Second Lens Swap - B&L LI61A0 vs Clareon CC60WF
This is kind of a follow up post / update to this post: https://www.reddit.com/r/CataractSurgery/comments/1stixgq/lens_swap_from_clareon_acrylic_to_rxsight_lal/
The LAL I had implanted to replace a Clareon CC60WF that was the incorrect power is damaged and needs to be replaced. I need to pick the right lens for this second IOL swap.
Background and Opinions From Two Surgeons
After seeing the Surgeon, and getting a second opinion from another Surgeon... both said the same thing. The LAL I had implanted to replace a CC60WF is damaged; There are scratches on the lens. PCO was present prior to the swap. The original surgeon said he feels the PCO is worse than it was pre-swap but still rates it as a "2" like before the swap. The second opinion surgeon also rated it as a "2". I have no pictures pre-swap so I don't know how much PCO worsened, and thus do not know how much of the massive starbursts and halos I see now can be attributed to PCO. I had minimal starbursts and no halos prior to the swap.
Pictures Of Damaged LAL
Here are some pictures taken during a slit lamp exam showing the scratches and my PCO:
- Scraches - I circled the main two scratches in red.
- Scratches 2 - Another good pictures of the scratches, also two "lines" that are parallel to each other and roughly parallel to the scratches can be seen. I do not know if these are two more scratches or capsular bag folds.
- Scratches 3 - Another shot of the scratches.
- Scratches 4
- Am I seeing the lens edge in some of these pictures? In all of these pictures but especially in picture 4 you see what may be the left and right lens edges. You can kinda/maybe see the lens at top and bottom of the pupil.
- If we are seeing the IOL edge while a light is shining in my eye (pupil not dilated), then my worries about edge glare and pupil size (outlined below) are well founded.
Pupil Too Large / Dilated?
While I do believe some of my glare issues are related to the damage to the lens and PCO, I am not convinced that is causing all of the issues.
If I'm looking at a light source at night and use my finger to cover just the very edge of my pupil on my nose side, some of the starbursting and halo effect go away. If I repeat this covering just the very edge of my pupil on my ear side (the side with the scratches), other parts of the starbursts and halos go away. The same goes for covering just the very top or the very bottom, but to a lesser effect. Using a pinhole makes the starbursts and halos go away.
This implies to me that the starbursts and halos are at least in part being caused by my pupil being larger than the 6mm of lens, and not the scratches on the lens or PCO. Note that I am only 44 and have large pupils. When I take brimonidine to shrink my pupils, the dysphotopsias do lessen, but do not go away.
Edge Glare
Another dysphotopsia I have with the LAL are seen in the right (ear) side of my vision. These are caused by light entering my eye from a source that is to my left. For example, holding a cell phone in my left hand in front of my left shoulder while looking straight in front of me. I get huge arcs/circles in the right side of my right eye's vision.
This seems to be a classic case of edge glare as outlined in figure A of this picture. Anything more than a few degrees to the left of exact center, all the way to being in my extreme peripheral vision, cause this glare. It is debilitating to my vision as I see it day and night and it is caused by all light sources. I never saw this with the Acrylic.
Edge Design And Size
The LAL and the LI61AO both have square edges on their front (anterior) and rear (posterior). These edges are 90 degrees. The Clareon CC60WF has a squared posterior edge, a rounded anterior edge, and the edge is not at 90 degrees, it's at more like 100 degrees. This is done specifically to reduce edge glare.
Both the Clareon CC60WF and B&L LI61AO are 6mm, but with Silicone lenses you don't get to use the whole 6mm as the haptics are embedded in the sides of the lens. The Clareon gives you the entire 6mm as usable. This, combined with the non-square front edge and non-90 degree edge may explain why the Clareon lens gave me fanstistic dim and dark vision with no glare while the Silicone lens I have now produces completely unusable night vision and I see glare even during the day.
I Need Another Swap And Need To Pick The Correct Lens
I have a second lens swap scheduled for the start of June and need to pick a lens in the next week.
My surgeon is strongly suggesting the B&L LI61AO, and doing a reverse optic capture when implanting it. I don't have (and never had) negative dysphotopsia, and I can't find any information saying that a reverse optic capture helps positive dysphotopsia... But I can see how mounting the lens closer to the Iris could assist with edge glare as there is less of a gap for light to hit the edge of the lens.
On the other hand, I want the Clareon CC60WF (of the correct power) implanted. My reasoning is... "I'd rather the devil I know than risk something worse". My night vision was fantastic with the Clareon. I had no glare from anything I was looking at, ever. The only glare was from light sources in the extreme ear side peripheral vision of the right eye. Yes it was annoying, but it would be alleviated by tilting my head, moving my eyes slightly, moving my body slightly, squinting, etc.
Questions
Can I get some input from folks on this? I feel like this is an impossible decision. Both potential decisions make sense...
- I can take my doctor's suggestion, which is always the smart thing to do. He's a surgeon and I trust him. Hell, even the second opinion told me "I'd suggest staying away from fancy lenses in your case. I feel your best option is to replace the RXSight with the LI61AO as it has the lowest rate of dysphotopsia". But... if my current massive amounts of dysphotopsia are indeed caused by edge glare and my pupil size, I don't see the LI61AO as being viable.
- I can go against my doctor's recommendation. I'm smart enough to know that this is rarely a good choice. But because I've had the Clareon CC60WF and I would currently give anything to go back to it and not have had the LAL implanted at all... I feel more comfortable accepting that, "I may have more dysphotopsias with the Acrylic due to the higher refractive index of the material; Though I may have less edge glare due to the edge design. I am not willing to risk of the LI61AO being worse than the CC60WF."
I'm not asking for people to make this decision for me. I'm asking for input on Edge Glare, reports from people with either lens and their experiences with positive dysphotopsias, information from people like me with large pupils and what lens type(s) they find work at or after dusk, etc.
Thank you all!