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Advice for Eldery Parents Please - Lens choice for double cataract and potential monovision strategy

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james12482
james12482

Hello,

Both my elderly parents require bilateral cataracts and I would be most grateful for some sound advice please following their most recent review with the consultant.

The consultant has suggested the Alcon Vivity EDOF Toric lens for both my parents, starting with this lens in one eye to begin with then assessing next steps. Specifically, he has said the following:

PARENT 1 (wants glasses independence for most tasks):

"At present, the left eye has good unaided near vision as there is a myopic prescription present. The rest of the eye exam was within normal limits. We discussed the option of right eye cataract surgery in the first instance with a replacement Extended Range Toric Lens aiming for good distance and intermediate vision. Once the right eye settles, we can then address the left eye setting this up for Intermediate and Near Vision if needed"

VISUAL ACUITY:

-Right 0.20 (6/9.5) with refraction (0.12 (6/7.5) with pinhole), Left 0.20 (6/9.5) with refraction

**Subjective Refraction:

DISTANCE

-SPHERE: OD +1.00 & OS -2.75

-CYL: OD -0.50 & OS -0.50

-AXIS: OD 177 & OS 13

ADD:

-SPHERE: OD +3.00 & OS +3.00

**IOP:

-Right 17 mmHg, Left 15 mmHg

PARENT 2 (Used to wearing glasses, but would like independence from them for reading, phone and computer work):

"Examination confirmed the presence of cataracts worse in Right Eye. The right macula had some evidence of degenerative change with appeared long standing but the rest of the fundal examination was within normal limits. We discussed the option of Right Eye Cataract Surgery with an Extended Range Toric Lens aiming for good distance and intermediate vision. Once right eye settles, we can consider left eye surgery as needed."

VISUAL ACUITY:

-Right -0.10 (6/4.8) with refraction, Left -0.18 (6/3.8) with refraction

**Subjective Refraction:

DISTANCE:

-SPHERE: OD -0.75 & OS +1.50

-CYL: OD -0.25 & OS -1.00

-AXIS: OD 20 & OS 7

ADD:

-SPHERE: OD +2.50 & OS +2.50

**IOP:

-Right 11 mmHg, Left 10 mmHg

SUMMARY:

Based on the above information, I would really be most grateful for opinions on:

  1. the Lens specified
  2. Whether the same lens should be used in both eyes
  3. If there is a case for (micro) monovision strategy in using an EDOF in one eye and possible a monofocal in the other
  4. Whether loss of contrast sensitivity is an issue, either with an EFOF in both eyes or EDOF + plus monofocal.
  5. General advice if there are better options (as the surgery will cost £4.5k per eye times 4 eyes as they do not hold insurance!)
  6. Whether a standard NHS-issue monofocal lens may be fine and potentially a good and cost saving option

Sorry for the lengthy post but totally out my depth after having read several posts on this forum trying to understand what is the best option for my elderly parents.

Thank you

0 likes, 14 replies

14 Replies

  • Bookwoman
    Bookwoman james12482

    Edited

    Just to address one thing that leapt out at me: one of your parents wants to be glasses-free for reading, phone, etc., which would argue for a near-distance IOL, and yet the consultant has recommended a lens for "good distance and intermediate vision." Now perhaps s/he meant to address this eventually with the 2nd eye, but it's a disconnect I would bring up.

  • trilemma
    trilemma james12482

    Edited

    I was surprised at the UK cost.

    P2 has low astigmatism in the right eye. That one could be a good candidate for the standard NHS lens.

    There is more than one right way. My opinion, based only on reading, is that ideal is mini-monovision with the near eye tuned to about -1.5 vs the far eye. Far eye should aim to be focused as close to infinity as almost guaranteed to be not at all farsighted. If that far eye is an RxLAL, you have better control of that. I have that done in my dominant eye.

    One possible additional consideration could be which eye is dominant. There seems to be a slight preference for making the dominant eye the far eye. Self testing for the dominant eye is very easy. A search will tell you the procedure.

    The light-adjustable lens RxLAL is a premium. I am not sure what that would be for you. But I think it worthwhile. Downside is that it is offered in fewer places, and it takes maybe 4 extra trips. Plus it takes wearing special UV-blocking glasses outdoors for the better part of 2 months.

    Your parents situation is pretty normal, so reading back to existing discussions will be fruitful. But again, there is more than one right way, especially for the near eye.

