Cataracts - op to be done for close work or distance - advice please.

Sorry for all the typos but u think you can understand me

In re reading what I sent u, I made a few typos.  I wrote t h e i r, when I should have written t h e r e.  And some other types too. I'm  a pretty educated person.  Those were just typos.  I hope u make the right choice for yourself and i hope it works out for you.

One comment I'd make based on your posts above is that  unless you have other eye health issues, after cataract surgery your vision should be able to be corrected to see well at whatever distance you choose. That means that if you don't have enough near vision without glasses, that a magnifying mirror should work, the question is merely how much magnification you need. 

I would suggest that a contact lens test is worth trying if possible, even if it is only for a day or so to get some idea, or even just for a few minutes in the office.  The issue is mainly whether cataracts have degraded your vision too much for contact lenses to give a good sense of what your vision would be like, which is likely the real problem. The contact lenses can set your eyes to about the same distance they would be after surgery, but the quality of vision won't be as good due to the cataracts. You also wouldn't get a good idea of how much nearer vision you'd have from that distance, depending on how much presbyopia you have now. 

You mention Moorfields, which might mean you    are getting the surgery done via NHS.  If so then as far as I'm aware  the only choice is monofocal lenses and not the accommodating lenses posted about above (I'm in the US but as far as I know the UK is like the US where government plans, and insurance, only cover the basic monofocal lens).  If however you are getting private treatment at Moorfields (they have a private clinic as well as NHS) then in addition to the accommodating lenses they also have multifocal lenses which give you a broader range of vision, like the Zeiss AT Lisa trifocal. Most people have great experiences with the lenses, but there is a greater risk of visual side effects with multifocal lenses, such as seeing halos at night from headlights and othr lights, but only a small fraction of patients find that to be a problem. There is also a  new lens called the Symfony which gives a wider range of good vision than the monofocal with risks of halos comparable to a monofocal, so overall if you are willing to spent he extra money it is a good bet since it improves the range of vision without much risk of any added problems.

In my case I went to Europe to have cataract surgery and get the Symfony lenses (since they aren't yet approved in the US, but are over there) and I have almost 20/15 distance vision,  and 20/25 near vision (so I'm guessing 20/20 at intermediate). I can read the small print on my eyedrop bottles, and use my smartphone  without trouble, though everyone's results differ.  If you chose to have the lenses set for intermediate  vision rather than distance you'd likely have very good near vision.  I'm a typical male who has no idea about what sort of vision would be required for makeup  unfortunately, I'd guess a cheap magnifying mirror might be required. Any of the types of premium lenses (accommodating, multifocal, or "extended depth of focus" like the Symfony) give you a wider range of vision than the monfocals, meaning even if you set them for intermediate you'll have better near than you would with a monofocal (or you could set them for a bit further out intermediate). 

wow, finally someone who got one of the newer options out there.  Where did you go to have the Symfony put in for you?  Do you know when it will be avaialable in U.S.?  Who do you go to if you have a problem since your doctor is overseas?  I heard multi focal had problems with halos, contrast, low lighting since it splits the light, and contrast. The symfony is suppposed to solve all that.  What is your experience?  trying to decide if i want to get distance / intermediate monovision or wait a bit and see if the next generaltion multi focals get approved in U,.S. like the symfony, 

thanks

The US is unfortunately a few years at least behind the EU and elsewhere, and in fact some companies don't seem to even bother applying for approval in the US for new lenses. I haven't heard anything for instance about the major EU trifocals, the AT Lisa Tri and the Finevision, even attempting to get US approval. Fortunately the Symfony is made by an American company AMO and the Tecnis family of IOLs is widely used in the US and so I've read they recently submitted data to the FDA for approval. The Symfony is consired to be in a new class of IOLs, "extended depth of focus" so I'd read they have been coming up with guidelines for how to evaluate such lenses for approval. So unfortunately how long approval will take is hard to guess, it takes a long time for even product categories they already have setup, so  I don't know if it'll be 6 or 12 or 18 months, I've seen different guesses.  I know Alcon has had a trifocal recently approved in the EU, the Panoptix, and since they are also a major US supplier of IOLs perhaps they will be seeking approval for that as well, though I've no idea the timeline. I've also seen absolutely no data or studies on the Panoptix, which is odd, though its likely similar to the existing trifocals.

 

After I got the Symfony, the US approved some low add bifocals earlier this eyar  which seem like a fairly decent option for those who need surgery soon in the US.  They will still split the light which reduces contrast sensitivity. I don't know if you'd tried multifocal contact lenses since those have the same issue. I never found it to be a problem with multifocal contacts when I wore them,  but with the Symfony I have noticeably better low light vision than I had with the multifocal contacts (a restaurant I have a weekly meeting in has lower light and I'm so familiar with it that I immediately noticed  the difference looking at the menu, and the room and people).  If the low add bifocals were available in the US at the time I might have considered going for those rather than traveling, but the Symfony still seems a better bet. 

Someone I know about the same age here had the Crystalens implants, and oddly even though those are a single focus lens, he notices a drop off in near vision with lower light. I met him after a lecture in a well lit auditorum and he had a near reading chart, and even holding a folder over the chart to cast a shadow was enough for his near vision to be reduced, but it didn't make a difference for mine. I don't know for sure how much is optics of the IOL vs. personal variation in our eyes. 

The optics of a multifocal contact lens aren't exactly the same as multifocal  IOLs (likely not as good as an IOL meant to last decades and not move as much), but they are still a good test case I think to get some idea. The fact that I preferred multifocal contacts to monovision contacts was one reason I was interested from the start in a premium IOL.  For instance even though I'd not noticed a reduction in stereopsis, 3D vision, when wearing contacts in monovision a few years, when I switched to multifocals I was suddenly aware of what I'd been missing, near objects did seem more 3D.

The Symfony has recently been approved in Canada, which isn't as far to go (although it may be comparable to US prices). I don't know if the trifocals are available in Canada, but I know the AT Lisa tri is available in Mexico in clinics that seem to be likely US quality treatment that are located just over the border from San Diego (at least one mentions they will transport people from hotels on the US side of the border to the clinic) to take advantage of the differing approval policies.  I hadn't evaluated clinics in either country since they didn't have the Symfony a year ago.

