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My Experience with Refractive Lens Exchange

 

I got my first pair of glasses exactly one week before my 8th birthday on Saturday 1 October 1968. They were much too strong, making it difficult to walk out of the opticians but I was too scared of my mother's reaction if I complained; so I said nothing and within days the glasses had moulded my eyes to their will. It was the start of a steady descent into high myopia and a long line of glasses that terminated in a prescription of approximately minus 13 dioptres in each eye with some inevitable astigmatism thrown in for good measure.

Wearing milk-bottle lenses to school in the 1970s was no joke, although I was once asked by a fellow pupil if I had demanded the power-rings as a fashion item! Naturally, I had a desire to rid myself of these beasts but this was not technically feasible at the time. In the mid-1980s the media published that the Russians were slicing away with knives at people's eyes in order to correct shortsightedness. A bespectacled work colleague at IBM asked me if I was interested in having this sort of surgery; I replied that I would not touch it with a barge-pole. It sounded far too risky but my colleague was clearly up for it. Surgical techniques greatly improved with the introduction of the laser but I had a prescription that was well out of its range, so I had to wait.

It is believed that the Greeks and Egyptians, amongst others, performed cataract surgery more than 2000 years ago by poking the lens to displace it into the vitreous cavity. Happily, things have advanced: a three week hospital stay at Moorfields in the 1940s and micro-incision surgery in the 1990s and now in the new millennium lenses are injected into the eye and unfolded inside the globe through slits of 2.3mm or less. But is it safe, safe enough for someone without a cataract to consider for the purpose of correcting refractive errors? Many thought it was safe and so Refractive Lens Exchange (RLE) surgery was born.

As techniques improved so the risks reduced, but risks will always remain as with any surgery. So my question was, when would they be low enough for me? I have the good fortune to be married to an optician, Penny, who was in an excellent position to provide feedback on the reputations of the surgeons performing cataract and RLE surgery in my area. She had long since praised the abilities of Mr Robert Morris, a consultant who works at the private Nuffield Hospital nearby (RLE surgery is not available on the NHS). But reputation alone was not good enough for me; I needed evidence. Then in June 2008 Penny mentioned that she had just examined the eyes of a patient who had recently had RLE surgery performed by Mr Morris. The patient was not only a high myope (approximately minus 8 and minus 16) but also, Penny assured me, as fussy and demanding as me. (Something that I found hard to believe!) Moreover, he was very satisfied with the result that had been achieved for him. Had my time arrived?

A short discussion with Penny ensued and I arranged a consultation with Mr Morris at Nuffield Hospital in Chandlers Ford. I was well aware of the risks. The list is long. Scanning the internet and reading the medical literature did nothing to calm my fears. It only added to the list of potential disasters that I had already thought of; and I can think of a lot. But people have a much greater tendency to complain about what went wrong for them than to write about what went right, something I kept well in mind when scanning the internet. My favourite two worries were retinal detachment and infection, with the second a long way behind the first. It seemed to me that many of the other risks could be greatly reduced by choosing a very experienced surgeon.

It is well-known that the risk of retinal detachment is already significant for very high myopes and cataract surgery increases the risk further [1]. Moreover, the risk is also higher the younger one is at the time of surgery and I would be just one week short of my 48th birthday, and that counts as very young when your talking about cataract surgery.

At the consultation my first and only big shock was that Mr Morris said he would only do the surgery under a general anaesthetic (GA). That, of course, meant two generals as, for reasons of safety, the eyes are operated on one week apart. Now I have a condition known as fibromyalgia and, unfortunately, the name is just about all anyone knows about it, and even that has changed over the years. So I was not at all sure how my body would react to a GA. It was just another item to add to my list of worries. Leaving the hospital after the consultation I suddenly had severe doubts but with a little persuasion from Penny they only lasted an hour; they probably would have lasted no more than a few hours longer even without Penny's help.

Mr Morris said only that the GA was necessary to achieve the best result and I later read a paper that stated the risk of error during a local anaesthetic was greatly increased, a factor of 30 times was mentioned, (although this was using needles) in very high myopes due to the long axial length of the eyes, and mine were long at 28mm and 29mm, whereas the average is around 21mm. After reading that paper I no longer wanted a local. Anyway, the decision was made to have the surgery and so it was booked for 5 and 12 August. I requested that my left eye be operated on first as I felt that it was my dominant eye. Mr Morris said that he normally aims for about minus one dioptre in the first eye as it not a good idea to end up with the eyes hyperopic. Unfortunately, the manufacturers of the intraocular lens only offer crude increments of power at my level of myopia, which seems a real shame after all those careful and accurate laser measurements of my eye at the initial consultation. I would also be left with some astigmatism as it could only be partially addressed at the time of surgery.