    EDIT: I just checked the RxSight website (provider of RxLAL, and I see there are no providers in the UK presently. And making 7 or so trips to Bochum, Germany would be a hardship.

  • RonAKA
    RonAKA james12482

    Edited

    1. I would consider the lens specified as a moderate risk. I seriously considered the Vivity but in the end after some discussion with the surgeon, declined. Cost was not a factor. My concern was optical side effects like halo and flare. The reduced contrast sensitivity was also a factor, but to a lessor degree. At the time the decision was made I already had a monofocal IOL set for distance in my other eye. The Vivity would have been used for the near eye only, and I was considering having it targeted to -1.0 D to get good reading vision. The Vivity only adds an effective -0.5 D, and would have given me a total myopia of -1.50 D. I consider that the ideal myopia for mini-monovision is -1.50 D. Without targeting the extra myopia of -1.0 D, I don't beleive the Vivity targeted to plano would give reasonable reading vision. It may allow you to see the dash well in a car, but is not good enough for reliable reading. I ended up with a monofocal in both eyes and do not regret it. On the toric option, this is a good idea if you want to be eyeglasses free. Normally they are only used if predicted cylinder is going to exceed 0.7 D. And if the plan is to wear glasses then a toric is not necessary as the glasses will correct the astigmatism, probably more accurately.
    2. If you are going to consider a Vivity, I would only use it in the near eye, and use a monofocal like the Clareon in the distance eye. That would offset some of the loss of contrast sensitivity with the Vivity. Otherwise and my choice was to use a monofocal in both eyes.
    3. Yes, as in 2 that is an option. But with the Vivity you need a significant offset to get good reading vision. It cannot be targeted to plano, and still expect good reading.
    4. As mentioned a conventional monofocal in one eye (distance eye) will offset some of the contrast sensitivity loss.
    5. That cost seems very high. I am in Canada and a toric Vivity would have cost me $2,200 ($CDN). A toric monofocal was $1,100. With those costs the very marginal if any benefit of using the Vivity would be quite questionable to me. I would recommend considering standard monofocals in both eyes. Start with the distance eye and target it to -0.25 D and wait until it heals fully - 6 weeks. If possible simulate monovision in the other eye with a contact. I would suggest correcting it to leave a residual error of -1.5 D. Use a toric contact if possible to take that effect out of the picture. Then do the second eye based on the results of the testing. My testing showed I could get away with a contact correction to -1.25 D, but I still have some accommodation and what I really needed with an IOL was -1.50 D.
    6. What is the standard NHS supplied monofocal? Are there options to get a different brand if you pay the difference? I like the Clareon or B+L enVista if there are choices. If the toric cylinder correction is quite low you may still be able to get the AcrySof IQ which goes quite a bit lower than the Clareon, and a bit lower than the enVista. My thoughts would be to stick to a monofocal lens with mini-monovision, and pay the extra to get a toric if it is required.
    7. And last but expectations for mini-monovision have to be reasonable to stay eyeglasses free say 95% of the time. When you correct to -1.50 D you are not going to get the same near vision as your parents are currently getting with their +3.0 D and +2.50 D add. And that is way too much to use in a min-monovision strategy. I am at -1.6 D in my near eye, and am eyeglasses free at least 95% of the time. There are times when reading very fine print in poorer light that I reach for my +1.25 D readers. But I only have them at home, and never need them when out shopping. I can manage without.

      .

      Hope that helps some. It is complicated, and if you have any questions, just ask.

  • Lynda111
    Lynda111 james12482

    Edited

    There are issues of optical side effects with the Vivity that would probably be worse in the elderly, especially since you mentioned the macular degenerative changes in Parent 1. I think it would much cheaper and certainly less problematic for your elderly parents to use a toric monofocal lens in both eyes. Mini-monovision might make them eyeglasses free.

  • james12482
    james12482

    Edited

    EDIT: How do you insert paragraphs on these posts? My initial post was edited as such to make things much easier to read but when you hit post, all editing, line spacing, etc. is lost! Even my reply has lost all paragraphing

    Thank you all for taking the time to read my post (and cry for help!) and providing such comprehensive and professional answers - really appreciated.

    **@Bookwoman **- that is a great point, I will certainly raise this!

    @trilemma - yes, the UK cost privately is very high, prohibitively so if you are uninsured like my parents. Even the cost of premium monofocal lens on a private basis is around £3.5k per eye.

