Need advice for pt with pseudophakia OD only w/ specialty implant, OS not operated

[KrystleClear]

Okay, need some advice on this one.

This patient, 55 year old, had cataract surgery with a specialty accommodative lens implant in the right eye (either PanOptix or Crystalens) and then a YAG laser to resolve PCO on that eye by another surgeon, not our MD. He was extremely unhappy with the results and hasn't had his left eye cataract surgery done as a result. He feels the eye was botched. Our MD saw him and feels that the wrong power lens implant was used resulting in unwanted hyperopia, but feels that replacing the lens is not doable. (We rarely see patients who are hyperopic after having cataract surgery and the goal with specialty implants like PanOptix is that the patient has very little if not any correction needed after surgery, and presumably this is what the original surgeon promised him.) He could do LASIK, but patient seems uninterested. The left is also hyperopic but still needs near vision correction, while the right eye does not, due to having the specialty lens implant. The patient has been wearing a pair of over-the-counter +2.50 readers all the time, for driving, reading, etc.. He's been treating them as distance vision glasses.

The MD instructed me to make him a pair of glasses with this RX, with a single vision lens OD and a progressive lens OS. It's important to note that he had never worn a bifocal or progressive before, ever.

OD: +0.50 +0.50 068 / NO ADD
OS: +1.25 +0.50 120 / +2.50 ADD

We selected a grooved rimless frame with a B measurement of 34. I used an OC of 21 OD, and a seg height of 21 OS. PDs are 31.0 / 30.5. I used a polycarbonate lens with a Varilux Comfort DRX and Crizal EZ.

Every time I encounter this situation, it ends with the patient frustrated, so I educated him during the fitting that the glasses are going to feel wonky when he goes to read until he can adapt to them. At the dispense, I told him that especially since he has been wearing his +2.50 readers all day, that it may be best to start wearing the new glasses tomorrow, when his eyes are fresh. I have him put them on and try to see what adjustments I need to make. He immediately does the "I can't see" thing and starts alternating closing his eyes and looking around. I get him to look at me and see that they are sitting high. (I had preadjusted them during the initial fitting but they came back from the lab with the nose pads squeezed way in, and when I did the bench alignment they now sat too high on him.) I adjusted them properly and splayed the pads out a bit to drop them down and added a little panto tilt, which seemed to help him with the distance vision, but he still feels he cannot see up close to read at all. He said it's all double. Even the largest text on my reading sample card is blurry to him. I asked him again to start fresh with these and give them a week or two to see if he can adapt to them.

I'm just confused as to why he feels he can see well at all distances with the cheap +2.50 readers he has been wearing, and they should be too strong for his distance. He still also has a cataract on the left eye that is limiting his BCVA (20/70), according to his exam workup. He is against having that eye done due to his negative experience with this other doctor. I also found out that he had an injury to his right eye as a kid - got hit with a BB gun, but not sure if that is relevant.

I'm going to be honest here. Every time we have had this situation in the past, where the patient gets the specialty accommodative lens in one eye and for whatever reason decides NOT to have the other eye done, and the doctor wants me to do some kind of bifocal/multifocal in the non-operated on eye, it goes poorly. The last time this happened with a patient, after first trying to make her aware that she really needs to have the other eye done, we tried the one eye single vision, one eye PAL to no avail. Then I tried one eye SV and one eye lined bifocal. Patient still unhappy. We offered single vision distance but patient refused and ended up just refunding her.

What would you do in this situation? Have you even encountered this before? I'm still going to see what my MD wants me to do.

[CME4SPECS]

Does the OS have prism thinning? This could explain some of the double vision.

[dwlk]

does he seem to be squinting in the readers/glasses? my guess is he's so used to squinting through trying to see out of the readers he doesnt know how not to essentially.. your doctor could try to over refract so when he's squniting he's getting to the rx he should be

[drk]

Problem #1 is monocular PALs. What the fresh hell is that?

Problem #2 is first time PALs with a full add. That's always hard.

Your best bet would be just segmented BF with equal BC and CT. Done and done. Maybe, maybe the add needs reduced a little in the mystery IOL eye (if it's Crystalens, his accommodation is really not going to be much.)(Can't you see the appearance of the IOL? Panoptyx looks different than Crystalens.) Refract the OD at near and see what the add needs to be. Spoiler alert: it ain't zero. It'll be like +1.50 and you can use that.

[KrystleClear]

CME4SPECS
I don't believe Equithin was done as it isn't on my lab invoice but will inquire.

dwlk
I didn't notice him squinting, but that could be.

Problem #1 is monocular PALs. What the fresh hell is that?

Believe me, drk... I agree. But is what the doctor wanted. This happens from time to time, usually when a patient gets gun-shy after having the first eye done with a specialty implant and decides to back out of the surgery for the left eye. Sometimes on my end I can convince them to reschedule the other eye's surgery because it leaves us in a crappy position.

[Uncle Fester]

Krystle-

What a mess! And you say this happens every time?

Maybe talk to your doc's and outside patients about next time, first putting them in a FT cr-39, no add on's to gauge reaction and form a baseline?

[KrystleClear]

Krystle-

What a mess! And you say this happens every time?

