any unnecessary risks. But improved vision and not needing glasses are so very tempting. I know I may need
a slight corrective lens in glasses but that would be nothing compared to what I currently wear.

Is your myopia very severe? The surgeon told me that those who have myopia as bad as mine also have a greater risk of
retinal detachment following surgery. Just an added risk but he did not seem to think I should be concerned. Anyway just wondering if your myopia was severe.
  #4  
Old 05-24-2011, 07:37 PM
Redwings Redwings is offline
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Hi Loved:
Iím in a similar situation, with steroid-induced cataracts that will likely need to be removed at some point. Due to years of recurrent optic neuritis, both of my optic nerves are severely compromised. I have to be especially cautious in the choices I make.

As far as any special risk of ON after cataract surgery, Iíd have to say that thereís always an element of the unknown in any surgery. But otherwise Iíd have to say that there isnít any special, known risk. Thereís nothing in the recent medical literature about a special risk of ON, even in patients who are known to have had ON before, whether or not related to MS. The few reports there are go back to the 1960s, when cataract surgery was a very different and far more traumatic procedure than it is today.

But there still are other risks, which become a more important consideration when a person doesnít have a ďspare eyeĒ to depend on in case something goes wrong. Cataract surgery is a fairly routine procedure and is said to be the most commonly performed elective surgery. About 95% of cataract surgeries are uneventful with good results. Itís the other 5% that are cause for concern. The results range from disappointing to catastrophic (complete loss of the eye).

More prevalent than ON after cataract surgery are cystoid macular edema, infection, inflammation ranging from mild to total, and retinal detachment. Especially on the first eye, thereís usually no way to predict or even guess which of those will occur. My own mother, who had no known risk factors, developed macular edema after her first cataract surgery and her life was never the same after that.

Sometimes even surgeons get careless about considering the possible outcomes and perform procedures where the risks seem to outweigh the benefits. Some will do invasive surgery on any eye, any time. There are even some ophthalmologists who are scummy enough to do cataract surgery on a blind eye (one that they knew wouldn't recover vision) just because they get paid for doing it. The risk may be only 5%, but the things that can and do go wrong in that 5% can be devastating. For example, in someone whoís lost peripheral vision due to ON, post-surgical macular edema can damage central vision. In a person whoís lost central vision due to ON, a retinal detachment can wipe out the peripheral vision the person used to depend on. Myopes (particularly high myopes) are at increased risk of retinal detachment.

So you can talk to 100 people who have had cataract surgery and 95 will tell you that theirs went great and you have nothing to worry about. But you also have to be mindful of what the other, unlucky 5% have to say.

In just the little you said about your own case, there are some difficult questions you should ask yourself. You didnít say which eye you plan to have operated on. In the case of your bad eye, if your vision loss is already significant, how confident are you that youíll get an increase in vision thatís worth that 5% risk of something going wrong? How willing are you to lose what vision you do have in that eye if something goes wrong?

In the case of your better eye, what does ďprobably some vision loss but not significantĒ mean? (Again, these are questions for you to answer for yourself.) If your other eye has had significant vision loss, are you satisfied with not knowing the precise status of your better eye? If the vision loss in your better eye isnít significant, why would you even be considering cataract surgery? If you meant that you do have significant vision loss in that eye but it's due to the cataract and not ON (or something else), how confident about that are you? How prepared are you to live the rest of your life dependent on the other, bad eye if something were to go catastrophically wrong with the better eye?

All things considered, post-surgical ON might be the least of the possible problems. Thatís why Iím in no hurry to push for cataract surgery on my severely damaged eyes. Of course, your mileage may vary.
  #5  
Old 05-25-2011, 06:43 AM
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SNOOPY SNOOPY is online now
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Hello Loved,

I agree completely with Redwing's post.

I have never had ON, however, I literally have had cataracts all my life. I have congenital cataracts in both eyes.

In my younger years (20s & 30s) I was searching for an Opthamologist that would remove them...no one would. As the years go by I have come to understand the risks involved.

My grandfather had cataract surgery, he ended up with a detached retina. When he developed cataracts in the other eye his doctor refused to do surgery...if he again had a detached retina he would lose whatever little vision he had.

I have a very good Opthamologist who I have seen for many years now and he does not want to remove the cataracts until absolutely necessary...I am fine with this.

Everyone is different and the outcome of cataract surgery is different. No one knows if cataract surgery will turn out to be a good thing or bad.

Good luck with your decision
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  #6  
Old 05-25-2011, 05:40 PM
Linda k Linda k is offline
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I have notice in just 2 weeks that I can see better in far distants. I was very near sided. Now I can drive without glasses. I know I will probably need ready glasses. But I will not know until my eye drop treatment is finish june 6th and I will see my eye doctor for my sight reading.