    The premium monofocal lens specified privately at this particular UK clinic is Rayone from Rayner

    I will find out the testing procedure to ascertain which is the dominant eye and ask my parents to complete this, thank you.

    @RonAKA - thank you for that very comprehensive overview.

    I have noted your comments on loss of CS with Vivity versus a standard monofocal, especially in low light conditions like night driving, and need to balance with the gain in intermediate vision via EDOF which seems to be minimal reading your post and the posts on this forum (i.e. 1.5ft vs 2ft or 1 line further down the eye chart). This, coupled with possible optical effects, especially at night, may provide the answer that standard issue NHS monofocal lens is the way to go rather than Alcon Vivity. But still unsure of this. It should be noted that the NHS do not offer Toric Lenses unless the astigmatism is severe, and it my parents' case they most likely wouldn't meet that threshold so corrective measures would be undertaken using glasses.

    Point 5 of your comment is particularly useful and will review this strategy carefully

    Re point 6,** could you please advise exactly what you mean by mini-monovision**? Unfortunately, I don't know what monofocal lenses the NHS use as their standard, but will endeavour to find out and report back. In your opinion, does the NHS monofocal lens manufacturer matter to the extent that if it was one you didn't know or wasn't highly rated, that would shift the consideration back to Alcon Vivity EDOF (our only choice with this clinic)? For comparison, the UK private clinic's premium monofocal is stated by them as follows: "The lenses we use are the Rayner Rayone hydrophobic monofocal and the Tecnis monofocal lens which correct natural aberrations within the cornea for superior visual quality." Even these lens cost £3.5k per eye, but would you recommend either of these?

    Re point 7, I don't fully follow this but will re-read and break it down to relate it the diagnostic numbers for my parents provided in my initial post (which I must I don't fully understand!).

    @Lynda111 - thank you for your insight, and we were informed that optical side effects with Vivity were almost nil and certainly much less than a Trifocal lens. I would really appreciate your breakdown of mini-monovision and what this means in practice and in relation to the numbers for each parent, if possible of course!

    Thank you

    • Lynda111
      Lynda111 james12482

      Posted

      I think the SAFEST way forward for your parents is to follow what Ron said about mini-monovision with a monofocal. He can elaborate on that. I live in the USA, but I find it hard to believe that the Tecnis 1 monofocal, which is about 10 years old, would cost as much as you said. What ever the monofocal lens the NHS uses should work well for your parents.

    • RebDovid
      RebDovid james12482

      Posted

      If your parents will be left with astigmatism that must be corrected by wearing glasses, then I don't see any advantage to either the Vivity IOL or mini-monovision. To my understanding, the aim of both is to reduce spectacle dependence; if one is lucky to eliminate spectacle dependence. But if your parents will need glasses anyway, there's no need to go beyond the plain vanilla approach of monofocal IOLs both targeted for distance.

      .

      Regarding formatting, one way people set paragraphs apart is by putting a period on the lines between.

    • RebDovid
      RebDovid

      Posted

      Also, a quick websearch suggests that the NHS typically uses the Alcon AcrySof SN60WF. This is the immediate predecessor to Alcon's Clareon monofocal. The SN60WF has a generally good reputation. So, if your parents will need to wear glasses because of their astigmatism, the NHS would appear to be a reasonable choice (unless going that route would incur undesirable delay or other problems incident to the NHS rather than the choice of IOL). Indeed, if mini-monovision is a viable option, that also might be something to get via the NHS.

    • RonAKA
      RonAKA james12482

      Posted

      It is unfortunate how NHS seems to work when they decide whether you can get toric lenses or not. Here you just pay the differential in the cost. Most monofocals are available as a toric as an option. As I said the extra cost is $1,100 for a toric where I am. If they force you to use a non toric monofocal there are some possible ways to work around it. Some participants here have gotten monofocals and been left with significant astigmatism. The negative cylinder counts as negative sphere but at a 50% weighting factor. Parent 1 has low cylinder at -0.5 D and most likely would not be enough to correct with a toric. Even Parent 2 which has one eye at -1.0 D cylinder may not justify a toric. The tricky part about astigmatism is that it is the vector sum of the cylinder in the cornea plus the cylinder in the lens. When the natural lens is removed in cataract surgery the cylinder in the lens is gone, and you are left with only the cylinder in the cornea. If you get the detailed measurements of the eye, the residual astigmatism can be estimated. If it is a smaller amount, for purposes of making a correction in refraction, They just add 50% of the cylinder to the sphere. The short story is that it is quite likely your parents do not need a toric lens, and the impact on vision without glasses would be minor. The measurement to estimate residual astigmatism if you are allowed to purchase it, is usually about $100 or so. Getting that measurement if NHS allows it would be very helpful.

