ICL for hyperopia

If you are thinking about having Lasik, IntraLasik, PRK, LASEK, Epi-Lasik, RLE, or P-IOL eye surgery, this is the forum to research your concerns or ask your questions.

ICL for hyperopia

Postby ness27 » Wed Oct 25, 2006 6:07 am

I am booked in to have Visian ICL into my left eye on 27th Nov and my right eye on 4th Dec. My vision is approximately +6 and +7.5 with 3 and 3.5 astigmatism. In other words my eyes are really bad. Anyway, they are going to do the iridotomy one week prior to the first eye being done and during the operation they are going to do PAK to fix the astigmatisms then insert the lens through the hole cut for the PAK. This is because i didn't really want toric lenses. So I would like to hear from anyone who has had this op done with success or not success and what i should expect. And also to the experts who answers these q's if you have heard of this op being performed on hyperopic patients with such enormous scripts such as mine. I am very nervous as i have worn disgustingly thick glasses since i was 3 years old and this is my dream but i am scared that it will all go horribly wrong. Any comments would be much appreciated. Thank you in advance.
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Re: ICL for hyperopia

Postby LasikExpert » Wed Oct 25, 2006 7:09 am

A phakic intraocular lens (PIOL) like the Visian Implantable Collamer Lens (ICL) is most appropriate for a person whose natural crystalline lens within the eye is able to change focus to see objects near. This process is called accommodation.

After about age 40 accommodation is reduced by presbyopia as the natural lens is less able to change shape and thereby less able to change focus. If you are near or past age 40, a P-IOL may not be your best option. Refractive Lens Exchange (RLE) would very possibly be a better alternative. RLE is exactly the same as cataract surgery - the natural crystalline lens within the eye is removed and replaced with an artificial intraocular lens (IOL).

ness27 wrote:It will all go horribly wrong.


The most probable "horribly wrong" scenarios (which actually are relatively unlikely) both have the same result - cataract. A cataract is when the natural crystalline lens of the eye becomes cloudy and blocks light from reaching the retina and being “seen”. Cataracts are a part of the natural aging process, but can be caused by trauma to the crystalline lens.

Trauma to the crystalline lens can occur with the Visian ICL primarily in two ways. One is that the doctor traumatizes the crystalline lens during surgery. The other is that after surgery the crystalline lens vaults forward during accommodation and hits the Visian ICL.

The probability of trauma induced during surgery can be minimized with the selection of a surgeon who has ample practical experience with the Visian ICL and patients with your level of hyperopia (farsighted, longsighted) vision. Several myope (nearsighted, shortsighted) ICL patients and a few low hyperopes is not the same.

The probability of both trauma induced during surgery and trauma by forward vaulting can be minimized by an exacting measurement of the distance between the back of the iris (colored portion of the eye) and the front of the crystalline lens. If your doctor has not made this measurement with near absolute precision, s/he is assuming there is enough room. This may or may not be an accurate assumption.

If you have the Visian ICL and for whatever reason a cataract develops, then the ICL will be removed, the crystalline lens will be removed, and an IOL will take its place. The downside to an IOL is that you lose the ability to change focus to see items close. There are multifocal IOLs and even IOLS that change slightly to accommodate, but these are nothing like the accommodation in a young eye and have definite limitations.

A very important question for you is if you are willing to risk not being able to change focus to see items close and needing reading glasses to see items near, for the convenience of a reduced need for your current glasses. If you are, then you are willing to risk the most probable "horribly wrong" outcome. Even this "horribly wrong" outcome is not highly probable if all other issues and measurements are appropriate.
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Postby ness27 » Wed Oct 25, 2006 11:17 am

thanks for your reply, I am only 27 so not quite close to 40 yet. I am aware of the cataract risk and that is a risk i am prepared to take. My doctor done scans of my eyes with all these super duper computers and said i have plenty of room for the lense then also dilated my pupils to make sure and said there was still plenty of room. My doctor also says he does one or two of these surgeries per week but did not specify if it was myopic or hyperopic. He also said he performed the first ever surgery of this kind in new zealand, his name is Dr [redacted] of Australia. Anyway, thank you again for your reply it has eased my nerves somewhat. Are there any questions i should specifically ask him?
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Postby LasikExpert » Wed Oct 25, 2006 4:52 pm

It sounds like you and your doctor are knowledgeable. You may want to review our 50 Tough Questions For Your Lasik Doctor. Most concerns apply to PIOLs.
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Postby ness27 » Tue Oct 31, 2006 11:35 am

Hi again, I have two more questions if you don't mind.
I was wondering if I can expect to have the same quality of vision as i have now with my glasses. I expect no more but i would be over the moon if my vision will be as good as it is wearing my glasses.
Also i was wondering what period of time it will be until I can expect the full extent of the vision to kick in. In other words, how long do i have to wait with this procedure until the best vision is achieved. Also will I be able to see clearly within a day or so, i have read that i will have perfect vision the very next day? I ask because i have 3 year old twins and a 4 day a week job and its gonna be a difficult time if i can't see! I have organised a week off work for the first eye to be done as i will not be able to wear my glasses but i thought i could go to work the second week after having my second eye done because at least i will be able to rely on the vision of the left eye which was done a week prior. Your thoughts would be much appreciated. Also i want to give massive praise to this web site, it is a wonderful thing that people can keep theirselves informed and share experiences with others in their same predicament. Thank you again.
ness27
 
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Postby LasikExpert » Tue Oct 31, 2006 6:11 pm

Thank you for your kind words about our website. Be sure to see Helping Patients.