Love I did not have any mopia. Just make sure you get the right eye doctor.

Good Luck
  #7  
Old 05-25-2011, 10:01 PM
Loved Loved is offline
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Wow, Redwings, SNOOPY and Oasis. Thanks so much.

Yes, I appreciate your thoughts and process the same way as you, Redwings. I am very cautious. Too many unknowns and I have risk aversion in all aspects of life.

The ophthamologist told me of the increased risk of edema and retinal detachment. I also have a condition called Fuchs' dystrophy which throws another variable into the already uncertain mix.

The severe cataract is in my eye that is already compromised. That eye used to be corrected to a reasonable amount of vision. Now it is not. Is it the ON damage? Or the cataract? No one can say.

The doc says if you do one eye you need to do both. He does not think the risks are that great. I know that he is good and I have known many who have had him as their surgeon. I have not heard of any horror stories. Yet the risks are there nonetheless.

Redwings, can you elaborate on macular edema? IOW this sounds like a condition that was never resolved for your mother. Is that always the case? If one develops this, is
it a permanent condition?

Thanks again for all the information.
  #8  
Old 05-26-2011, 09:59 PM
Redwings Redwings is offline
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Hi Loved:
Even though there are less than about 5% of cases that donít turn out well, there are, as youíve found, some individual considerations.

As an example, from what youíve told us about your own situation, severe myopia and Fuchís dystrophy raise the risk of an adverse event in cataract surgery. So even if the risk of a terrible outcome is only a couple of percent overall, your doctorís feeling that ďthe risk isnít that greatĒ has to be interpreted differently than for someone else -- whose risk is already small -- who doesnít have those factors. Because even though the risk is still small, the outcome can be disastrous. That might not be so bad if it happens in your worse eye, but can be catastrophic if it happens in your better eye.

Part of that consideration is how severe your myopia is. There are a lot of people with low amounts of myopia who think that their -2.00 is severe. (My -5.00 is still only moderate myopia.) From a surgical viewpoint, there isnít universal agreement about magnitude of myopia and risk of retinal detachment. Some ophthalmologists think that any amount of myopia puts a person at equal risk, while some do consider the magnitude because of the other factors associated with it. They view -12.00 differently than -6.00.

Cystoid macular edema is also a little unpredictable. The estimates Iíve seen of its occurrence are up to 20%, but most cases resolve without serious consequences. Sometimes it resolves on its own, other times through some aggressive medical treatment. But sometimes the retina incurs too much damage and good vision never returns after the edema resolves. You can Google cystoid macular edema to read about the range of treatments and outcome possibilities.

Another consideration is what the estimated improvement in your worse eye will be after cataract surgery. If it used to correct to a reasonable amount a vision, thatís a good sign. There are a couple of tests that can be attempted to determine how much vision loss is due to a cataract and how much due to another condition. But they donít always work. For that reason, some surgeons wonít even try them and just go with their best estimate.

Saving the most important consideration for last, a big red flag went up with this one:
Quote:
Originally Posted by Loved View Post
The doc says if you do one eye you need to do both.
Did your doctor explain why he feels that way? There are many doctors who would disagree. There are reasons why it might be [I]advantageous[/I] to do both eyes, but it isnít a necessity and depends on other factors.

So the $64,000 question is: If your better eye isnít Ė on its own Ė ready for cataract surgery based on benefit vs. risk, can you justify cutting into it and exposing it to the small but real risk of an adverse outcome?

One of the complicating factors comes from aiming to set the operated eye at plano after surgery (eliminating most or all of the myopia). That introduces some optical challenges that can influence some surgeons and patients to operate on the second eye before itís medically ready.

This is something thatís quite individual and requires some thought. As a myope, how are you going to feel about not being able to see up close anymore after cataract surgery? At least not as close as youíre used to?

For me, the [I]last[/I] thing I want after cataract surgery is to not be a myope anymore. Thereís no optical advantage for me to not need glasses for distance if Iím already not seeing well because of ON damage. There [I]is[/I] an optical advantage in being able to see up close. It would be a disaster for me to not be able to see up close after Iíve been able to all my life and have come to depend on it more and more as my vision declines. The second last thing I want is to have paid for a deluxe multifocal implant only to find that Iím really unhappy with the quality of the close-up vision it does give me.

Again, with all of these considerations, post-surgical ON is probably the least of the concerns. You have many of the same considerations that I do, making the choices a bit more complicated than for the average person thinking about cataract surgery. A second or even third opinion might not be a bad idea, just to make sure all of your bases are covered.
  #9  
Old 05-27-2011, 05:37 PM
chalknpens chalknpens is offline
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My ophthalmologist has offered to remove my cataract for over ten years now ... but has honestly stated that with MS and ON he cannot guarantee a restoration of 20 20 vision. I'm in no hurry to risk what i have.
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  #10  
Old 05-27-2011, 09:22 PM
Loved Loved is offline
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Thanks, once again, Redwings. My myopia is severe. I don't have my prescription handy but I am -12.00 in one eye and the other eye is either the same or -11.00 so we're talking severe. And I think that is part of why they think if they do one eye, they both would need to be done. Otherwise you will have one eye needing a great amount of correction with glasses.

