Around age 40, it slowly started becoming more difficult to focus (when wearing correction) at close distances, especially in low light. This is a very common condition called Presbyopia which is due to your crystalline lens becoming less elastic. This loss of accommodation is analogous to camera lens that won't focus close. So I started wearing reading glasses (when wearing contacts) or a different glasses prescription for computer/close-in work. Wendy made fun of me, but I said "wait until your turn" and yes, a few years later, she had to start wearing reading glasses - her distance vision remains excellent.
In 2010 (age 46), I noticed that my right eye had more difficulty seeing things. I had been told it had a "small" cataract, but these can often exist for years with no impairment of vision. Unfortunately, I had a Posterior Subcapsular Cataract - these "grow" faster, are more prevalent in younger people, and cause greater visual degradation due to the location at the rear of the visual axis. Because of the cloudiness, you are no longer able to correct to 20-20. An analogy would be a blown window that now has a permanent haze. In addition, the cataract causes a "Myopic Shift" which means increased spherical power (also noticeable via reduced minimum focusing distance) and astigmatism - i.e. a new pair of glasses/contacts every several months which is a bit of a PIA. Cataracts typically don't interfere with vision and lifestyle until age 70 or later ... so it kinda sucks to have it happen to me a few decades early - darn!
I'm a bit of a photographer who analyzes camera gear (and shoots with my right eye - bummer!), so I'm aware that image quality encompasses more than just seeing "20-20" on the eye chart. For instance, I check the MTF curves and will often see various visual defects in my pictures such as Chromatic Aberration that might not be apparent to others - sometimes it's not good to know more. Being an Engineer, I'd periodically "test" my vision and needless to say, even pre-Cataract, I knew it wasn't sharp as it could be, but you just have to manage with the eyes you get.
Even with best correction, the cataract impairs the vision and causes all sort of visual aberrations beyond just blurriness due to the cloudy lens. Point sources of light are "replicated" (as seen below) and high-contrast or low-light situations are difficult. Interesting enough (to me at least!) is that with one "good" and one "bad" eye, it's fairly easy for me to compare the visual degradation. It's amazing how the brain is able to "filter/figure" out the "bi-polar" vision (up to a point) but it requires a lot of "work" to see and I often get visual fatigue. Below is an image that simulates (as of July/2011) the difference I see between the left and right eye - HEY, less wrinkles with the later! ;-)
But recall that accommodation (or focus) is done by your eye's Ciliary muscles moving your natural lens ... which has now been replaced. So until about 10 years ago, IOL's were "mono-focal" - i.e. you could see 20-20 distance, but had no ability to focus at Intermediate or Close-in. Therefore, you'd still need to wear glasses for reading, and the fuzziness at Intermediate distances would affect your day-to-day life.
In the last decade, two competing technologies have tried to address this shortcoming. Multi-Focal lens are basically concentric rings of far/close focus so two images are presented to the brain and it is able to "pick" the sharp one depending on if you are looking far or near. Advantages are that you have a good chance of seeing well at far and near. Disadvantages are that your Intermediate will be fuzzy, and high contrast situations can be difficult with halos and glare. As an engineer, this is obviously a compromise solution ... but if no perfect solution is available, one often uses what is available/works ... and Multi-Focals are commonly used today.
The other approach is Accommodating Lens which uses the eye's own Ciliary Muscles (which focus your natural lens) to change focus. Obviously this would be the "Holy Grail" of IOL's ... if it works. As of 2011, the Bausch and Lomb Crystalens is the only accommodating IOL to have FDA approval. There seems to be more variable results with the Crystalens, but ideally, you should end up with excellent vision at Far and Intermediate, but you almost certainly will need Reading Glasses for close-up work. I.e. If all goes well with the Crystalens, you will have at least a diopter of accommodation and be able to go glasses-free for most day-to-day life, but need glasses for reading. Because it's not a compromise solution, halo/glare is less of an issue and I would expect better low-light vision than multi-focals.
It's interesting talking to Eye Doctors as there definitely are Multi-Focal and Accommodating "camps" with both believing their solution is the best and the other is (basically) no good. So as a layman (or at best a eye-doctor-wanna-be), it's quite confusing who to believe and select an option. And what is really a bummer is that there is lots of research (and money!) in this area so even a couple of years from now, there probably will be other options. For example, Synchrony and Tetraflex are two lens awaiting FDA approval that claim greater accommodation. Femtosecond Lasers may soon be the new scalpel in eye surgery, offering more precision and consistent results.
