Try to mace an family tree if there is someone who has similar disease in familly and if it is positive send him to analyse geneticist to resolvethe genetics of  maculopathy .

Sy

Vida

Sir,

I have few suggestions and few queries:-) 

1. Can you provide K-readings also?  We can go for AK to reduce corneal part of astigmatism.

2. Sometimes early central PCO decreases near vision first as pupil constricts while viewing at near distance. So if PCO is there, we can go for YAG Cap.

3. Is NEAR VISION not improving with higher addition too?

I agree with questiones of Dr. Patel,besides it will be useful to view keratotopography - may be limbal relaxing incisions.

Dear all,

I agree to what has been said and the steps of checking PCO and higher addition first. Also, if the VA for far is so different from near, I don't think macula is the reason (but I agree it might nor be normal). One of the things that you can do is check the endothelium to see if further intraocular surgeries are possible. If not try corneal incisions. If yes, and the age allows, consider anterior chamber lens to correct astigmatism.

Regards

Try cycloplegic retinoscopy.  You might have a latent hyperope.

But Madam,

It's pseudophakic patient. So there will not be any added advantage of cycloplegic refraction.

Does the patient remember the diopters he had on the glasses before surgery? Also what is the status of the posterior capsule?

Hello Everybody

I liked your comments. I can add some points:

1. you need to know the K readings, either from topography or pentacam

2. you should do a dilated exam to assess the position of the IOL (is there a subluxation? is one of the haptics in the bag and the other one in the sulcus? is there some zonulolysis and in-the- bag decentration of the IOL? and also check for PCO)

3. If any of the above mentioned IOL-related issues is present, you then check for endothelial cell count (specular microscopy) and if the patient general condition allows go for IOL exchange or repositioning.

4. If you find nothing wrong with the  IOL (centered, in-the-bag IOL with clear posterior capsule), then we have a corneal astigmatism to deal with. in this case surface ablation does not seem to help. one approach which I have experience with especially in patients who have undergone ECCE many years ago and now present with high against the rule astigmatism (as in your case) is to make large full thickness limbal incisions on steep meridian (LRI does not work here because you have 7 D of cylinder) and then close the incision with tighter than usual interrupted sutures. after 2 months you can start removing the sutures based on corneal topography. make sure to repeat the topography each time you want to remove a suture. and the most important thing is to leave patient with some with rule astigmatism (not to neutralize whole cylinder), because over years there is a trend to shift toward with the rule astigmatism in patients who undergo ECCE.

5. The macular OCT shows a thickening on top of the ILM, which is possibly an ERM (epiretinal membrane) and does not explain the discrepancy between far and near vision.

Very high astigmatism can actually change at near fixation. I suggest you do cross-cyl with a near target. With that amount of astigmatism even a small change in axis will have an effect.

How was the vision of the patient after the op? If it was good and has deteriorated recently, there is something new. Otherwise, it is just corneal or lenticular astigmatism (which need K-readings and the need to rule out a tilted IOL). The problem with near vision could be related to his high plus requirements in LE. Is there a faint pigment epithelial detachment (PED) ? That could cause problems with near vision but probably not as much from such a small lesion. An LRI might work by reducing the astigmatism to acceptable levels. I have done for a patient with nearly 9D, which came down to 2D after LRI and was acceptable to the patient.