The bad eye was corrected to 20/70 vision a number of years ago. That wasn't a clear field of vision but so much better than what it is now. So how do they access whether that is further ON damage or cataract?

The information regarding close up vision is significant as well. And I had been thinking about that. I don't think others really understand all of the various considerations in a decision like this.

I am going to speak to my primary physician next week about all of these considerations. And I will speak to him about my getting a second opinion from an ophthamologist as well. I have not spoken to my neurologist yet and am wondering if he would have any thoughts in this regard.

At this point I am much more hesitant to proceed. Thanks for all your help.
  #11  
Old 06-01-2011, 07:24 PM
Loved Loved is offline
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Redwings,
I was hoping you would share what you know re: the assessment of vision loss from cataract vs optic neuritis.

Thanks, Loved
  #12  
Old 06-01-2011, 10:59 PM
Redwings Redwings is offline
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Quote:
Originally Posted by Loved View Post
I was hoping you would share what you know re: the assessment of vision loss from cataract vs optic neuritis.
Hi Loved:
There are a couple of ways to tell. Both are estimates rather than absolutes. All of the considerations get a bit complicated, so stay with me on this.

One way is just the eye doctor's estimate based on the appearance of the cataract. Not only does the doctor judge the density of a cataract by looking [I]at[/I] it, s/he also judges density by looking [I]through[/I] it at the inside of the eye. The lens inside the eye is like a window. The doctor is looking [I]in[/I] through the same window you're looking [I]out[/I] of. So the doctor compares the view in to your view out.

For example, if the doctor has a 20/20 (all of these acuities are best-corrected) view in through a clear lens but the person has only a 20/70 view out of an eye that's know to have had ON (and nothing else), the drop in acuity can be attributed to ON because the view out would otherwise be clear. If the doctor has what would be in the ballpark of a 20/70 view into an eye that used to be 20/20 and no other problems are apparent, the drop in acuity can be attributed to the cataract.

If the doctor has a poor view into an eye that sees 20/200 but was known to see 20/20 before, the view in corresponds roughly to the view out and the drop in acuity can be attributed to the cataract. If the doctor has a poor view into and eye that was known to see 20/70 before and sees 20/200 now, that estimate becomes less reliable, but still points to the possibility that the difference in acuities is due to the cataract. In an eye with no risk factors, it might be worth doing cataract surgery if the improvement to 20/70 would improve the person's quality of life. Surgery becomes less attractive if there are risk factors like high myopia that might end up with the acuity being less than the 20/200 the person started with. An improvement from 20/200 to 20/70 might not be worth the risk taken to get there. But worse acuity improving to 20/70 might be worthwhile, depending on other factors.

If the doctor has about a 20/70 view in and your view out is worse, the tendency then is to think that the cataract has some effect, but the difference in acuities might be more attributable to ON, perhaps another episode you weren't aware of. Any estimated improvement in acuity from surgery might not enough to justify surgery, especially in a highly myopic eye. It's also possible that there won't be an improvement in acuity. It's possible that there might be an improvement in visual field that would improve your quality of life, but that would have to be determined based on what your field was like before.

The drawback to this method is that the view in vs. the view out is just an estimate, and the correlation isn't one-to-one. Actually, it's kind of a loose estimate. But because it works so well in eyes [I]that were known to see well before the cataract advanced[/I], it's probably the method that's used most often to determine when a person is ready for cataract surgery. But for eyes that didn't see well before, it becomes less dependable as an estimator.

The other method that's used is a bit more reliable because there's an actual ophthalmic instrument involved. It's called a potential acuity meter (PAM). It's a nifty device that projects a little eye chart through a window in the cataract directly onto the retina. If a person who sees, say, 20/70 looking out through their cataract sees the 20/30 letters of the little eye chart, it means that the retina is capable of at least 20/30, making that a reasonble expectation of cataract surgery. If a person who sees 20/200 sees only the 20/100 letters of the PAM, it indicates that the expected improvement after surgery won't be much. 20/200 to 20/70 is a bit better, but maybe not as good as 20/400 to 20/70. And other factors, like high myopia, still have to be considered.

There's a serious drawback to the PAM method: there has to be a clear window in the cataract to allow projection of the eye chart onto the retina. Most cataracts don't have a clear window, so this method can't be used. And that's why a lot of doctors don't even bother trying it.