      .

      To put things in perspective a bit on the astigmatism, I had more eyeglass prescription astigmatism than your parents, and have non toric monofocal in both eyes. One eye came out at -0.5 D but has since moved to -0.75 D. The other eye came out at -0.75 D and held. For the most part this was predicted and allowed for when the sphere power was selected. Done properly the IOL power calculation is done based on spherical equivalent (sphere plus 50% of the cylinder), so to some degree the sphere can correct for the cylinder without going for a toric lens.

      .

      Any standard monofocal can be used for mini-monovision. The distance eye is targeted to -0.25 D which is slight myopia, and the near eye targeted to -1.5 D mild myopia. For most that is enough to read in good light. The near eye has good vision from about a foot to 9 feet, while the distance eye has good vision from 3 feet to the moon. There should be no extra cost to mini-monovision. It is all in the selection of the target for each eye.

      .

      Find out what monofocal lens is offered at no cost, and I can give you my thoughts on it.

  • RonAKA
    RonAKA james12482

    Edited

    I did a quick Google search on what IOLs the NHS cover. I found an interesting clinic called SpaMedica. They claim to be able to provide cataract surgery under NHS coverage. On their site under the "What type of lens will be used" page they say they primarily use the B+L Akreos Adapt AO lens. It is a neutral asphericity lens that will leave a +0.27 um of effective asphericity. This makes the lens more tolerant to position in the eye, irregularities in the eye, and will have an increased depth of focus. It probably has more depth of focus than the J&J Eyhance lens which is claimed to be an "enhanced monofocal". From what I know about it, this should be a very good lens for a monofocal, and would be well suited for mini-monovision.

    .

    SpaMedica claim to be UK's largest provider of NHS cataract surgery services.

  • james12482
    james12482

    Edited

    @RonAKA

    @RebDovid

    @Lynda111

    Thank you all for your replies.

    .

    I have finally received the information regarding NHS and Private lens options which are presented below. I would be most grateful for some further direction and advice for my parents.

    .

    **PRIVATE LENS OPTIONS (circa £3,750 GBP per eye):

    Options here are provider dependent.

    After selecting a provider my parents are comfortable with (called Optegra) who have both NHS and private pathways, and after sound advice on this thread to drop EDOF lens options, their Enhanced or Premium Monofocal Lens options are:

    Johnson & Johnson's Eyhance OR

    Rayner EMV

    .

    **NHS MONOFOCAL IOL (NO COST) OPTIONS:

    Johnson & Johnson's DCB00 (by Optegra) OR

    Bausch and Lomb’s Akreos Adapt AO lens (by SpaMedica)

    Note: it is unlikely that the refractive target required by my parents would be achieved either NHS IOL.

    .

    Based on the above lens information and potentially considering a (micro) mono-vision strategy in line with their diagnostic results in my first post, I would welcome your valuable input with and whether an expensive enhanced/premium monofocal is worth the >£7k expense versus the standard NHS IOL no-cost option. Cost is not the lens selection driver, rather the best outcome for my parents for their vision.

    Thank you

    • RonAKA
      RonAKA james12482

      Edited

      Some comments:

      .

      Process - The NHS seem to have you in a corner that is very punitive to those wanting something more than a basic monofocal non toric lens. At least in the province I am in, we can choose the basic lens at essentially no cost, or other lenses and only pay the differential cost between the basic lens an the optional lens. As an example my wife got a basic monofocal lens but the toric version, and paid an extra cost of $CDN of 1,100 (£670). Your parents are in a bit of a catch 22 situation. You really can't make a decision about whether or not a toric lens is justified until after the detailed eye measurements are taken. It almost sounds like you have to immediately jump into the non NHS stream to get the measurements. But from what I read at SpaMedica, you may be able to pay for those measurements up front and then make a decision. If that is posible with SpaMedica or Optegra, that is what I would do as a first step. What you want are two basic measurements:

      1. Eye measurements, with the prime one being the eye length. This can be done ultrasonicaly which is the cheapest, but least accurate (A-Scan), or optically with an instrument like the IOLMaster 700, or Lenstar 900. I think the IOLMaster is better as it take a much shorter period of time with the eye held still, but both will work. The Lenstar measurements may have to be repeated several times to get a good reading. I would highly recommend the optical method over the ultrasonic method of eye measurement.
      2. The cornea topography measurement which determines how uniform the astigmatism is, if it is present. The Pentacam is a common instrument used.