 I had decided to go to Europe to get a better lens, and then discovered the UK was somewhat expensive and that there is a medical toursim industry elsewhere in Europe to take advantage of that, with the Czech Republic a common destination for high quality treatment at lower prices. I figured that as long as I was traveling, if I could get high quality treatment I may as well go for a lower priced country. I was only 52 when I had the surgery so I figured it was worth some hassle to get a better lens since I may be living with it a few decades, and since I'd been highly myopic all my life I liked the idea of not needing correction anymore. 

Most doctors here didn't have any trouble with the idea of doing followup visits (though ask around, a minority seem to dislike following up other people's patients), there is nothing medically different about the Symfony compared to other IOLs, the optics are just different. It is the same overall physical shape and material as the widely used Tecnis lenses in the US.  Also, after I had my surgery there have been Symfony trials in the US so some US surgeons do already have experience with it. I think the trials are over since they have submitted data to the FDA (if there are   any trials ongoing for the Symfony in the US,  it may not be a good option since at least the initial one I heard of was  randomized, a 50-50 chance you'd get a monofocal).

 Since I spent a great deal of time on the computer (as my username was meant to indicate re: my visual needs), intermediate distance is important and when I had my surgery done a year ago the only bifocals available in the US were high adds that weren't as good for intermediate vision, and in a small fraction of  patients the Crystalens doesn't provide anything more than a monofocal (and has some risk of complications other lenses don't have, like z-syndrome, though the newest version seems to be better). I'd had good luck with multifocal contacts so I wasn't worried about going for a multifocal, so initially I'd expected to go outside the US for a trifocal lens to get better intermediate. Then the Symfony came out, which has better intermediate vision than the trifocals, but not as good really near. I figured that was an ok tradeoff to make since it also has contrast sensitivity comparable to a good monofocal and lower risk of problematic halos, comparable to a monofocal (some folks see halos even with a monofocal).

 I turned out to be in the minority of patients who do see halos with the Symfony, but they are translucent, I see through/past them, so I don't find them to be a problem. Overall  as far as I can tell my night vision is better than it was before I had a problem cataract, less glare from headlghts for instance, which makes up for halos from headlights. I'm not sure if being atypically young to get lens replacement made seeing halos more likely with any lens. 

Intermediate vision was important to me since aside from computer distance, it includes most social distance and household tasks, TV, etc. I also realized after the fact that since I hike&run on trails around here that its useful to have crisp intermediate vision since that is what you are using to pick out your footing amidst rocks and avoid icy patches during the winter (even just for normal walking around outside during the winter its good to be able to spot ice of course, unless you live in a warmer area).  I think  the trifocals would still have been good enough for that, even if their intermediate isn't quite as good,  I can't picture how much difference it would have made.

Wow, thank you so much for that detailed explanation.  So you had your procedure done in Czech Republic?  Yes Canada would be closest for me since I live in U.S. (Florida).  I was going to get my procedure done this year since I had met my insurance deductible this year, but I thought that should not be the main reason to get it done.  I've been told I had cataracts for about 5 years now, and, while it gets a little worse each year, still not so bad that it interferes really with my lifestyle.  But I know I have to get it done eventually.  I was quite excited when I read your post.  My doctor recommended a monofocal because he did not think I would be a good candidate for multi focal since he thought I would not be happy with the side effects and also that it doesn't work all that well, considering that it splits the light and has low light issues and the halos and loss of contrast.  I wanted the best possible vision with glasses and you cannot correct for loss of contrast.  Then I read your post and I though wow, symfony iol's .  That sound like it would be perfect for me.  Seems like all the advantages of the multifocal without any of the disadvantages.  I was mostly concerned with loss of contrast and halos so bad that i might have to go thru the ordeal of changing lenses.  I am extremely sensitive to things touching my eye. I put in drops by closing my eye and blinking them in.  But they told me I would be almost out during surgery lightly out, and so I am ok with that.  So, as I understand it, the symfony gives you all the ranges, although maybe might need glasses for pefect near.  But I should be able to see near enough to read a letter or text on my phone?  But I will have really good distance and intermediate?  To me, that means I will not have to wear glasses anymore?  AND much less chance of halos, and even if i get halos they will be much less severe than with today's multi focal.  Also, based on your post, I have been reading up on it.  They expect approval in U.S. by end of 2016 or beginning of 2017.  The way it transitions from distance to intermediate to near is different too.  Much more natural than with a multi focal.  Seamless they say.  So you have them so it seems you would be a good person to ask.  I can live with not so perfect near as a trade off for no low light problems and no contrast problems and less severe halos, if any.   Are you happy with your choice?  Can you read near, even if not perfectly, but well enough that if you had to read a note or something for a few seconds you wouldn't have to search around for your glasses to read it?  Is you distance and intermediate (computer) nice and sharp?  Any other issues?  Based upon your post I have decided to forego my surgery this year and either go to Canada or wait until 2017 to get symfony put in in the U.S.  Seems to me like the best of all worlds.  Do you agree?  I just hate the idea of a monofocal where I only see at one focal length.  If I get intermediate, then cannot see near or distance and I tried two distance contacts to experiment the simulation and it was like being blind up close.  could not read the caller id on my phone.  And monovision with one eye distance and one intermediate is a little strange. Seems like symfony is the way to go for me.  Even better than tri focals because it does not split the light like trifocals or even bifocals and you don't have the same halo problem or loss of contrast and it transitions between the distances more naturally.  So you are wearing them. Are they as good as I am envisioning them to be??  thank.

Yup, I went to the Czech Republic from Boulder, Colorado for my surgery.  I can read the text on my smartphone with no trouble (4.7" screen), in the web browser with a newspaper with 2 columns I'll usually zoom in on one column to read it more comfortably, but can make it out without zoooming.   I've no trouble at all with maps or email on the phone. If you aim for micro or mini monovision you can get a bit more near without a noticeable loss of stereopsis. I think the stat is that perhaps 20% need reading glasses with the Symfony set for distance, I suspect few do if they do micro or mini monovision. 

I may do micro-monovision eventually via lasik. Unfortunately I wound up with one eye plano, but the other perhaps +0.5D hyperopic which reduces its near vision, so I may bring that in to -0.5D someday to give me a bit more near (I haven't noticed a great need for it, but it just seems a waste to have the eye hyperopic). So actually the near vision to read my  smartphone is mostly coming from one eye due to the other eye being a bit hyperopic. Unfortunately there isn't an exact formula to determine the lens power, it is based on statistics of past operations, and usually for most people its accurate but for high myopes for various reasons it can be off a bit and it was in my case for that eye.