Penny and I were off on holiday to France in the meantime and were due to return on 23 July. The holiday was well timed to keep my mind off the surgery. Upon return I received a call from the hospital saying that the surgery would have to be put back by one week, to the 12 and 19 August, as Mr Morris wanted to work with his usual anaesthetist who happened to be on holiday himself on 5 August. I was disappointed by the delay but it was clearly in the interests of safety.

I duly received a letter from the hospital stating that the surgery was planned for the 12 and 19 August and requesting the £4,032 fee up front (I had already paid the £100 consultation fee). I wrote a cheque the very next day and took it straight to the hospital. I deliberately did not pay by credit card as this would have given me some insurance and thus more possibility to chicken out. In the meantime I must have come close to reading just about every paper available on the subject. My O-level knowledge of eye anatomy rocketed skywards as did my knowledge of optics. Within weeks I could have cited journals, volumes and page numbers of many relevant articles to anyone sad enough to ask. None of this did me much good, although it did satisfy my need to know.

The pre-assessment clinic was on Monday 4 August in the morning. All went well. Despite my health problems the ECG showed I was not about to keel over with a heart attack. One hour after the pre-assessment clinic I got on my bike to do my regular two mile lap of Chandlers Ford. Due to my health problems I needed to stay close to home so, generally, I did 3 or 4 laps. I wanted to be as fit as was possible before the surgery. And that's when it happened. Suddenly, I had black threads swimming before my left eye and it was clear that they weren't on my cycling goggles. I returned immediately to the house and told Penny, who thought it very likely that I had had a Posterior Vitreous Detachment (PVD). A visit to Southampton eye hospital the next day confirmed this and also that there was no visible damage to the retina. The examination was very thorough, which I was grateful for as my high myopia puts me at great risk of a retinal detachment (RD). But what would be the consequences for my eye surgery, due in exactly one week's time?

The next day I phoned the Nuffield hospital to let them know what had happened and was phoned back later to be told that following a PVD Mr Morris likes to wait six weeks before operating to allow the eye time to settle. This was not good news; I had already been disappointed by the one week delay. New dates for the surgery were duly arranged for the 23 and 30 September, a delay of seven weeks. But was there any good news in any of this?

My initial instinct was that a PVD, if one “gets away with it,” (that's to say it does not lead within a certain space of time to RD) ought to greatly reduce the risk of RD. I posed the question at the eye unit but only got a blank look so I checked out my thoughts on the internet which confirmed my instinct [2]. However, I was left with large moving blacks threads before my vision, which were highly obtrusive and sufficiently distracting to affect my concentration. I knew that over time I would get more used to them and, perhaps, they would become more translucent but I had requested that the left eye be the first one operated on. After the first operation I would effectively be one-eyed as the difference between the image sizes on the retina would make it impossible to have binocular vision, even using my previous glasses with only the lens corresponding to the untreated eye in the frame. Did I really want to be staring at what looked like a pair of black tights blowing in the wind on a washing line for a week? It would certainly not encourage me to use the operated eye. Thus, I emailed Mr Morris asking if the decision over which eye to do first could be left to the day of the surgery and, also, I added another concern: I felt the left eye (the PVD eye) needed to be rechecked before surgery. Although the eye had been checked at the eye hospital further problems could have easily developed in the ensuing weeks and I had no desire to arrive at surgery day without more security.

Mr Morris suggested a further appointment and so I went along to the Nuffield to see him. It was impossible to decide on the night which eye to do first, so I opted for the right, a difference from my initial wish. He also checked my left eye and it was all clear. Just for good measure I posed the question about my PVD and its relation to the probability of a later RD. Fortunately, he did not contradict my instinct or my findings on the internet.

The extra 7 weeks delay from 12 August to 23 September did not pass quickly. I imagined every sort of bad outcome but in the meantime tried to keep myself as fit as possible. As a fibromyalgia sufferer, I have many problems with muscles, joints, connective tissues and fatigue, to name but a few, and so keeping fit was not at all easy. But I managed up to 6 or 7 two-mile laps of Chandlers Ford each day on my bike. I knew that I would have to rest after the surgery, and rest (as well as too much exercise) can have a significant negative effect on my health. I wanted to reduce the effects of the ensuing enforced rest as much as I could.