I appreciate the significance of your myopia. It's the factor that drives everything that's involved in cataract surgery for both eyes. That's because surgery in your worse eye sets into motion a cascade of other factors that will affect your better eye. The question you have to answer for yourself is: Will getting 20/70 (if that much) back in your worse eye improve the quality of your life enough to put your better eye at risk?

Although there might be an advantage in remaining a myope after cataract surgery, remaining a -11.00 or -12.00 just isn't practical when you could be a -2.00 or -3.00. That would make your glasses much lighter and more comfortable, and make your life so much simpler optically, so significantly reducing your myopia makes more sense. Even setting to plano (zero) makes sense if you can adapt to not being a myope anymore. (As I said before, I don't think [I]I[/I] could adapt.)

The problem is that, once one eye is a -2.00, there's too much optical difference between the two eyes to be made up with glasses. It's impossible for the brain to fuse images that are that different in size, which is what happens when the powers are so different. (The limit to fusion is about 3 dipters.) Your choices would be to 1) leave your better eye blurry with glasses (doesn't make sense to be -2.00 in an eye that's only 20/70 while leaving your better, more myopic eye blurry), 2) leave the operated eye blurry in glasses (not worth doing surgery for, then, if you're going to have to leave it blurry), 3) wear a contact lens on the better eye to make up the optical difference between the two eyes (works quite well when the optical correction is put right on the cornea) or 4) operate on the better eye and bring it into line, optically, with the other eye.

I don't have the same situation because my myopia is only moderate. Whether I set my -4.00 or -5.00 to -3.00, the other eye is still within the "fusible" range without a contact lens and without artificially forcing surgery on the other eye.

So that brings you full circle. How much better is your life going to be if you get back 20/70 in your worse eye? Is the risk of retinal detachment in your better eye worth getting back 20/70 in the other eye when the other eye still wouldn't be the one you're using for your best vision? Is that risk worth taking when your better eye isn't ready for cataract surgery on its own? Is getting 20/70 back in your worse eye worth the risk of your better eye having an adverse event and coming out worse than that?

A contact lens on your better eye until it's ready for surgery is an option. Soft contacts are [I]much[/I] better than they were 10 years ago. There are newer materials that transmit 5 or 6 times more oxygen than the older materials. So, while a -10.00 or so (the equivalent of your prescription in a contact lens) is still a hefty lens, the newer materials make a lens of that power more comfortable to wear and don't impose the degree of health risks as the low-oxygen materials.

The disadvantages to the contact lens option are that 1) if you wanted to wear contact lenses you'd already be wearing them, 2) to avoid having to wear [I]really[/I] expensive contacts you'd still need to wear bifocals or reading glasses and 3) you'd still have to deal with handling, cleaning and maintaining the contacts, even with disposable lenses. The nice thing is that you can try some high-O2 contacts before you have cataract surgery to see how they work for you. I've worn all types of contacts, from the hard plastic lenses of the 1970s to the high-O2 soft lenses, and the new soft lenses are nice. But a -10.00 is still a pretty hefty lens...

I hope that gives you a few more things to consider before deciding on cataract surgery. I went into possibly TMI because once you have surgery on your worse eye, it will force you to make choices for your better eye that you wouldn't have to make otherwise. Is getting 20/70 (with unknown visual field) back worth what you're going to have to do and risk with your better eye?
  #13  
Old 06-02-2011, 01:34 AM
Redwings Redwings is offline
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Oops! Typo!

Quote:
Originally Posted by Redwings View Post
The limit to fusion is about 3 dipters.
That's supposed to be 3 di[B]o[/B]pters. (Proofread, darn it!)
  #14  
Old 06-02-2011, 11:34 AM
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Redwings, rarely have I seen someone so well versed in various medical subjects as you are. I have been very interested in what youve written on cataracts because my neuro-ophthomologist keeps commenting on the cataracts forming in my eyes on top of their neuological problems. Forewarned is forearmed - I am printing out this thread for future information.
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  #15  
Old 06-02-2011, 01:29 PM
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Well......

..Count me as # 96 that is completely happy (elated) after having the cataracts removed from my right eye about ten days ago.

Am on schedule to do the left eye if my doctor is pleased with my progress. I have requested that he plan on a mono-vision outcome. I've worn contacts forever and and am quite pleased with the current mono-vision situation.

I was born quite nearsighted. I wore coke bottle lenses in the first grade. The original Mr. Magoo at age 73.

It is the oddest thing to look at the world through my new bionic eye. What I see is a world much brighter. Blues are bluer etc.

When I look through the yet to be corrected left eye-the world I see is darker as if I am looking through a light tan filter !

I am by no means an expert on vision issues, but I am currently feeling very good about my decision

Maxx aka TexOP
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