Distance vision is comparable to a good monofocal, mine was almost 20/15  a week after surgery and is probably at least that now since subjectively it seems like  it  improved a bit during the first few months as I adapted to it. I'd always been highly myopic, but even with contact lenses I can't recall my distance vision ever being corrected as  crisply as it is now with the Symfony. I don't know whether some of that might be because of the extended depth of focus which means more things are in focus at once, whereas before surgery the eye would be accomodating to change focus to see objects at different distances.  Even a year later when out hiking  I'm still constantly appreciating how good my distance vision is (and intermediate, rocks on the trail   being in crisp 3D). 

Yup, the way it transitions from intermediate to near is more natural than a multifocal since there aren't 2 or 3 different peaks of visual acuity. Just  like with presbyopia,  the further out you hold something the crisper the focus  is but the smaller it is. There is no hunting for a "sweet spot" the way there might be in theory  with 2 different focal points.  That said, with multifocal contacts I don't recall ever consciously thinking about  the hunt for the "sweet spot". To me the Symfony feels like vision just when presbyopia started to become noticeable but where I didn't really need glasses aside from things like threading a needle, perhaps vision like in my early to mid 40s. I don't notice that I need to hold objects out further to see them or anything, I hold my smartphone at a natural distance. It is only say reading the fine print on an eyedrop bottle for instance where I had to hunt for a good distance to be able to read it.  I think I made the right choice of lens for my case. I do sometimes wonder what the added near of  a trifocal would be like, but I think the crisp intermediate vision and better low light vision, etc, is worth the tradeoff.  I'd guess my intermediate is  20/20 or 20/15, I hadn't measured it but its in between distance and near in quality.

You'll see comments from many US surgeons who are optimistic about the Symfony, one recent video I saw interviewing a US surgeon who is an expert at a conference on treatments for presbyopia asked what he would do if he had to get cataract surgery this week, and he said he'd likely go  have one of his European colleagues implant the Symfony.  

There is another "extended depth of focus"/possibly-accomodating lens that is approved in Europe, the WIOL-CF, but there isn't much data out there on it yet so I'm not sure its an improvement over the Symfony, it seems perhaps comparable. It sounds like the manufacturer is doing some more trials and refinement before trying to widely commercialize it, which suggests some caution. One reason for that I suspect is that it doesn't have haptics like most lenses (the arms that stick out to hold the lens in place) and instead relies on filling the capsular bag to stay in place. One surgeon commented via email that he is concerned that the lens wouldn't be as stable for that reason, and there is one article talking about a couple of cases of disolated WIOL-CF lenses, though I don't know what the statistics are to know if it is really an issue.

There are some next generation accommodating lenses in early clinical trials around the world, but  it'll be a while before they are even approved in Europe and due to the issue of them needing to move (and to continue to do so for decades) it may be a technology to be cautious about when it first comes out. The Symfony is the same material and shape as the rest of the widely used Tecnis family of lenses. The only new technology in the Symfony is the design of the  optics and that isn't something that requires movement so there is no issue of how well it survives wear like there is with an accommodating lens. Optics are  something they could easily study on optical benches outside the eye, and model on computers,  to be sure they got it right. 

I know what monovision is but I don't know what micro, or mini, monovision is.  Are you saying to get the symfony set one eye for intermedate and the other for near?  I want to get one, or both, set for distance because I would like to not have to wear glasses anymore.  If I understood you correctly, you can see 20 /15 distance, 20/20 intermediate and 20/25 near.  I would be very satisfied if I achieved the same..  You are looking back and wondering if you could have done something else to give you a bit better near but if you can read the back of a pill  bottle without glasses, how much better does it have to be than that?  You said you wound up with one eye "plano".  What does "plano" mean?  Don't know what hyperoptic means either.  Wow, didn't realize there was so much I didn't know. 

It seems like the symfony is the one for me and, if I understood you correctly, if you had it to do all over again you would have gotten the same symfony lenses put in as what you had and that you have no regrets and are happy with your decision.  The press i read on it says that it transitions better for all focal lengths, not just from intermediate to near, but from distance to intermediate too, and even from distance to near and  back again.  Of course I am not expecting it to be like when I was 20 but I started wearing glasses for near signtedness when I was around 15 so I've always worn glasses for as long as I can remember.  My reasons for wanting the symfony are many.  1.  better transitioning, 2  better low light  3  better contrast  4  doesn't move like accomodating so no wear and tear issues  5 can see all ranges of vision without glasses and 20 /25 for near is certainly acceptable for me.  6.  Don't have to wait years for approval since it seems approval for U.S. is around a year away before it is commercially available here.  7. the nice guy from softwaredev from the cataract forum got them and is very happy with his decision.

And how about halos and sensitivity to glare?  You mentioned you see them but it is a very minor inconvenience when compared to the severe halos and glare you can get from the standard multifocal IOL's our there today.  Also I heard that with the premium lenses you run a higher risk of secondary cataracts.  Have you had any issues with that?  And I assume of course that the haptics are a non issue to you, that you don't feel them and wouldn't even know they were even there unless you were told about it, right?  So the only thing that a tri focal would give me is maybe some better near vision and not wroth the trade off of all the other known issues with today's multifocals.   So I was thinking both eyes at distance, which is what you got, right?  When you are talking about minr or micro monovision, what exactly are you suggesting?  If you got both eyes with symfony for distance and wound up seeing now as you do, I would be very happy with that.  Would not want to sacrifice distance (and hence have to wear glasses to drive) just for a slightly better near.  thanks.

Mini and micro monovision are just small amounts of monovision, I don't know that there is a precise definition for how small each prefix is used for. The manufacturer's site for the Symfony (easy to find, this site sends posts with links to the moderator so I won't give the link) gives information on studies of the Symfony with a tiny amount of monovision. A tiny amount of difference is something people adapt to without thinking about it and which doesn't noticeably impact steropsis or contrast sensitivity. It also only has a minor impact on distance vision with both eyes. 