        These two measurements are what is needed to decide if a toric lens is needed, and also provide the basic data to do the IOL power calculation. While Patient 2 has a higher eyeglass cylinder eye, that does not necessarily mean it is in the cornea and will remain after the natural lens is removed. As an example I had much higher cylinder in both eyes and did not get a toric lens. I now have 0.75 D which is on the limit of whether correction is necessary or not. And remember that toric lenses are not a silver bullet that will eliminate all astigmatism. My wife got a toric that should have reduced her astigmatism from 1.0 D down close to zero. She ended up at -0.50 D cylinder.

        So, bottom line is that I would try to figure out a way to get these measurements done first regardless of what lenses are considered. The accuracy of the power calculation depend on the accuracy of these measurement, no matter what lens you choose, so it does not pay to cut corners on the cost of the measurements.

        .

        Lens Choice:

        .

        J&J Eyhance - This is marketed as an enhanced monofocal because it falls short of the minimum focus extension of 0.5 D. It is probably around 0.3 D at best. It uses positive spherical aberration (SA) to achieve this, which means the power varies from the center of the lens to the edge. There is a small cost in visual acuity to stretch the focus point.

        Rayner EMV - This lens is marketed as a monofocal to be used in an enhanced monovision configuration. Their claims are not well substantiated with hard clinical data. They probably use positive aberration as well, but are not transparent about how much, and what extension of focus depth is achieved. I would avoid this lens, for these reasons.

        J&J DCB00 - I believe this a packaging of the common Tecnis 1 monofocal. It is unique in the four choices you have as they attempt to reduce the combined spherical aberration to zero buy building in a -0.27 um of SA which in theory offsets the +0.27 um that the average person has in their cornea at an elderly age. It probably has the potential to provide the best visual acuity at the targeted focal point of all the lens choices, providing it is ideally located in the eye and the eye is in perfect condition. It however is provides the least depth of focus of all 4 of the lenses. Analogies are dangerous but it is like the McLaren F1 car - highly tuned for a specific purpose.

        B+L Akreos Adapt AO - This lens is kind of the opposite of the Tecnis 1. It provides zero spherical aberration correction, and leave the average eye at +0.27 um. Like the Eyhance, there is a small cost in visual acuity, but a significant gain in depth of focus. In fact it probably has a bit more depth of focus than the Eyhance lens. But, it falls short of the EDOF status as well. It is much more tolerant of the lens position in the eye, and any defects in the eye. With the car analogy it would be more like the Range Rover, in that it would be more forgiving of road conditions, but not as fast!

        .

        Without consideration of price, with what I know about these lenses, I think the B+L Akreos Adapt AO is probably the best choice, and the one that I would pick. Now, if it turns out a toric is needed for one eye in patient 2, then from what I can see this lens is not available in a toric version. In that case (which I suspect is unlikely), you could use the B+L enVista which has the same optical advantages of spherical aberration neutrality, but can be had as a toric.

        .

        I will post again with a graphic that shows the difference in visual acuity and depth of focus for some of these lenses. It will get moderated, so you will have to check back tomorrow to see it.

    • RonAKA
      RonAKA james12482

      Edited

      Here is the graph of visual acuity vs depth of focus that I promised. The Tecnis 1 is on the graph, as well as the B+L enVista which will be the same as the Akreos Adapt AO. I have put a red dot on the graph which came from B+L where I think the Eyhance lies. The Rayner EMV would probably end up between the red dot and the AcrySof lens shown, but that is just a wild guess as they provide so little data on the lens.

      .

      image

      .

      Hopefully that helps some

  • trilemma
    trilemma james12482

    Posted

    Parent 2 needs toric in the right eye. Left eye can be NHS lens.

    Parent 1 has been living with monovision pretty much already. Could get two NHS lenses. Target near plano in the right eye first. Then decide what to do with the left. Parent 1 would be testing monovision in the interim.

    As to EDOF lenses, I am not sure. As you know, there are tradeoffs.

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