My guess is that by time I'm 70 (when most people start to be affected by Cataracts), technology will progress such that Accommodating Lens with multiple diopters of accommodation (so you can see Far/Inter/Near) will probably be commonplace. In fact, it would not surprise me that (similar to Lasik), refractive Cataract Surgery becomes popular as an elective option to correct vision and address Presbyopia.
Note that you really do NOT want to remove an IOL after it has been in
your eye as the risk of complications goes way up ... so "upgrading" years
later would be difficult. But speaking from first-hand experience, the
degraded vision from the Cataract really affects your lifestyle (and it is
rapidly getting more annoying) so I'd like to do something about it rather
than wait for the "next great thing." People describe Cataract Surgery
as an incredibly positive life-changing experience ... lets hope that
is the case for me.
So what did I decide to do? Turns out that Dr. Don Keller (who you may recall did my wife's Lasik) is huge fan of the Crystalens ... and was actually the first Doctor in Colorado to use 'em. So he obviously has a lot of experience doing them ... and while Cataract surgery is fairly routine, there certainly is a skill/experience element involved. He also spent a lot of time with me discussing the various pros/cons/aspects of Cataract Surgery. I'm OK with wearing glasses for reading, but it would sure be nice to see 20-20 (or better!) at Far/Intermediate for sports and normal day-to-day life ... and hopefully no halo/glare at night. So Crystalens seems to be the right choice for me at this time.
Some additional concerns are that due to my high Myopia, I'll have an even higher risk of Retinal Detachment during my lifetime. Also, I will probably have Posterior Capsule Opacity (PCO) sometime soon after the operation, but this is fixable with a ND:YAG laser that basically burns a hole in the back of the bag to clear the visual axis. My astigmatism (pre-cataract) isn't too much, but am hoping that a Limbel Relaxing Incision (LBI) during the operation may be able to reduce most of this. Note that while a Lasik tune-up is possible afterwards, you can't do a "custom" job after the IOL is in place since it messes up the measurements. Exercising the eye muscles by reading afterwards is highly recommended to "get/tune" them back into shape with the new accommodating lens and may take several months.
I should add that while the cataract in the left eye is not interfering with my vision too much, with -7 diopters of correction, you really need to have both done to balance things ... plus in dry Colorado, there is no way I could wear contacts all day long, every day. So another decision will be whether to do a ~1 diopter offset in the other eye (i.e. like mono-vision) to provide better near vision ... but this gives up some clarity at distance along with depth perception. For similar reasons, I'll want to do the 2nd eye as soon as possible (one week) after the 1st eye.
Cataract Surgery is covered by insurance, but only for mono-focal lens.
The upcharge for premium lens (multi-focal or accommodating) is about
$2,000 an eye. This is in addition to insurance deductibles, so it's not
cheap ... but since I'm not even 50 yet (and hopefully have some good years
left in me), it would sure be nice to see well after a lifetime of vision issues ... so I plan to have it done after Labor Day, 2011.
Expectations: While everyone wants 20-20 (or 20-10!) at Far/Inter/Near, that's not realistic with today's technology and Dr. Keller thinks that "20-functional" is quite doable. A very successful outcome for me would be sharp (good contrast with no halos, glare, etc.) 20-20 vision at distance and intermediate to 1/2 meter ... i.e. would be super to get a full 2 diopters of accommodation and he says my high myopia may help in that area as the football'ness shape of the eye provides more flexure on the IOL.
As noted before, there are risks with any surgery, but they are pretty low for Cataract surgery and obviously I hope none of the short or long term problems crop up for me. One thing I'll have to worry about for life is retinal detachment ... with high myopia and cataract surgery, it seems this happens to over 5% of people - not insignificant!
Cataract surgery is often described as life-changing since it restores vision. And as someone who has always been very near sighted and needed glasses/contacts all my life (and now has presbyopia), that hopefully will be the case with me.
So ... thanks for reading this far and I hope it was helpful/informative to 'ya. Wish me luck! ;-)
The Corneal Topography showed 1.12 diopters of astigmatism in the right eye and 0.63 in the left, so Dr. Keller will perform Limbel Relaxing Incisions (LRI's) and hopefully reduce most of this. The IOL calculations recommend an 11 Diopter lens in the right eye that will (ideally!) result in a refraction of -0.16. For the left eye, he may slightly under-correct the power to allow for a bit more close-in vision depending on how it goes with the right eye. BTW, my pupil size was ~5mm in a dim examination room.