Hyperopic means far sighted, the opposite of nearsighted. That means that it takes 0.5D of the "depth of focus" merely to see distance, which means I have 0.5D less of near vision in that eye. That eye doesn't have any astigmatism.  Both my eyes were targeted for distance, so ideally that should have been 0D. In retrospect I should perhaps have gone for some tiny amount of monovision. Since that eye is farsighted, which isn't of any use, I might consider a laser tweak to make it slightly nearsighted instead for micro minovision. 

Plano means 0D, no spherical refractive error. I should add that eye has perhaps -0.5D of astigmatism which means it isn't perfectly corrected, but that isn't enough to notice, it might give a minuscule boost to near (since that is the "spherical equivalent" of -0.25D, but the fact that astigmatism adds blur may cancel that out).  

Yup, I think the Symfony was the right choice for me, and still would be. If I'd stayed in the US, perhaps the +2.75D Tecnis bifocal would have been my choice. Yup, as I said it won't give you the same degree of acccommodation, near vision, as you had when you were 20, perhaps more like early to mid forties. Your distance vision may be comparable or better though than when you were 20 due to the correction for chromatic abberation beyond what a natural lens has.

There are lots of articles and videos on the net about the lens now where you can see surgeon's comments, all of which tend to be positive. The only study I've seen that was a bit negative regarding its level of near vision was one where it showed the patients wound up even more farsighted than my one eye is, so it isn't surprising they lack near vision. 

Unfortunately things like halos vary with the person, and some people have problematic halos even with a monofocal lens, so you are merely playing the odds, and the odds are this is comparable to a monofocal. Back even before cataracts I still always was bothered by glare from headlights, and I seem to notice less glare from them with the Symfony, which may be part of why I don't find the halos to be a problem. The risk of "secondary cataract", PCO, has diminished over the years so its fairly low with any lens these days, and it has to do with the material&overall shape of the lens and its edges, and not its optics (the curve for the optics isn't the issue). The surgeon who did my last followup here said he would bet that the way I was healing I'd never have an issue with PCO. 

The haptics are a non-issue in terms of the patient perception, you don't feel them, they are merely what holds the lens in place. The Symfony has regular haptics, again it is the same shape as the other Tecnis IOLs like their monofocal and multifocals. It is the WIOL-CF that doesn't have haptics, instead relying on the lens being physically larger and almost filling the capsular bag to hold it into place as the bag heals around it. Some surgeons suggest that is a good approach, I've just heard from one who is skeptical of the idea (but has never implanted the lens) and saw a paper talking about cases of dislocated WIOL-CF IOLs. However I haven't seen any statistics, those cases may have been rare, and even lenses with regular haptics can be dislocated. I admit I'm curious about the WIOL-CF and how it would compare to the Symfony, they are fairly different designs. In retrospect it might have been better in my case since I have a rare side effect  of light flickering that has nothing to do with the lens choice (at least among lenses other than the WIOL-CF). Rare as in one out of tens of thousands perhaps or more, I never got any surgeon to give a guess. 

Highly myopic people usually have larger eye structures than average, including a larger natural lens. The IOL is physically the same size no matter what power it is, so for a minority of   highly myopic people when the natural lens is replaced by a smaller artificial lens, the iris can lose support and jiggle when the eye moves (not in any way that others notice, but I caught mine doing it on video from my phone). Usually that is harmless and never noticed, but in rare cases it seems to be responsible for a flickering side effect that I have. My iris is light colored, blue, but has darker striations, so when the iris moves the stray light coming in through it changes, which causes flickering when my eyes move a lot in order to read. It is headache inducing when trying to read for a long time, but my brain has been slowly learning to tune it out. In retrospect I wonder if the larger WIOL-CF lens would have supported the iris better, but its too rare an issue for others to consider when choosing a lens. That side effect is part of why I keep checking eye related forums and opthalmology news, in case any way to deal with it appears that the surgeons I've talked to hadn't come up with (they suggest that any possible treatments risk more harm than good and its best to see if my brain  will eventually tune it out completely). 

 

so then mini monovision would be something like one eye distance and one eye intermediate.  normal monovision would be one eye distance and one eye near and micro monovision would be one eye intermediate and one eye near?  Do I have it right now?  I am wondering what is it about the haptics that another company is trying to achieve the same optic result without the haptics.  If there is no downside to having them, then why? 

So you would have preferred a bit larger lens so as not to have any flicker or jiggle, but that is not available at this time.  Is it something I should bring up with my doctor whether I have a large, normal or small iris in comparison to the lens he would be inserting?  But other than this new WIOL-CF lens you mentioned, all of the IOL's are the same size, right, whether you got monofocal, multifocal, accomodating or symfony extended range, right? 

Anyway if you had it to do all over again wouldl you get the exact same distance symfony in both eyes or would you get one distance symfony and the second eye at a near or intermediate symfony too? 

For me, I don't see any emergency of having to do this immediately so if I have to wait a year for the symfony to be commercially available in the U.S it seems like it would be worth the wait.  I shied away from the multi focal since my doctor told me about all the side effects and didn't think I would be a good candidate since he considered me a "picky" person and I said to him that if I would be a little "picky" and dissatisfied with a not so perfect multi focal IOL, how unhappy do you think I would be not being able to see what time it is on my watch if I got two monofocal for distance?  To me, this is a decision I will likely live with for the rest of my life so if a better lens most of the benefits of a multi focal without the side effects is coming out in a year, why not wait and try to be able to achieve great vision without glasses. 

Do you wear glasses now or do you keep a pair handy for reading very close or other such tasks or are you completely glasses free.  Would a pair of glasses be able to tweak what you have now without glasses to make you see even better or are you pretty much max'd out with what you have now?

In my case the problem cataract first caused issues in only one eye, and even though it was bad enough that they'd operate,  since the other eye was still good I was able to  postpone surgery for around 2.5 years in hopes of a better lens given I may live with the results for decades.

Micro or Mini monovision merely refer to the size of the difference between the eyes compared to regular monovision where the difference is fairly large. In all cases one eye is set for distance, the issue is how far in the other eye is set. Micro is the least difference between the eyes, one eye set just a little bit in, e.g. perhaps -0.5D, mini a little more, say -1.25D, regular say -1.75D (though those numbers are just illustrating the issue, there is no strict definition for the dividing lines).