An important consideration regarding your postoperative vision is your very high astigmatism. I believe the Visian to correct astigmatism is available in Austrailia, however due to the nature of this particular PIOL it is possible it will shift after implantation. Astigmatism correction requires the PIOL to be at exactly the proper axis. Rotation could be very problematic.

Your glasses correct both your hyperopia and your astigmatism. Ask your doctor for a pair of contacts that correct only your hyperopia or only the amount of hyperopia and astigmatism expected to be corrected with the PIOL. You will undoubtedly have blurred vision at all distances, doubled images (ghosting), and these symptoms will become worse in low light environments if your astigmatism is not corrected.

If the PIOL does not correct all of the astigmatism, you would probably need glasses (much thinner) or contacts. The doctor may recommend a cornea-based refractive surgery like Lasik to resolve the astigmatism.

If there is no surgery induced problem, the PIOL will almost immediately provide vision correction, however there may be some distortion for the few days to weeks while the eye heals. You should expect at least "functional fuzzy" vision very quickly. Do have others available to drive you around or help if you don't have a fast recovery.

Three year old twins: you have both my congratulations and condolences! 8^)
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Postby ness27 » Wed Nov 01, 2006 5:59 am

Thank you once again, my dr has informed me of the toric lenses which correct astigmatism but i opted out of that because of the experience i had with contact lenses moving on me while i was driving etc. Anyway, he has offered me what he called PAK which is to make an incision in the top and bottom of the eye and he said this will correct my astigmatism? He also said that he will insert the ICL through the incision. He also said that if they got it wrong (heaven forbid) that they could do some laser to fix it up. I am not very keen on having laser at all i don't like the idea of my eyes shape being changed so hopefully that wont happen, but have you heard of the PAK procedure? I am really glad my vision will be good quickly and thank you for your congrats and condolenses, sometimes i need more of the condolenses!! :D
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Postby LasikExpert » Wed Nov 01, 2006 6:24 am

The "AK" part of PAK is Astigmatic Keratotomy. If the doctor is simply going to position the incision for PIOL insertion in such a manner that it may reduce astigmatism, then I concur that this is a good plan. If the doctor is actually going to attempt to resolve 3.50 diopters of astigmatism with AK, then I respectfully disagree.

AK is a derivative of Radial Keratotomy (RK). An incision is made in the cornea. This incision weakens the cornea so it changes shape. Although AK may be appropriate for minor astigmatism, I very strongly do not agree it is appropriate for your very high astigmatism.

There are other considerations as well. AK commonly requires incision through the majority of the cornea. This may limit the procedures available for laser assisted correction later. AK weakens the cornea similarly to RK and many people who had RK more than 10 years ago are now having problems with vision fluctuation. AK may be fine for small amounts of astigmatism, but not for 3.50 D, in my opinion.

There is yet another concern. The physics of laser corrective surgery dictates that for every 1.00 diopter of astigmatism correction, there is an automatic correction for myopia. The ratio varies from laser to laser, but it is about .35 diopters of myopic correction for each 1.00 diopter of astigmatic correction. That means that you would have about 1.25 D of myopic correction to correct your 3.50 D of astigmatism. If the PIOL puts you to plano (no refractive error) and a laser is used to correct the astigmatism, you would end up about 1.25 D hyperopic again.

If the surgery was planned to use the PIOL to resolve sphere and laser to resolve cylinder, then the PIOL could overcorrect you from your hyperopia into about 1.50 D myopia, and then the laser would correct the 3.50 D astigmatism while taking you back to plano with the automatic myopic correction. I do not believe it is ideal to use the PIOL to correct you to plano, use AK to correct some of your astigmatism, and then use a laser to correct whatever astigmatism remains.

Please note that what your doctor means by PAK may be different than AK and that may make a difference in my opinion, but the issue of the coupling of myopic correction with astigmatic correction is very real and would be consistant throughout.