September 23 eventually arrived and because I was to have surgery under a general anaesthetic I could not eat after 11:00 nor drink after 15:00. Hence I had a very early lunch and a last glass of water just before 15:00. Penny came home from work early to take me to the hospital. We arrived at 17:00, fifteen minutes early. Cataract surgery is usually done in the evening at the Nuffield and the patients go home the same evening, all being well. Penny and I went straight up to my room and a nurse appeared and explained the remote controls of the telly as well as one or two other things of no interest to me. I was also asked what sandwiches, fruit and drink I wanted for after the operation so I chose tuna and cucumber, an orange and orange juice. Shortly, another nurse came around to warn me of the impending dangers of the surgery (retinal detachment, blah, blah, ...) before asking me to sign the consent form. I could have added a few more risks to her list but duly signed the form anyway. Over the next 30 or 40 minutes enough drops were put in my right eye to top up Lake Mead and my pupil swelled to the size of a planet, well almost. My legs were also measured for stockings that were to prevent thrombosis during surgery. The stockings were not easy for the nurse to put on due to my sweaty feet. Mr Morris stuck his head around the door and asked if I had any questions. I said that I was exhausted with questions and he said, with a smile on his face, “So am I.”

I was pleased to be informed that mine would be the second operation of the evening and the only general anaesthetic. The time passed extremely quickly and not long after 18:30 a nurse came to take me to the theatre. I left my glasses in my room as I did not want to see the theatre and said goodbye to Penny in the corridor before going in. I was asked to sit on a bed and someone took my hand and started to squeeze it in preparation for the canular for the anaesthetic. My name and date of birth and the operation which I was about to have were all verified again. I felt the needle go in my hand and asked if I should count (I remember counting to about 5 when I had my appendix out at age 17) and the anaesthetist said, “If you want.” So I started to count in Spanish, which amused the staff, as I felt the cold rush of the anaesthetic rise up my arm. I got to “doce” (twelve) and was starting to worry that I was not yet out and was about to ask how long it would take...

“You've been asleep for 35 minutes,” said the nurse leaning over me. “They gave you a big dose.” I wasn't sure whether this was a joke and, anyway, all I wanted to do was go straight back to sleep. “The operation went well,” she said, reminding me of the question I had meant to ask when I came around. It may have gone well but I could barely see anything out of my right eye as my pupil was still enormous and there was a see-through plastic patch over my eye. After the required wait in the recovery area I was wheeled back to my room and can only vaguely recall the change in scene. I was clearly out of it and so the nurse recommended that I wait a good hour, or as much time as I needed, before attempting to eat anything. I tried to use my new eye to read the clock on the wall. It was only about 3 metres away but was right at the limit of my vision. In fact, all distances were extremely blurred and of course I could see nothing out of my left eye thanks to its minus 13.25 dioptres. I could not even put my glasses on due to the patch.

An hour later I was feeling slightly more human and pushed the button to call the nurse and request my food. An unbelievable amount of time passed, although it was probably only between 5 and 10 minutes (enough time to die had it been an emergency) before the nurse appeared and apologised for the delay. I requested my food, which arrived shortly. I didn't really feel like eating but forced my way slowly through the four sandwiches and garnish of tomatoes and lettuce, none of which I could see. I attempted to attack the orange by peeling it but this was a non-starter, so I cut it into quarters and ate it that way. Having finished my meal and drink I knew that I should go to the toilet as this was something that had to be done before leaving the hospital. However, I had been told not to attempt to get out of bed for the first time without a nurse present so I pressed the call button. Again nothing happened. I sighed and resigned myself to another interminable wait but someone eventually showed up after a few minutes.

Toilet done, I said I felt ready to leave and the nursing staff phoned Penny to tell her to come and collect me. She arrived with my son Neil about 30 minutes later and we all left, my right eye constantly scanning our surroundings to test the quality of its vision, which was of course not too good at this point but I knew I could not expect much as I'd only had the operation less than 3 hours ago.