The WIOL-CF wasn't intentionally trying to get rid of haptics due to a problem with haptics, its intention is to be a larger lens that mimics the natural lens more closely. The side effect of making it larger is that they think it doesn't need haptics to stay in place, and that there isn't  room for them. I can't recall if there is a toric version of the lens, since that would present more of a challenge since toric lenses need to avoid rotation since they aren't symmetrical. 

The WIOL-CF is approved in Europe, but it is not being actively marketed or commercialized last I read since the company is instead focused on refining it and testing it more, which suggests caution before considering it. At the time I got my surgery there wasn't much information out about it so it didn't seem worth the risk, and I had no clue I'd wind up with a rare side effect that in hindsight might perhaps have been alleviated by using that lens, but even that possibility is pure speculation. I haven't seen enough data from the WIOL-CF to get a good sense for how it compares to the Symfony in terms of visual quality, so far I'd consider the Symfony a safer bet. It is just an option to keep an eye on if someone is waiting another several months. 

Other than the WIOL-CF, other IOLs tend to be approximately the same size, with perhaps only slight differences between brands/models that aren't as big a deal as the difference with the WIOL-CF. 

Out of the options available, if I were doing the surgery today, the Symfony would have been my choice still (given that I wouldn't have known about my rare issue that appeared after surgery and  shouldn't be a factor for others). Based on my experience, I'd have targeted one eye for distnace, but targeted the other for -0.5D, especially knowing that in highly myopic people the lens power can wind up being off slightly  (I don't know if you are highly myopic to the degree that is an issue).  The Symfony results suggest that the average patient still has a bit better than 20/20 distance vision even with -0.5D of micro-monovision. The Symfony manufacturer's give the results of one study on their site showing the results for different levels of micro-monovision. I guess I was playing it safe initiallly targeting both eyes for distance though, its perhaps simply because I see the results I got that I'm thinking after the fact that micro-monovision might work well, though I'll try it in contact lenses. Some surgeons offer a package deal where when you get a premium lens, if the power is off then after surgery they include the cost of doing a laser enhancement to adjust your eyes to hit the target. 

Wearing reading glasses can improve near vision with the Symfony, or monofocals, or an accommodating lens. It will also improve near vision with a multifocal, though of course it moves all the focal points in so it may be trickier to find the "sweet spot".

For visual acuity purposes, the only time I've felt a need to wear glasses so far  is for threading a needle. I never have any with me when I leave the house, I don't need them for phone, watch, shopping, etc.  I mentioned the rare side effect of light flickering which is problematic when reading (due to the constant rapid eye movements leading to jiggling), and so even though I don't need glasses to see the computer clearly, wearing them seems to cut down on the flickering side effect so if I am on the computer for more than a few moments I tend to wear glasses to cut down the flickering. If I didn't have that rare side effect, I wouldn't use glasses for the computer or  reading. It is still slowly improving so I'm hoping the flickering will eventually go away and I won't bother wearing glasses at al.

 However results do vary by person, studies just show average results, so there is a chance you'd need reading glasses with both eye's set for distance. Using a slight bit of monovision would make it less likely you'd ever need glasses for any reading, but would reduce distance vision a bit, so it depends on your priorities and which visual range you'd risk giving up a little on. 

The side effect I have is so rare and unpredictable there isn't really anything to ask the doctor about since they wouldn't have a clue beforehand, and most surgeons never encounter it.  Iridodonesis, iris jiggling, is a rare risk for those who are highly myopic, but even those who have the issue are never aware of it since its innocuous. Among those rare few who do have issues from it, it seems mostly those with light colored eyes, and many see it go away quickly. Mine is an unsual case. Often those on forums like this are atypical patients and have encountered things the vast majority never need to worry about. 

Thanks, I'll keep an eye on the WIOL-CF but all roads seem to point to the symfony for me.  As to mini or micro or no monovision, yes, as the name implies micro and mini refer to the degrees of difference between the two eyes to give you an overall broad of range.  Got it.  Thanks.  However, what is still confusing and unclear to me is your starting points.  I am doing a contact lens simulation experiment at this time and, although it is hindered by the fact that I am seeing thru cataracts, my contact lens doctor examined me and determined that for distance, I need a -2.50 in my left dominant eye and for intermediate that I needed -.75 in my right eye. And that if I wanted to simulate distance in left eye and near in my right eye, then I should just wear the -2.50 in my left eye and nothing at all in my right eye.  My cataract surgeon, on the other hand, who sent me to the contact lens doctor, thought I should be wearing -2.0 in my left eye to simulate distance in that eye.  In that case,, the difference between the two eyes would be -1.25, almost full monovision.  As it is, if I wear -2.5 in my left and -.75 in my right, I am at a difference of -1.75, which would be full monovision accoring to what you wrote me, and my right eye would not even be optimized for near yet, but only intermediate.  So when you say the difference should be only -50, are you saying that I should get my left eye for -2.5 and my right eye for -2.0?  OR if my eye surgeon is more correct than my contact lens doctor, -2.0 in my left and -1.5 in my right?  What would that gain for me since, according to my contact lens doctor, I would have to go all the way to a -.75 to experience even intermediate optimization in my right eye, forget about what over the top difference there would be between my two eyes if I wanted to try to simulate optimization for near in my right eye.  The person I buy my eye glasses from, who also sells contact lenses, told me I would need a +.50 in my right eye to simulate near vision in that eye, which would represent a whopping difference between my left (-2.5) contact lens and my right of 3.0!  I actually tried that and couldn't wait to take them out, too much of a difference! 

One of the reasons I am postponing my surgery, the main reason being I want the symfony, based upon everything I have read (and based in large part to your helpful comments from a patient who is actually wearing them) is because every doctor I speak with tells me something different.  Nobody takes the time it seems to really care if they get it right I am the one who will be wearing these things likely for the rest of my life!  With so much uncertainly, better of to wait for the symfony.  But what is confusing to me now is, whether my distance would be like wearing a -2.0 contact lens or a -2.5 contact lens, if I just got my left eye a micro monovision of -2.0 or even a -1.5, if intermediate is all the way to a -.75, how is having an IOL set to -2.0, or even -1.5, going to do anything at all to help my near vision?  And if it does nothing to enchance my near vision, which you tell me you have uncorrected 20/20 with both eyes set for distance, why would I give up any distance accuity and perhaps even a slight depth of field (the problem with monovisoin, at least for with monovision, is you lose your depth of field perception I have been told, not only just some sharpness) ?  Thanks.

