Long starburst/circles of light/vitreous gel clumps after cataract surgery and YAG laser

So I saw another post about complications after YAG laser one user was having and I guess I wanted to expand on my issues I am having also.  I am 50 years old and had my cataract surgery one year ago (toric lenses), since then I have been through some horrible stuff.  I had Macular Edema in both eyes a short while after my cataract surgeries, but this seems to have cleared up according to my retinal scans and multiple examinations.  Once my Macular Edema cleared up in both eyes I had the YAG laser to clear up my posterior capsular opacification.  The next morning after my YAG laser, I woke up and I knew something was terrible wrong, In dim light (even indoors with fluorescent lighting), I could see a fuzzy halo around lights and starbursts too.  At night time when I am driving, every light ranging from headlights to traffic lights....any light at night, I can see long stretched out spiky starbursts.  The brighter the light (like those super bright headlights you see in newer cars), the longer and stretchy the starburst will be.  Every once in a while the starburst will also have a rainbow effect to it that is inside the starburst itself.  I am also seeing bright oddly shaped circle lights every morning right now like when I had my macular edema, when I went to my doctor he did another retinal scan of my eyes but it showed no macular edema.  My vitreous gel seems to be a mess also, I can live with floaters, but now it seems like the vitreous gel is clumping together or something, and when I look to the left or right or up and down I see like something hazy and sweeping going the opposite way that I am looking.  I asked if my lenses got pitted or damaged or something during my YAG laser treatment but my doctor said no.  My doctor had some "copy and paste" explanation for everything (like basically well...just live with it), so I went to see a second doctor (at my HMO hospital), and after her examination she basically said the same thing "well you're seeing 20/20 with glasses" along with her "copy and paste" explanations as well.  Not happy with her responses, I asked politely to be referred to the retinal surgeon...she didn't like it that much, and after that her demeanor changed for the worse.  So moving forward...I've been researching  Dr. Google (doctors hate when I do this, lol), I was thinking that maybe they should widen the YAG treatment area more (maybe it will clear up  the starbursts cause I have large pupils), and maybe I should get a vitrectomy (for my clumpy vitreous gel or whatever else it might be that is possibly pulling at my retina causing the circles of light in the morning right when I wake)?  I see the retinal surgeon later this month, is there any suggestions you guys might give me that I might bring to the table when I see him?  I feel like I am going blind or something.  Thank you. 

Original Post

Sorry to hear about your problems.

I had Macular Edema in both eyes a short while after my cataract surgeries, but this seems to have cleared up according to my retinal scans and multiple examinations.

That's interesting. I rarely see post-IOL macular edema these days and that would be limited to patients whose maculas are already compromised, yet you experienced this in both eyes.

Once my Macular Edema cleared up in both eyes I had the YAG laser to clear up my posterior capsular opacification.

It usually takes years before posterior capsule opacification occurs. How long after your surgery did you have YAGs done?

The next morning after my YAG laser, I woke up and I knew something was terrible wrong, In dim light (even indoors with fluorescent lighting), I could see a fuzzy halo around lights and starbursts too.  At night time when I am driving, every light ranging from headlights to traffic lights....any light at night, I can see long stretched out spiky starbursts.  The brighter the light (like those super bright headlights you see in newer cars), the longer and stretchy the starburst will be.  Every once in a while the starburst will also have a rainbow effect to it that is inside the starburst itself.  I am also seeing bright oddly shaped circle lights every morning right now like when I had my macular edema, when I went to my doctor he did another retinal scan of my eyes but it showed no macular edema.

I've been in practice for years and this too is highly unusual. The day after YAG, after the eye is no longer dilated, patients normally see a definite improvement. You say "the next morning after YAG laser" ... I am assuming this is in one eye only and that both YAGs were not performed on the say day?

My vitreous gel seems to be a mess also, I can live with floaters, but now it seems like the vitreous gel is clumping together or something, and when I look to the left or right or up and down I see like something hazy and sweeping going the opposite way that I am looking.

Remnants of the capsule could be floating near your visual axis, just in front of the vitreous gel. Over time the capsular remnant should drop inferiorly and any visual effect should dissipate. Your doctor should be able to see this on his/her examination.

I was thinking that maybe they should widen the YAG treatment area more (maybe it will clear up  the starbursts cause I have large pupils), ...

Capsulotomies are normally large enough (and certainly easy enough).  The only time I have seen YAGs that were too small was on patients with extremely thick capsules, certainly not for someone who had IOL surgery just a year ago.

... and maybe I should get a vitrectomy (for my clumpy vitreous gel or whatever else it might be that is possibly pulling at my retina ...

This is not something that would create your present visual experiences.

... causing the circles of light in the morning right when I wake)?

Circles of light in the morning when you wake?

This is not suggestive of any retinal issue. It is, however, suggestive of a corneal problem, particularly the posterior (endothelial) surface. I have an idea this has been the issue all along. Ask your surgeon where you could get a Pentacam or Orbscan done.

I see the retinal surgeon later this month, is there any suggestions you guys might give me that I might bring to the table when I see him?  I feel like I am going blind or something.  Thank you.

Better yet. Tell the retinal specialist that your "online consultant" (I know, they hate that.) suggested looking at the posterior cornea.