Dr. Keller inserted a Crystalens model AT-52AO 10.5 diopter lens (SN#10-681616) through a 3mm opening - an 1/8" inch! This is slightly less than the 11.0 power "recommended" from the biometry data. He explained that as the eye heals, it usually "pulls back" a 1/4 to 1/2 diopter, so he's hoping the 10.5 will result in me ending up plano - i.e. focus point at infinity when relaxed and hopefully clear 20-20 (or better) vision.
I didn't feel any pain in the eye and the most annoying thing is that the patch is not opaque ... so you have a "white veil" image coming in from the right eye that totally messes up your brain when it combines with a "good" image from the left eye. So I put a "pirate patch" over it to better obscure the right eye which makes it *much* easier to see - too bad it's not Halloween! ;-)
So far, so good ... the patch comes off Tuesday morning and we'll "see" what my vision is like.
This is obviously an excellent sign and after examining my eye, Dr. Keller said everything looked good and healthy and he'd expect some improvement in distance vision by the Friday appointment. I was able to read (barely) 20-40 in an intermediate vision test 24 hours after my surgery, but the accommodation can take several months and you don't want to be over-corrected. Recall I had -7 diopters of myopia so I could focus 5" from my eyeball - knew I'd lose this ability and will miss it. Initial impressions are low-light/night vision is improved. I do see some occasional "shimmering" on bright light sources in my peripheral vision along with a few dark floaters - I believe both are normal.
Another thing I have noticed is colors are more vibrant plus generally brighter. This is common with cataracts and makes sense as the cloudy lens obscures vision. But it is pretty subtle as it can "sneak" up on you more so than the loss of vision. I used Photoshop to simulate this by applying a +15 with Selective Color (Yellow/Yellow) and -15 on Brightness. The image below gives an idea of how a cataract shifts colors. Note that this is based on a direct comparison between my right eye (new lens) and my un-operated left eye (48 year old natural lens) which did not have a vision impairing cataract. I.e. the cataract was surely causing even more dullness - see what it did to Monet!
We debated whether to go with an 11.0 Crystalens or an 11.5. As mentioned earlier, one can "offset" the two eyes so you have better closer vision, but at a loss of distance acuity and depth perception. According to the calculations, the 11.0 in the left eye would be 0.08 diopter more myopic than the 10.5 is in the right eye - the 11.5 would be another 0.31 diopters myopic. My goal is still the same - hoping to have sharp vision at distance with adequate accommodation for intermediate computer work ... and am willing to wear reading glasses for close-in. We decided to go with the 11.0 to match hopefully match the right eye as I would surely "notice" the mono-vision option.
Recall one main reason I selected the Crystalens was for the accommodative ability. Using the FAA Eye charts, I'm seeing 20-20 at distance (not quite as good as measured at the eye doctor), 20-40 at an intermediate range of 32" and 20-100/J10 at close-in range of 16". I'm hoping in the weeks to come to "see" some improvement in those areas. For comparison, while wearing my (distance) glasses on my (un-operated) left eye, I see 20-20 at distance, 20-25 at intermediate, and 20-50/J5 at near ... the accommodation is worse with contacts.
I have a bit of a "dull ache" in the left eye (more than I remember in the right) but nothing alarming. I was able to "function" around the house (with only one eye of course) and go for an extended walk around the neighborhood with my wife. I again used a "pirate" patch to darken the semi-translucent patch ... so I'm scary looking and can say AYE MATEY! ;-)
So far, so good ... the patch comes off Tuesday morning and we'll "see" what my vision is like.
Right eye correction didn't change much at +1.00/-1.00@145 so (applying half of the cylinder power) I'm slightly Hyperopic (means I "lose" some of the accommodative power) ... but Dr. Keller thinks I might see a quarter/half diopter pull back which would make me plano. With the correction applied via glasses, the 20-15 line was very clear plus I got some letters at 20-10, so my visual system is working well - WOOT! ;-)
I had some +1.50 reading glasses, but picked up a +1.00 (for $3!) so my eyes will have to work "harder" for intermediate and close-in work. Spent a good part of the day on the computer without glasses, but I get tired after a while ... good exercise/training for the Ciliary muscles! ;-)
The refraction for the right eye didn't change much in the 2nd week ... in fact, she originally got the same +1.00,-1.00@145, but Dr. Keller showed that +0.50,-0.75@145 was very similar. The left eye was 0.00,-0.50@180 after one week, but I feel like it sees less astigmatism. Not perfect numbers, but not too shabby!