Also have some dry eye issues.  More so in my left dominant eye.  I was told that could make me not a good candidate for multi focals.  but symfony is not a multi focal.  Hope I am still a candidate for the symfony and that my dry eye issues don't disqualify me.  It seems head and shoulders above all my other alternatives, especially monofocals.

btw, your prescription is rather low, low myopia, so it is likely the lens power formulas will work well for you and they will hit the right power without need for laser correction (though no guarntee). High myopia tends to be considered usually -6 and above (or based on the axial length measurement of the eye that they do before cataract surgery).  You are at much lower risk of any side effects than high myopes like I was.

I am guessing  your dry eye won't disqualify you, but I don't know for sure. I didn't have any issues with dry eyes before surgery  so I perhaps didn't pay attention, but I don't recall seeing much concern over dry eyes for patients considering multifocals, it tended to be mostly concern over more serious eye health issues or things like corneas that are too irregular from prior refractive surgery.

 I have read sugeons comments suggesting that they are likely to consider the Symfony even for patients who have some eye issues that make them not a candidate for multifocals, and that most patients are likely candidates for it. Even though it isn't a multifocal though, it does use a diffractive lens, and that complicated optics might potentially be an issue for some minority of patients, but I don't know what the limitations are. I suspect some doctors will be cautious at first until more study is done. 

The sign of the numbers being used can be a bit confusing when talking about this.  If someone uses a -5D lens usually for distance and they want to instead be focused in a bit near, say 1 diopter more myopic, targeting a focal point of  -1D (which puts the best focus at 1 meter) that would mean they'd use a -4D lens. 

In terms of monovision, the issue is how much the near eye is undercorrected for distance compared to what a perfect precription would be.  It isn't clear which of those numbers you give is your usual perfect distance prescription, so I'll use an example. Lets say person A usually wears contacts with -6D for the left dominant eye and -5D for the right   eye , both corrected for full distance. If they were going to have micro monovision of 0.5D they would undercorrect the right eye so it was left a little nearsighted, so they would use a lower power lens. They would use -6D for the left eye and -4.5D for the right. For monovision of 1D they would use -6D for the left and -4D for the right.  Of course if the person wanted monovision targeted at intermediate for the "distance" eye then both numbers would be altered, e.g. bring them both in by 1D to make it -5D for the left and -3D for the right to give 1D of monovision with one eye targete

 You don't mention what your usual distance prescription would be in contacts to guess at why they are giving different numbers. It  may be that one doctor is suggesting not to use full distance correction for the distance  eye, but to undercorrect it a bit to give you more intermediate and to lessen the difference between that and the nearer eye. People who are undercorrected for distance a little bit can still have 20/20 or 20/30 vision at distance and see well enough to drive. 

One problem with trying to simulate monovision prior to cataract surgery is that monovision with contacts is different from monovision with monofocal  IOLs if you are young enough to still have accommodation (e.g. being 52 when I had surgery I had presbyopia, but still some accommodation left),     For instance a 20 year old wearing a contact lens for distance will still have great near vision in that eye, but if they were given a monofocal IOL for distance they would of course not have much near vision.  To give a 20 year old the feel for what a monofocal IOL set for distance would be like, they would need to give them a contact lens that made them so farsighted that all of their accommodation would be used up just to be able to see well at distance, and they wouldn't be able to see well at near anymore. So for someone around 50 to give them a good sense of what a distance monofocal might be like, they might make them slightly farsighted in their far eye to reduce some of their remaining accommodation, say if there usual prescription were -5D for that eye they might give them say -6D or -7D to leave them a bit farsighted, which reduces their near. 

Actually my uncorrected near is around 20/25, which might be a bit better than average, but since that is tested at my "best near" I'm not sure. The average  uncorrected near with the Symfony set for distance in both eyes is closer to 20/30 according to the data on the Symfony site, with the average distance acuity a bit better than 20/16. With 1D of monovision the average near is almost 20/20 and the average distance is still almost 20/20.  

Here is why I am confused.  If I am told that to simulate distance in an IOL I would need -2.5 in my left eye, and -1.75 in my right eye, and if to simulate intermediate I would need -.75 in my right eye, never mind even trying to see near, how would moving my right eye from -1.75 to -1.25 make any difference to my ability to see near when -1.25 is still .5 away from the -.75 I am told I need to simulate even intermediate? 

So you are suggesting that if I get -2.5 in my left eye in a symfony lens, that I should consider a -2 in my right eye OR if I get a -2.0 in my left to consider a -1.5 in my right to have mini monovision and that that will somehow make my near vision better, even though the correction doesn't even come close to the -.75 I am told I need to even achieve optimal intermediate in a monofocal?  Of course I will pose the same questions to my doctor but I am asking you because the are already wearing the symfony lenses, both set for distance.

Going from -1.75 to -0.75 is undercorrecting your eye by 1 diopter, leaving it focused 1 diopter nearer. Focal distance in meters is (1/diopter_measurement) so that is focusing your eye at 1 meter. Moving your eye from -1.75D to -1.25D would be undercorrecting by 0.5D, focusing your eye at the -0.5D  which would focus your eye at (1 / 0.5D)= 2 meters.  

The difference for monovision is the difference between each eye's best focal point (not the prescription).  If one eye is focused for distance, 0D (whether it takes a -5 or -10 lens or whatever to do it), then for micro-monovision of 0.5D (a focus at 2 meters) your other eye would be corrected 0.5D less than the power to correct it for distance (e.g. if it takes -6 to focus that eye for full distance, it would instead be corrected -5.5D to have it focused best at 2 meters). 

The further in your best focus is for an eye, the more near vision you get. If your eye is focused best at 2 meters, it can see a bit closer in than that (due to "depth of focus" which lets you see some number of diopters closer in than your best focus), and you'd have more near than if it were focused at infiinite distance. If your eye is focused best at 1 meter then you'd have more near than if it were focused best at 2 meters. The amount of near vision you get depends on the depth of focus of the lens, but the closer in you move its best focus the more near you get.   Picture it like holding a rule in front of you pointing ahead where  ruler  is   the depth of focus, you move the farthest point of the ruler in or out, and the near point of the ruler moves in or out.  The Symfony has a larger "depth of focus", like a larger ruler,  so it already provides some decent near even when targeted at distance, so moving its best focus in a little bit helps your near. 