Maybe talk to your doc's and outside patients about next time, first putting them in a FT cr-39, no add on's to gauge reaction and form a baseline?

I try to do as the doctor recommends but from experience, yeah. The patients hate it. I try to manage their expectations by explaining during the fitting that it will feel wonky having one PAL and one SV lens but to please give them a fair shot before coming back. The fact still remains that this gentleman still has a visually significant cataract on one eye so no matter what he probably won't have the best vision until he relents and allows our MD to operate.

[AndyOptom]

Solid advice already given on the lens correction options and how to go about that.

Having dealt with similar patients since these sorts of implants became popular (almost all of which eventually relented to get the other eye operated on), thought I'd share a tidbit regarding the observation you made with the OTC readers +2.50:

For monocular post-op IOL cases with resultant aniso plus, I have also observed them happily using OTC readers that somehow seemed to work despite being right in the middle of what should have been the proper distance and near Rx (in this case, OTC readers +2.50).

From the Rx you shared, it's about distance RE +1.00/-0.50, LE +1.75/-0.50, near RE ???, LE +4.25/-0.50.

So, +2.50 DS used for distance would be a fog RE +1.50, LE +0.75 (not too surprising, I've seen quite a few office lens wearers happily driving around with about +1.00 fog originally intended for their intermediate). And while too weak for the LE near, it's probably just tolerably over whatever residual add the IOL has on the RE.

After the first couple such cases, I eventually wound up doing a normal refraction to get the full distance and near Rx for my records, then using the SV power they had been wearing as a baseline. From that baseline, backing it off binocularly until the best tolerated distance clarity (adequate for standard road signage font) and easing it stronger for the best tolerated near clarity, yielded the improvised multifocal Rx (not perfectly clear at distance or near, but the best that could be done in light of the circumstances).

So for a case like this, maybe something like this could result after such binocular adjustments:

Patient's OTC Rx: +2.50 DS OU
Improvised multifocal RX: distance +1.75 DS, Add +1.50, OU (putting the +2.50 approximately in the middle)

As mentioned, almost all such cases eventually relented and opted to operate on the other eye. But for the rare few who didn't, the improvised Rx as described above worked out to their satisfaction. Not perfect and definitely wrong clinically, but an extension of 20/happy, I suppose.

Last thing of note, though: I'm in the relative wild West of Southeast Asia, where such matters rarely lead to litigation, enforcement is rare, many patients do take their respective healthcare practitioners' advice in good faith. So I do acknowledge that my general mindset towards experimentation in this regard may seem inappropriate in the eyes of a more regulated industry professional and established clinical guidelines.

[KrystleClear]

Solid advice already given on the lens correction options and how to go about that.

Having dealt with similar patients since these sorts of implants became popular (almost all of which eventually relented to get the other eye operated on), thought I'd share a tidbit regarding the observation you made with the OTC readers +2.50:

For monocular post-op IOL cases with resultant aniso plus, I have also observed them happily using OTC readers that somehow seemed to work despite being right in the middle of what should have been the proper distance and near Rx (in this case, OTC readers +2.50).

From the Rx you shared, it's about distance RE +1.00/-0.50, LE +1.75/-0.50, near RE ???, LE +4.25/-0.50.

So, +2.50 DS used for distance would be a fog RE +1.50, LE +0.75 (not too surprising, I've seen quite a few office lens wearers happily driving around with about +1.00 fog originally intended for their intermediate). And while too weak for the LE near, it's probably just tolerably over whatever residual add the IOL has on the RE.

After the first couple such cases, I eventually wound up doing a normal refraction to get the full distance and near Rx for my records, then using the SV power they had been wearing as a baseline. From that baseline, backing it off binocularly until the best tolerated distance clarity (adequate for standard road signage font) and easing it stronger for the best tolerated near clarity, yielded the improvised multifocal Rx (not perfectly clear at distance or near, but the best that could be done in light of the circumstances).

So for a case like this, maybe something like this could result after such binocular adjustments:

Patient's OTC Rx: +2.50 DS OU
Improvised multifocal RX: distance +1.75 DS, Add +1.50, OU (putting the +2.50 approximately in the middle)

As mentioned, almost all such cases eventually relented and opted to operate on the other eye. But for the rare few who didn't, the improvised Rx as described above worked out to their satisfaction. Not perfect and definitely wrong clinically, but an extension of 20/happy, I suppose.

Last thing of note, though: I'm in the relative wild West of Southeast Asia, where such matters rarely lead to litigation, enforcement is rare, many patients do take their respective healthcare practitioners' advice in good faith. So I do acknowledge that my general mindset towards experimentation in this regard may seem inappropriate in the eyes of a more regulated industry professional and established clinical guidelines.

Thank you for the insight!

[KrystleClear]

Update: Patient came back in saying he absolutely cannot tolerate the glasses. He said he "can't see anything." The technicians tested his VA both distance and near with the new glasses and he sees well enough with them when reading the snellen chart (the one eye is still limited by the cataract). They re-refracted him with basically no change in RX. So, we decided to remake the lenses into flat top bifocals IN BOTH EYES with the full add and this time I used poly just to cover my butt. He really favors those OTC readers, and I think this way will be easier for him to accept... I hope. Wish me luck.