I still have occasional shimmering in my eye - typically when a strong light source is at the edge of my vision. This is called pseudophakic photic phenomena or Dysphotopsia and is common in Cataract patients, especially initially. A related phenomena is Negative Dysphotopsia - an occasional dark spot pops up in my peripheral vision. This catches my attention - was that a person (or animal/bird) over there! ;-)
Both are due to the different light paths through the intra-ocular lens (especially the edges) and in many cases, these will go away as the brain figures out they can be filtered away. That's been my experience as I hardly see 'em anymore from the right eye, but still periodically from the left eye, which is one less week post-op. Dr. Keller says a common occurrence that should go away soon ... so I basically just try to ignore 'em.
Dr. Keller and I discussed the "violet glow" I mentioned earlier - this is seen equally on both eyes. I stopped by a Halloween store yesterday and when looking at a (fluorescent) black light, it appeared a very bright blue. When I put some poly-carbonate safety glasses on, it went back to being a dim deep purple. Several other adults saw the later with no difference with/without the glasses ... and my 13 year old son only saw a very slight difference with/without the glasses. Medical literature says that the photoreceptors are capable of seeing UV light, but it's typically filtered by the natural lens, especially as it yellows with age. So now that my lens has been removed, I'd consider the test case above fairly conclusive evidence I'm seeing in the UV spectrum. Dr. Keller doesn't have the right gear to test this and has heard this rarely happening with the Crystalens and other IOL's - presumably those that don't filter UV. Read more about the Ultraviolet glow.
Overall, I'm very pleased so far with my Cataract Surgery and Crystalens implants. There's a few oddities (but I'm very analytical), but being able to see sharp (!) without glasses is great and the brightness and vivid color of the world is fantastic to look at.
It's been great playing some sports recently as I can see the spin of the baseball, arc of the frisbee, and trajectory of the football. A week before my surgery I mountain biked to the top of Rollins Pass and remember how difficult it was to see coming down as my eyes/brain didn't seem to be able to process the distorted/fuzzy imagery as I bounced along. I did some off-trail biking with my younger son today and it was night-n-day difference ... the world is in focus and just stays that way without having to "work" on it. In a similar fashion, stuff such as running around on the frisbee field and driving are much easier - I'm excited to see what it's like snow skiing this winter.
I no longer feel even the occasional "piece-o-sand" in my eyes plus there is minimal dryness. Another interested aspect is that I think (!) I can "hear" the world a bit louder - most notably birds chirping when walking. Perhaps my brain was working so hard pre-op on deciphering my blurry vision that I just didn't hear so well ... or (more probably) I'm just imagining it! ;-)
I still have some old habits such as sometimes reaching under the bed for my glasses when I wake up in the morning - don't need 'em anymore! And if I'm wearing reading glasses and want to focus even closer, I periodically look above the glass, since in the old days, my -7 myopic vision would allow me to focus very close - doesn't work anymore. Another peculiarity is that the world is not only brighter and more vivid, but larger. When I was wearing glasses, the magnification was outside my eye and things appeared smaller - remember my "Coke-Bottle" commentary early. While the image sizes are now matched (thankfully!), I truly do notice that things look a little bigger than I remember them such as golf/ping-pong balls and the moon.
Finally, a number people who have read my writeup (and visual examples) of
seeing ultraviolet light have written to say they see exactly that.
So while I'd still love to do some rigorous testing at an optics laboratory,
I'm pretty darn certain now that I'm truly seeing in the UV spectrum.
I continue to sometimes see purple on grey/black items, but at least so far, this hasn't been annoying and it's more an interesting oddity.
There's more pictures/analysis on the Ultra Violet page but in summary, I was able to see down to 340/350nm ... whereas similar aged people cut-out between 410-430nm. So this seems to conclusively prove that I'm able to see into the Ultraviolet spectrum.
I also picked up 400nm and 365nm UV flashlight to "test" my vision more.
While both have leakage into the visual spectrum
(which starts around 400nm), the 365nm light is a faint/pale grey to "normal" people ... whereas I see a bright purple.
So makes for a very easy demo of my ability to see UV.
Here's a picture of them "lighting" a non-fluorescent wall - remember that the camera doesn't "see" UV.
In terms of accommodation, the left eye has gotten a bit more, but the right eye has regressed slightly. Both are less capable in the evenings; perhaps the muscles are tired at the end of the day. When looking at the 32" intermediate chart at arm's length (~30") in good light with +1.0 readers, the left eye can read 20-15 and the right 20-20 ... my layman's interpretation is that this is about a 1/2 diopter of accommodation.