 Unfortunately the ruler isn't an exact analogy, since a 0.5 diopter difference is  a different meter difference  depending on whehter you are going from 0 to -0.5D or from -2D to -02.5D

Also I should note that these are using the sort of diopter measurements you'd use in contact lenses to achieve monovision. The actual IOL power would be a bit different (since it is replacing your natural lens, rather than adding a contact lens on top of it), though you don't really need to know those numbers . Even though you are myopic it would be a positive power, e.g. for example it might be  say +18D for distance and then for monovision it might be say +19D to correct your eye a bit closer in.  

Thanks.  To be clear, you got symfony iol's for distance in both your eyes.  You don't notice any loss of contrast (commonly a problem with multi focals) you don't notice any halos or glare (you mentioned you had "translucent" halos but that they are minor and you don't really notice them, also that this was something unique to you and that you don't think I would experience any at all- the website says you get halos and glare similar to a monofocal lens) You don't have any night vision problems or otherwise any low light issues (also a common problem with multi focals) and you sed 20 15 distance, 20 20 intermediate and 20 25 at near.  Do I have that all right now?   I know everyone's eye is different but you are the only person I know that actually is wearing these new lenses so, while I will certainly ask the surgeon I select these questions as well, hearing about your personal experience really helps.  

I will let me doctor explain to me more thoroughly what my options would be for micro or mini monovision.  Thanks.

I got Symfony lenses targeted for distance (though one eye hit the target and was plano, the other eye was slightly off at +0.5D, slightly farsighted, which slightly reduces near in that eye). I don't have issues with glare, I see less glare with headlights than I can remember having before I had cataracts. I do see halos from lights at night as you went on to mention, so it isn't that I don't notice them, they just aren't a problem since I see through/past them and my night vision in general is better than I recall it being even before catraracts and it balances that out.  It isn't "unique" to me that I see halos, merely that only a small percentage see them. 

In terms of halos I didn't say you "wouldn't experience any at all", I said the odds are low that you will (and if you do, low that you will consider them a problem). Even monofocals leave a minority of people with problematic halos,  so there are no guarantees. The risk of halos is merely comparable to a good monofocal like the Tecnis (I get the impression some monofocals may even have higher risk of halos). 

My low light vision like in a dimly lit restaurant is better than it was with multifocal contacts, and I don't notice a problem with it. It can't recall well enough what it was like with regular single focus contacts several years ago so I don't know if its as good as that, but it isn't a problem. Comparing low light vision to someone here about the same age who has the Crystalens, he seems to have a noticeable drop off with even slightly dimmed lighting (despite it being a single focus lens), which I don't have. 

The last test I had for distance I saw almost 20/15, I suspect it is 20/15 since subjectively it has improved, and at near I saw 20/25. Intermediate I didn't explictly test but is somewhere in between, likely 20/20 to 20/15 depending on the distance.

In terms of the results of others wearing the lens, obviously they have some in the studies if you learn the jargon to read the results.  The ASCRS and ESCRS conferences have searchable abstracts that give several study results, in addition to what shows up in articles on the net and on the manufacturer's site.  

Spoke the doctor's office in Ontario Canada who is installing the symfony lens and they told me that I can expect good distance and intermediate but that I will need reading glasses for close up.  That is different than what you have told me and you are a patient who is actually wearing them.  So I asked them about mini monovision because if I have to give any thing up, I would rather take it from my distance vision to be able to see good intermediate and up close.  I need to be able to read and work on documents and read the prescrfion on my pill bottles and see the caller id on my phone and I don't mind having to wear glasses to drive (although obviously would love it if I could drive without glasses too).  They also told me that there is some problem still with halos and glare but less of an issue than it would be with today's multi focals.  Just wanted to hear what you had to say about that.  thanks

Each patient differs in the exact results. The manufacturer's website quotes study data showing 87% report never needing glasses even for near. (presumably they aren't counting rare cases like threading a needle once in a while). Presumably some surgeons wish to underpromise since anyone could wind up in that 13% and so they wish to prepare people.  Other studies give varied figures for what % use glasses for near, but any that I've seen show only a small minority need reading glasses. 

If you do micro-monovision or mini-monovision that lowers the odds you'll need reading glasses. You could also opt to wear glasses for distance and have both eye's set in a little bit, e.g. -0.5D for one to focus best at 2 meters and -1D for the other to focus best at 1 meter for a bit of micro monovision and make it even less likely you'd need reading glases. That would give you great intermediate vision for social interaction and household tasks, and lower risk of glasses for near. Or you could bump those in even further, -1D and -1.5D, though it seems likely having one eye at 2 meters would be useful to cover social settings, like someone on the other side of a larger dinner table, and other intermdiate tasks beyond computer distance.

As I said some people get problematic halos even with a good monofocal lens. There is currently no lens in existence that can guarantee you won't have problematic halos, its merely a matter of risk. Even with good multifocals only a small minority have problematic halos. The risk with the Symfony is reportedly comparable to the risk with a good monofocal, and likely better than some monofocals. 

Again, trifocals might give you more very near than the Symfony, at some slight reduction in intermediate. I finally saw more info on the new Panoptix trifocal which sugggests it might be a little better for intermediate than the currently widespread trifocals. Links send messages to moderators and I don't know how long that takes, but if you do a search  there is an article on the new Panoptix trifocal in Ophthalmology Times from December 1, 2015.

Actually I got that information from a doctor in Canada who is actively working with the symfony and his nurse (whoever returned my call) told me to expect to have to wear readers for near vision.  Didn't get the impression she was talking about 13%, more like she was talking about 90% chance I would need readers.  But then there is you who actually is wearing the symfony lenses.  As for tri focals, London Eye Hospital is now installing quad focals, believe it or not.  But what attracted to me to the symfony was that it was not a multi focal, but rather an extended range of focus IOL. ALL of the multi focals, whether bi focal, tri focal or even quad focal, split the light and that gives you low light issues, transitioning issues, halo issues and, most important for me, loss of contrast issues.  Contrast is importnat because you cannot correct for loss of contrast.  Apparently, with the symfony, you don't have low light issues and you don't have loss of contrast issues.  Near vision can be corrected by glasses but you cannot correct for loss of contrast or poor night vision or halos or low light issues.  Am I correct in assuming I will not have these issues with the symfony, or, if I do have them, they are no bigger issues than those that I would have if I went with a straight monofocal lens? thanks.

re: "but then there is you who is actually wearing the symfony lenses"

I am just one example and since results vary I may be atypical. If their impression about the statistics were right then I might merely be one of the lucky 10%. However other studies I've seen on ESCRS and ASCRS sites suggest that most people don't need reading glasses, if I recall correctly the worst case figure I'd seen is perhaps 20% may need readers. You might try checking with   places in Europe that have been using the Symfony longer to see what they say in terms of their statistics. 