Hi Dr DavOD Hartzok:  My first doctor stated I needed the YAG for "Small central posterior capsular plaque unable to be removed during surgery". Then for my second opinion doctor she noted "central PCO, PCIOL for both eyes" so I'm a little confused if the "plaque" is the same thing or not as PCO? I had cystoid macular edema in my right eye first a few months after my lens implant, then my left eye a few months after my cataract surgery/toric lens implant, so we had to wait for these to clear up with the: Prednisolone Acetate 1% one drop 4 times daily RIGHT EYE and Ketorolac 0.5% one drop 4 times daily RIGHT EYE before I could do the YAG.  The YAG was done on both eyes at the same time, and it didn't help that the doctor was literally running to the other room to fire up the YAG laser since it was closing time. I can only hope the procedure wasn't compromised due to this. And it seems that as soon as I stopped my steroid eye drops that cleared up my edema that I got those bright circles back again in the first 5-10 minutes of waking up (and sometimes see a small faint fast blinking light almost like a strobe light).  One other thing I wanted to mention is that I had Lasik done 20 years ago with a re-touch a few months after that (to try and get closer to 20/20) so I'm not sure if this has anything to do with all my complications.  Thank you for your feedback doctor, and I will surely mention for the retinal surgeon to check the posterior cornea and also ask about the Pentacam or Orbscan. 

 

 

My first doctor stated I needed the YAG for "Small central posterior capsular plaque unable to be removed during surgery". Then for my second opinion doctor she noted "central PCO, PCIOL for both eyes" so I'm a little confused if the "plaque" is the same thing or not as PCO?

You probably had posterior subcapsular cataracts which, after removal, may leave a trace of obscuration. (I've not heard the term plaque used for this.) In these cases the posterior capsule is not clear and, unlike most situations that require YAG where the capsular clouding can take months and years to develop, in these instances the YAG is often done within a month or so following surgery.

I had cystoid macular edema in my right eye first a few months after my lens implant, then my left eye a few months after my cataract surgery/toric lens implant, so we had to wait for these to clear up with the: Prednisolone Acetate 1% one drop 4 times daily RIGHT EYE and Ketorolac 0.5% one drop 4 times daily RIGHT EYE before I could do the YAG.  The YAG was done on both eyes at the same time, and it didn't help that the doctor was literally running to the other room to fire up the YAG laser since it was closing time. I can only hope the procedure wasn't compromised due to this.

It's pretty hard to mess up a YAG on the posterior capsule so I wouldn't suspect an issue there. Certainly the cystoid macular edema would blur your eyes. The problem in that situation is how much the CME was blurring your vision versus the capsular clouding.

The reason for my concern for the posterior cornea is because you noticed blurring particularly upon waking.

One other thing I wanted to mention is that I had Lasik done 20 years ago with a re-touch a few months after that (to try and get closer to 20/20) so I'm not sure if this has anything to do with all my complications.

The LASIK does perhaps alter the picture here. Since you were on steroids (prednisone) in each eye for several months following your surgery, you might have had a rise in your intraocular pressure. (This would have subsided after you discontinued the drops.) Certainly the retina specialist would have checked your pressures. However, because of your prior LASIK, eye pressures reads artificially LOW. Consequently, any rise in pressure may have gone unnoticed. If, by chance, you are experiencing a rise in pressure as a natural development (i.e., glaucoma) typically pressures run higher in the morning. Because of your thinned corneas, that pressure rise can alter that curvature of your cornea, throw off your prescription and blur your vision in the morning. (This is not conjecture. I have cases where LASIK patients who develop glaucoma experiencing these problems.)

Going back to your original post ... The next morning after my YAG laser, I woke up and I knew something was terrible wrong, In dim light (even indoors with fluorescent lighting), I could see a fuzzy halo around lights and starbursts too.  At night time when I am driving, every light ranging from headlights to traffic lights....any light at night, I can see long stretched out spiky starbursts.  The brighter the light (like those super bright headlights you see in newer cars), the longer and stretchy the starburst will be.  Every once in a while the starburst will also have a rainbow effect to it that is inside the starburst itself.  I am also seeing bright oddly shaped circle lights every morning right now like when I had my macular edema, when I went to my doctor he did another retinal scan of my eyes but it showed no macular edema.

With all that you have gone through it's challenging to pick through it all and arrive at a solid diagnosis. The best you can do is remove as many variables as you can. You cataracts are gone. The posterior capsules have been YAG'd. Your CME is under control. What's left is ... cornea.

As I said above, it would be good to scan the posterior cornea (endothelium) but I would also suggest serial refractions and keratometry (corneal curvature) readings (at varying times during the day) to see if your vision is subject to fluctuations. This should be coupled with pressure readings to see if any fluctuations can be correlated to pressure changes.

And if this isn't complicated enough, you also mentioned having large pupils. The halos and glare, etc. that can negatively impact patients following corneal refractive surgery is certainly worse for patients with large pupils. Even if these were not an issue for you following LASIK, it may be now. Cataract surgery always INCREASES the anterior chamber depth, moving the pupil posteriorly, which mimics the effect of having an even larger pupil diameter. (I've run the calculations and the effective surface area of the pupil can increase as much as 25% following cataract surgery.) So some of your frustration can simply be a (mechanical) consequence of the combined cataract surgery and LASIK. This effect, of course, would be more noticeable in low light conditions. (This particular consequence has never been given its due in the literature but it's a simple deduction and calculation. Fortunately for most patients the effect is minimal but it all depends on each particular patient's parameters.)

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