Close-up vision in dim light remains a challenge - I need readers to make out the menus at restaurants unless very good light. My son had an eye appointment with Dr. Brain Nichols (Dr. Keller's partner) and he was gracious enough to take a quick look at my non-dilated eyes and said it looked like a slight amount of posterior capsule opacification with a bit more in the right eye ... so it's possible this may be contributing.
Finally, an interesting "visual" while taking an evening walk with my wife tonight as we spotted a Great Horned Owl in a heavily wooded area. With the fading light, it was very difficult to pick him (her?) out as the owl's feathers blended in with the branches. Wendy is an extraordinary wildlife spotter ... and pre-surgery, she pretty much always saw wildlife before me. But in this case, I actually was the first one to pick out where the Owl had landed. I.e. an impressive demonstration of (distance) visual acuity in a cluttered low-contrast, low-light situation.
That's a good question in terms of the actual mechanism of UV vision ... and I actually have not done any spatial resolution tests which would require an eye test on a chart only seeable in the UV spectrum ... seeing the purple'ish ting on a pair of "black" shorts doesn't count!
It's not a big difference on the eye chart (which is very sensitive to the amount of light) but quite noticeable in my day-to-day routine as I am reaching for reading glasses more often, especially in low light. At night, I struggle a bit to read the newspaper at about 18" away even with +1.5 readers ... which should correct to 1/1.5 meters or 26" ... so I don't seem to be always getting that extra 0.5 diopter of accommodation. I also notice the limited depth-of-focus when the newspaper is on the table since the print is at varying distances. My arms and head seem to be moving things back-n-forth more as the focusing mechanism! ;-)
This may be due to posterior capsule opacification (note comment on March 18th) which I'm hoping is the case since this is semi-expected and should be fixable with a YAG laser. I'll do a formal eye appointment at the one year point and we'll "see" what happens.
He felt the change in the right eye was probably due to some slight scar tissue that may be preventing movement, but otherwise the inside of the eye looked good with some very slight PCO. He also saw some floaters in the right eye, although the left is much more noticeable to me. So no need to do YAG at this point (from a visual point of view) although he did say that people often see a slight improvement in accommodation from this procedure as it can allow the Crystalens to flex more posteriorly.
There was no difference after rinsing the eye with a few drops of saline - just wanted to make certain this is something internal to the eye rather than on the surface. It is completely localized to the right eye and there is no associated pain/feeling - just a slight obscuration of vision that mists over in normal activity due to the "floater" - I did not see any "flashes" of light - another sign of possible retinal detachment.
I was a bit concerned as my risk for vitreous separation (and retinal detachment) is much higher after cataract surgery and especially being highly myopic. Fortunately, Dr. Keller was able to see me the next morning, and after a dilation, he confirmed his suspicion of a posterior vitreous detachment (PVD) in the right eye. These are actually quite common, especially as we age ... and fortunately, I don't have a retinal tear or detachment as these require surgery. Earlier that day, I had a pretty good (accidental) collision while playing Ultimate Frisbee, and getting bumped can cause a PVD.
There is no real treatment for PVD - it eventually heals itself and most symptoms (including hopefully the floater) will go away. Dr. Keller said keep an eye out (pun intended) for an increase in floaters (especially black or red ones), flashes of lights, and the before-mentioned curtain ... as in the short-term, my chance of a retinal tear/detachment increases. However, over the long-term, he said it actually does down after PVD.
Happened to noticed that the Skeptics Guide to the Universe did a podcast that talked about my UV vision - here's an excerpt just about that.
|Eye Surgeon Pre-Op||280.00||85.04||194.96||154.96||40.00|
|Eye Surgeon #1||2,240.00||1,322.25||917.75||534.20||383.55|
|Eye Surgeon #2||2,240.00||1,322.25||917.75||734.20||183.55|
|Crystalens Premium x2||1,800.00||0||0||0||1,800.00|
|Eye Surgeon Premium x2||1,900.00||0||0||0||1,900.00|
|Pre/Post-op Eye Drops||181.83||0||0||126.83||55.00|
|Date||OD - Right Eye||OS - Left Eye||Best Corrected Visual Acuity/Comments|
|Pre-Op||20-50w/-7.75-1.00x155||20-15w/-7.25-1.00@012||Pre-op numbers are BCVA - needed +2 for reading|
|+2 Week||20-15-/30/50-/J5-||20-15-/30/50/J5||OD:20-15+w/+0.50-0.75@145||OS:Not tested|