I've seen the London Eye Hospital reference to a quadfocal but I haven't seen any indication of what model lens it is. It may actually be the Panoptix trifocal which I've seen refered to in one place as being actually a "modified quadfocal" design, but which most places refer to as a trifocal. I haven't seen any other reference to a quadfocal IOL so thats why I suspect they may be stretching the definition a bit when even the manufacturer seems to be marketing it as a trifocal rather than quadfocal. Yup, it will likely have lower contrast sensitivity than the Symfony, though the design is supposed to minimize that and I haven't seen a direct comparision. The studies seem to show less loss of contrast sensitivity than I would expect, in some cases better than the average for age 50-75 (but that includes up through like age 75 which presumably includes people with natural lenses still that are clouded even if not enough to have led to cataract surgery).  I get the impression the loss of contrast sensitivity  than multifocal contacts, which I had no trouble with and that many are happy with.

re: "assuming I will not have these issues with the Symfony"

Again, there is no guarantee with any lens, including monofocals, that you won't have problematic halos. The odds again are comparable to a good monofocal. Studies show contrast sensitivity also comparable to or better than a good monofocal, and better than the AT Lisa trifocal (the only head to head comparision I've seen between the Symfony and a trifocal).

No, no, I think you misunderstood me.  Nobody told me "90%".   The doctor's office in Canada who returned my inquirty told me that I should expect to have to wear readers for seeing near if I opt for the symfony.  The way she said it gave me the impression that everyone who gets the symfony needs readers from her experience or at least 90% of them. Yes I have read the same studies and reports, all of which say aroudn 88%-90% do [u]not [/u] need readers for up close and when I pointed that out to her she was quick to point out to me that there is no IOL out there today that has achieved the holy grail of IOL's that being all three distances.  So the fact that you do not need glasses after surgery makes you the majority, not the minority.  This was what I got from a Canadian doctor. I posed that same question to the LEH and they told me they would get back to me after the 1st week in January, but if you are in fact the norm, I don't know why anyone would even consider any other lens at all.  I don't see any downside on the symfony.  Glare and halos the same or even better than a monofocal.  No loss of contrast like you get with a multifocal.  No splittingf of the light so no dim light or night driving issues.  Excellent distance and intermediate and not so bad near either, smooth transitioning between various focal lengths instead of noticeable jumps between the different lengths. What am I not understanding?  I know everyone is different and I know it is surgery and there are no guarantees but it almost sounds too good to be true.  When you wear glasses, would glasses make it any better for near?  for intermediate?  for far?  I know you see excellent for far, for example, but would progressive glasses tweaked to your eyes make it even better or you are as good as it gets right now, other than perhaps for near?  happy new year by the way

Yup, I assume I'm in the majority based on what I'd read. My point was of course merely that my comments don't disprove her claim that most patients do need readers since I might be the exception. Likely the studies are right and I'm in the majority  and most do not need readers. 

it isn't  "too good to be true" in the sense that of course you don't have the same level of accommodation someone in their 20s does, for some closeup tasks glasses may be needed, even if rarely. Occasionally there will be a need to thread a needle or whatever other infrequent small near task. Some people prefer to risk the potential negative side effects of a multifocal to get a bit more near.  I haven't seen enough studies to be sure about the Pantoptix trifocal, but since it has a bit better intermediate than the Finevision, along with good near, it might be worth considering for some

 There are many surgeons who do think the Symfony is a major advance and will have a big impact on the premium lens market because it does seem it improves on a monofocal with no (or statistically insignificant) added risk. 

 Even if vision is great at intermediate and decent at near,  if your best focal point is at distance then glasses can always be used to improve things for other distances. Its just that usually they aren't needed, and the difference may not be apparent. 

 I assume progressive glasses should be able to be used with the Symfony if desired  as well, perhaps focused on intermediate&near, even if hopefully they aren't needed. For the most part vision with the Symfony is similar to early presbyopia, and since it is a single focus lens (even if the focus is "extended")  I can't think of   any reason why progressive glasses wouldn't work, even if I hadn't read of people using them with the Symfony. Progressive glasses might also be usable with a multifocal IOL, I hadn't read about it, though its possible the multiple focal points would confuse someone as to which point in the progressive lens is best to look through. The Symfony is a single focus so that shouldn't be an issue.   I don't know if multifocal contacts would interact well with the Symfony's optics or if for those who like them that would be an option as well to get more near.  (I don't know enough about the exact details of the optics to be sure, or whether the multifocal contact would interefere with the method to extend depth of focus). 

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If you are putting off surgery, I would suggest keeping an eye on the Panoptix to see if they do any direct comparisons with the Symfony and if more comes out about the risk of halos&glare. I've only seen one article with any data on the lens, not enough to be sure what to think. It may be that its new design is better than existing multifocals in terms of side effects. and that it will give more near than the Symfony. 

 There is another new IOL that seems to be getting less attention and study, the "Mini Well". There hasn't been enough info available to evaluate it well, but if you are waiting on surgery I thought i'd mention it is another to keep an eye out for if more information appears.  I don't know how it compares in terms of contrast sensitivity and risk of side effects since it is sometimes described as "extended depth of focus" but also sometimes as a "progressive multifocal" (but that may be because people are used to the word "multifocal"). The fact that its getting less attention may be because it is less promising, but its possible that is because it doesn't have an existing big player in the IOL market behind it. One study suggests it is perhaps slightly better than the Symfony at certain pupil sizes, but that wasn't based on patient data but merely  based on an optical bench study and  and it didn't give statistics on the other factors like halos&glare and other factors to get a sense of how it compares.  I suspect its less likely to be approved in the US anytime soon since I haven't heard of any clinical trials, and because it doesn't have an existing US company in the IOL biz behind it.