As I walked out of the hospital an overhead orange light in the car park caused some unexpected diffraction patterns right across my vision. Somehow I had been led to believe that modern day intraocular lenses had solved that problem; obviously not as well as some would like to believe. I knew the left eye would soon follow, but it was nothing I could not get used to and, anyway, it was only noticeable in low light and, at the same time, when there was a bright light source to the side of my vision.

I offered to drive but Penny kept a tight grip on the car keys. On arrival my other son, Adam, was keenly waiting to hear all the details, so I duly obliged. Adam is shortsighted but after listening to my account he was less inclined than ever to contemplate eye surgery. It wasn't long before I went to bed. It took me a bit longer than normal to fall asleep because the eye patch felt slightly unusual although I had absolutely no pain from the operation but, once asleep, I slept very well.

The following morning I removed the eye patch and bathed the eye in the solution provided by the hospital and commenced the regime of putting drops in my eye every four hours, or I should say Penny commenced this regime as I did not want the all important first few drops to end up on my cheek. My pupil was still huge and consequently the vision was not good so I wore a patch over the operated eye and used my left eye and glasses to see. I could only look through one eye or the other at a time due to the very different images sizes on the retinas. It was impossible to obtain binocular vision. In fact, this was the most troublesome part of the entire procedure. It was very uncomfortable, from a psychological not physical aspect, to try and use both eyes, thus one eye had to always remain covered even though I would occasionally switch between the two.

Within a few minutes of getting out of bed, already, I could not wait for the week to pass. I wanted that second eye operated on! I could not help thinking about all that might go wrong: would my slight cold turn into pneumonia, would I be knocked down by a car or would Mr Morris, the eye surgeon, break his arm or even survive the week? The list started to grow.

One of the slight risks with RLE surgery is infection, so I was very relieved that on the first morning all appeared to be normal with my eye. Another risk is retinal detachment but there was no detachment so far, although trying not to worry about the latter possibility is easier said than done. Several times during the nights of the following week I would wake up and wonder if I had lost part of my vision; but it was always fine, these were nothing more than tricks of the light in the dark. One unexpected phenomenon that I only noticed once the eye had settled was that in the dim light of the morning I could make out the pattern of blood vessels on my retina; it was floating over our ceiling! This was so startlingly clear that I could have sketched a picture. On these mornings, as I lay in bed, the images slowly faded as the dawn light intensified. The spidery patterns had always completely disappeared after 3 or 4 minutes, not to return until the next morning, and then only if the light was favourable.

A lot of tasks are a tad more difficult with one eye such as chopping up food or filling a cup of tea. I even found placing things down on a surface a little more difficult until I got used to it. Exercise is very important to me due to my severe chronic muscular problems and so I usually like to cycle gently whenever I'm able, but now to avoid unduly raising the blood pressure I had to stay off the bike for at least 5 weeks. It was going to be a long five weeks.

Three days after surgery my right pupil had finally returned to its normal size and the vision had consequently improved to a good standard: better than I had expected for distance but slightly disappointing for closer work due to some remaining astigmatism. Without glasses I could read some small letters on the telly that no one else in my family could read, even with their glasses. However, the week between the two eye operations was one of the longest weeks of my life. It was difficult to concentrate. I went out for many walks around the local streets and lakes. It was in the open air that I could fully appreciate my new vision. I was conscious of not having glasses before my eyes to protect them from unexpected branches so I was naturally more cautious when walking along narrow paths.

Every morning when I woke I mentally ticked off another day until next Tuesday, the day of the second operation. And finally it arrived. I followed the same dietary measures, so no food after 11:00 and no drink after 15:00. As before, Penny took me to the hospital just before 17:00. I was shown up to a different room after a very brief wait downstairs, trying not to distance the other old lady behind us who was clearly here for a cataract operation as well. Things started to happen almost immediately: a new nurse started the shower of drops to dilate my pupil, I choose cheese and tomato sandwiches, orange juice and a pear to eat after the operation, and before long Mr Morris poked his head around the door, looking rushed but in good humour. I was very relieved to see that he had survived the week. The anaesthetist also had a word and I asked him if he could go more easy on the anaesthetic this time.

It turned out that I was again second in order on the operating list, out of six. Apparently, they preferred to schedule any general anaesthetics as either number 2 or 4, and as I was the only general tonight I was again listed second, That suited me fine; the sooner the better. Penny was about to say goodbye when to our surprise the nurse arrived to say that they were ready for me; it was only 18:30 and I had expected to wait longer. Good news! I said goodbye to Penny in the corridor and entered the operating preparation room. I started counting in French as they put me under and awoke only a split second later, as one does from a GA. There is no feeling that time has passed.