Do you really believe that the convenience of a reduced need for corrective lenses is worth this level of risk?
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Postby ness27 » Thu Nov 09, 2006 4:13 am

Hello again, well now i am a little worried. It is to the best of my knowledge and how it was explained to me that they were going to put a cut in the top of the cornea and in the bottom to "flatten" out the astigmatism and all would be resolved. They specifically said to me that the pak would resolve my astigmatism problem. They have said that the ICL and PAK would work perfectly and my end result would be exactly of that with my glasses. They did mention the chance of slight over or under correction which they said would be fixed by laser - i expressed my dislike for this idea however. I did not realise it was possible to go from being hyperopic to myopic! I was so excited up until this point the doctor seemed so confident and told me that it was simple, uncomplicated and would work. I have worn heavy and thick glasses (as you can imagine at +7 & +6) since i was 3 years old and i hate them passionately they destroy my self confidence, but to maybe its not worth the risk of having permanently damaged eyesight? In your opinion, what is the worst scenario if the PAK and ICL were done at the same time?
Thank you I am sorry to keep harassing you!!!
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Postby LasikExpert » Thu Nov 09, 2006 5:06 am

You are not harassing me. You are keeping me employed!

8^)

The worst case scenario is not likely so there is not much need to dwell on severe loss of vision function.

I very highly recommend that you seek a second opinion, or maybe even a third. Seek a surgeon who performs both cataract surgery and refractive surgery and has a significant amount of experience with phakic intraocular lenses. Feel free to print this thread and discuss the issues I have raised. The opinion of a competent surgeon who has actually examined your eyes is always better than someone over the Internet, but I think I have given you some questions to ask and concerns to raise.

Focus on what you really require to say surgery was a success. If you want much thinner glasses, then the PIOL alone would probably achieve that with reasonable predictability. You could always to the AK or laser later. If you want to be without glasses altogether, that may be much more difficult to achieve. Don't be in a hurry. This is elective surgery and you are the one electing when it will be done, if at all.

I'm sorry to rain on your parade a bit, but it is much better to be dissapointed now than disappointed after surgery because you did not get what you thought you would achieve.
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Postby ness27 » Thu Nov 09, 2006 5:53 am

Thanks again! I have printed out all the correspondence we have had and faxed it across to my surgeon about an hour ago. Hopefully he will get back to me soon and ease my concerns. My surgeon does have extensive experience with cataract surgery and does 2 or 3 ICL insertions per week as well as laser etc. I do trust his expertise even though i have met with him only once. Indeed I shouldn't dwell on loss of vision etc, and you have hit the nail on the head by saying what do i want from the op to say its a success - once upon a time i would have been extremely happy to wear thinner glasses and in the big scheme of things, would probably be that happy now - but the cost eats away at me saying it costs you this much money you should be glasses free - maybe i need to be a tad more realistic :-) I think i got too excited about the opportunity not to have glasses and cancelled out any other options. I will now wait to hear back from my surgeon with my fingers crossed - if you don't mind i would like to email you back with his reply for your comment. I feel good now though knowing that i can get to the operation room and say "no i changed my mind - i only want you to do the ICL and not the PAK and i will wear thinner glasses simply for astigmatism correction."
Thank you soooooooooooo very much your advice is invaluable. :-)
ness27
 
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Postby LasikExpert » Thu Nov 09, 2006 7:17 am

Emailing the doctor's reply would be ideal.
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Postby ness27 » Fri Nov 10, 2006 3:28 am

Hello once again, I have faxed all our correspondence to my surgeon, the response went along these lines: you were right in saying the AK stands for Astigmatic Keratotomy but the P in PAK stands for penetrating. You stated that the incision goes partially through the cornea but penetrating astigmatic keratotomy goes all the way through the cornea, through the whole lot. He said that he has had success with this treating up to 10 diopters (he said that was a rare case) but regularly performs this on 5 & 6 so my 3 astigmatism is not really that bad. He also said the success rate is extraordinary. He also said that of course there is the chance of over or under correction as with any surgery and he did say that to me in our consultation also, and he said if that was the case a small amount of laser would be used to correct it. Their ultimate goal for me providing everything goes to plan is to NOT have to wear glasses at all WOO HOO! After doing some extreme investigation i also asked him about epithelial counts as i did not believe they had done this and he said they very rarely do it as it had something to do with damaging the back of the eye and they will know if they do that anyway. He said its more of an "academic" test. He also said my vision would be functionally hazy the next day and after having my second eye done i should be able to go back to work (i only do paperwork etc.) a couple of days after having the second eye done. So once again, my faith in this operation has been restored. I trust them for some reason, I don't know why i have only met with him once and very briefly but i have a quiet confidence in him. Anyway, your opinion would be much appreciated. And rest assured, I have seen how many people have been reading our correspondence, and i will be posting in the just had it done section when it is completed. Thank you for the 20th time for your advice.
ness27
 
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Postby ness27 » Fri Nov 10, 2006 3:59 am

LasikExpert wrote:Be sure to see Helping Patients.


I can't find this section.

Edited by webmaster for context.
ness27
 
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Postby LasikExpert » Fri Nov 10, 2006 5:53 am

I'm not sure what is happening, but others have also said the can't find this article.

Click on the "Lasik and Eye Surgery Q&A Forum Index" link above (just under our logo) and visit the bottom forum.
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