I felt much less groggy than I had done with the first operation. I was wheeled back to my room after only a short spell in the recovery room and declared that I wanted to eat after only 20 minutes or so. But the nurse said that I had to wait at least one hour, otherwise I risked being sick. The food arrived after the said hour and this time I could see what I was eating, thanks to my right eye. The pear was a little hard but the sandwiches and orange juice were fine. Penny arrived just before 20:30, this time accompanied by Adam who wanted to take a look at the hospital. When we got home I was actually fit to have a cup of tea and watch a bit of telly before going to bed. The eye patch, now over my left eye, was a similar nuisance to the one last week but I still managed a good sleep.

The next morning the second eye looked good: no sign of infection. I bathed it as before. The cascade of eye drops was now doubled, since they had to go in both eyes, but fortunately the frequencies would start to taper off within a week. I could now put them in myself without too much trouble but when Penny was around, in the mornings, I preferred her to do it to avoid any mistakes. As with the right eye, it was impossible to verify the quality of the vision in the left eye until almost 3 days after the operation due to my dilated pupil. When the eye finally settled, I was pleased to discover that the vision in this eye was even better than the right. I had better distance vision and better reading vision! The downside is that I now wanted the right eye to be as good, but it was never very likely that they would turn out exactly the same so a slight difference was almost inevitable.

I was pleased that both operations were finally over and keen to know at what level my vision would settle. After a few weeks I had a check at the hospital and then another a few weeks later. Everything was fine and I was less troubled by the potential of a retinal detachment. Around six weeks after the operations Penny tested my eyes. There was a very slight pressure increase in both eyes but well within margins of error and certainly nothing to worry about. At the hospital I could read the bottom line unaided but on Penny's chart it was only the second to bottom since she had one extra line.

I wanted glasses for studying, reading, the computer and distance. Now this may seem a lot for someone who has just had an operation to rid themselves of glasses but the only ones absolutely necessary were those for studying; I study real close. The others sharpened the image but I could get by without them, so for the majority of the time I was no longer wearing any glasses.

As far as reading was concerned I had lost a bit of sharpness which could not be corrected by glasses. With a small amount of difficulty I was able to read print in a novel unaided and I could also watch the telly with even less difficulty. This is quite a feat as our telly is almost two parsecs from the sofa. But, again, the image was not quite as sharp as before. Nevertheless, the vision is now good enough that I often watch telly without glasses when I cannot be bothered to fetch them. Another notable aspect was that everything seemed a bit larger: the small shower room off the bedroom had grown, so had the sinks and even my meals! This was due to a change in image size on the retina and was something I quickly adjusted to; it was indeed an advantage and how most people were seeing the world.

I stopped the drops after nearly four weeks, a few days earlier than recommended and recommenced my exercise regime on the bike. My face was so much more comfortable without heavy glasses behind my cycling goggles. As the weeks and months passed I became more and more pleased with the result. I have no trouble driving in the daytime without glasses, as I am well within the driving standard, and use my distance glasses while driving to sharpen the vision at night. The only time I tend to use glasses in front of the computer is when I want to study and read the computer screen at the same time (I have bifocals for this), otherwise I use the computer without glasses. I read a book in the morning at breakfast without glasses but when I want to read for longer I do use them. Overall the operation has been a great success, I would recommend it to any mega myope but choose your consultant carefully and certainly no more than one week between the two eyes!

UPDATE: On 29 April and 8 May 2013 I had YAG laser capsulotomy to treat the opacification that had occurred in both eyes. The left eye, which was treated first, was more affected than the right eye. But I had the right done as well since the remarkable difference in vision after the capsulotomy on the left eye really highlighted the problem in the right eye. My vision is now very clear in both eyes. It actually seems clearer than it was just after the original RLE surgery, though this may just be an illusion. I've become about 1 dioptre more shortsighted in both eyes since the original operations, but I'm still pleased with the result.

References

[1] N Horgan, P I Condon, and S Beatty. Refractive lens exchange in high myopia: long term follow up. Br J Ophthalmol. 2005 June; 89(6): 670–672.

[2] Roibeard O'hEineachain. Emmetropic eyes without PVD at risk of retinal detachment following cataract surgery. ESCRS EuroTimes 2007 July.



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Derek Jennings.