Cataract - I Should Have Chosen Near Vision
Posted , 17 users are following.
Hello - I hope someone can help me or offer some advice. I recently had a Toric IOL lens put in my Right Eye for distance after removing a cataract about 10 days ago. I had a choice of Near, Mid Range or Distance. My doctor didn't want to chance a multifocal due to my astigmatism and prior history years ago of "corneal erosion" (right eye only) which I've been free of the condition for over 10 years. So, we went with a monofocal alcon lens which gives the "clearest" vision without risk of halos and other things.
The problem is when given the choice of Near, Mid Range or Distance everyone said go with distance. I never really thought this through at all. If I could turn the clock back, I'm quite certain I would have gone with near vision in a heartbeat. I've been nearsighted for over 20 years and I don't mind wearing glasses to look at a computer (mid range) or for driving. I have NOT done (cataract surgery on) my left eye as of yet. The very next day after the surgery I thought I made a big mistake. I kind of feel like my life has been "on hold" for the last week and I'm not sure what to do. My left eye is my dominant eye and the cataract is not bad at all yet in that eye. I'm thinking about holding off on doing that eye until I know what I want to do. I just can't imagine always having to wear reading glasses to see things up close. I've been in tears off and on since the surgery. Overall my distance vision is very good and the surgeon did an excellent job. However, I should have carefully thought this through rather than just gone with the hype "almost everyone chooses distance." There are so many reasons to choose near vision I keep compiling a list of all the reasons I want my near vision back in my right eye. I'M STUCK. Has ANYONE else gone through this? Will I just get use to this? Should I consider a lens exchange, piggback, laser or something else? My fingers are blurry even as far as 12 inches from my face. How long do I have to wait until my near vision will get as good as it is going to get? Maybe it will get a little better but I do not know. What should I do? Thank you all for your input.
0 likes, 102 replies
yvee77362 michael74313
Posted
Good liuck
i had surgery in dec on my left eye
the mono given was for closeup and I couldn't see clearly pass 16 inches
the surgeon doesn't really explain this
I was told I would be able to see about 20/30 but it never happpened
so in feb got it changed to a bifocal lens
very uncomfortable because they had to replace the replacement lense due to a tear in the the new lens
and very blurry postoperative thought it was permanent
but since then the blurriness has decreased and vision improving but still not clear and crisp yet
hope u get better over time
michael74313 yvee77362
Posted
I just recently read that near vision monofocal has really poor quality mid range and distance (maybe worse than my nearsighted uncorrected left eye is now). So, maybe the distance choice was a good one after all. But, I don't want to go ahead with removing the minor cataract in my left eye so quickly if I'm going to lose all my near vision. I'm starting to think about the Symfony lens for my left eye as an option but I'm going to really research all my options. I'm wondering if Symfony for my left eye will be a good choice. I'm also wondering if near vision will get any better after 10 days and how long it might continue to improve. I can't stand how blurry things are up close. I'm wondering if a laser correction might help since the toric was slightly off and my distance vision is not quite 20/20. I'm easily 20/30 and maybe 20/25 but the toric is slightly off. Can a laser tweak help this? Best to you also.
yvee77362 michael74313
Posted
and the answer given me was
wait and see
be patient
Remember the eye is swollen
any surgery takes time for swellling to go down as least two weeks
also once done with drops gets better
at201 michael74313
Posted
It is a shame that your vision after cataract surgery did not work out to be like you expected, but these are my comments and suggestions at this time.
1. LASIK will give you a corrected vision much closer to what you want to end up with than a lens exchange (I have had LASIK enhancement in both of my eyes after cataract surgery). Most of the LASIK surgeons will make another correction, if needed further, free of charge. The lens exchange may not get rid of your astigamism anyway.
2. Your eye will be changing a lot during the first month, specially in your case with a toric lens. The toric lenses sometimes tend to rotate from the position where they are originally set, which may be part of the reason for your significant astigmatism. So, don't do anything major for at least 1 more month.
3. Usually, it is better to have the dominant eye for the longer distance. So, if you want to have good reading without glasses, you should definitely have the right eye for reading when you have the cataract surgery in that. The question is whether you want the left eye to be for midrange or near vision. My suggestion will be midrange because otherwise you will end up needing glasses for practially all activities other than reading.
By the way, how well can you read with your right eye at this stage?
Just for your information, I have a Symfony lens in my right eye (set for distance) and a monofocal lens in my left eye set for reading. Have very good day vision (after LASIK enhancement), but less-than-desirable night vision due to seeing Symfony-related multiple concentric circles around lights at night.
softwaredev michael74313
Posted
How nearsighted is your unoperated eye? Can you see near ok with that one, if you don't wear correction do you get a good range of vision between the two eyes with what is essentiallly monovision, one eye set for near and the other for distance? There is a decent chance your unoperated eye is too different than the operated eye to work well that way. People adapt to a limited amount of monovision, but too much of a difference causes problems adapting. Do you know your current refraction, prescription, for both eyes?
If you have any residual astigmatism, that will reduce vision at every distance. I recently saw a meta study suggesting that 29% had residual astigmatism of > 0.5D after implanation of a toric lens. A toric lens needs to be oriented exactly to work or it changse both cylinder and sphere, and sometimes the lens isn't place precisely during surgery or rotates afterwards in the initial healing period while the lens heals into position during the first couple of months. If that is an issue, the lens is sometimes rotated back into place right in the office with a needle since the procedure is minor, other times they do use a surgical facility. They sometimes do some rotation early on, otherwise they may wait some weeks to see if how much if any is needed.
If that doesn't correct the residual astigmatism, or to make that eye more nearsighted if you wish, then laser correction is likely an option depending on the state of your cornea. PRK is used at times for corneal erosion so it could be if you had any recurrent erosion that it'd improve your best corrected vision in that eye anyway, but it depends on the state of your cornea.
During the first couple of months or so while the lens heals into place, there is a minor chance it'll move slightly forward or backward a tiny amount, leading to a slight shift in how nearsighted you are. So they usually wait to be sure vision is stabilized before considering a permanent change via laser. Often they even try to wait a few weeks before prescribing glasses (though if you understand you might need to pay for any updated glasses later, they'd likely be willing to do so early, though if you don't mind waiting for delivery there are places on the net to get dirt cheap glasses, especially if you look for coupons/sales, as cheap as over the counter readers).
Although there is some chance you could be lucky and the lens will move to make you more myopic, or a slimmer chance that further healing will improve visual acuity at all distances if your eye hasn't fully recovered, I don't think there is any neuroadaptation that improves near with a monofocal the way there is with some premium IOLs.
With your past corneal erosion issues it isn't clear if you might have difficulties with contact lenses, though it depends on the details, conversely sometimes contacts are used as bandages to protect the cornea in people with certain types of corneal issues. Ideally you would use a contact lens trial to decide on what laser correction you'd want. If you hadn't tried contacts recently, with modern disposable lenses you should be able to walk out with a trial pair they should have in stock and they are more comfortable than even older soft lenses.
Since it sounds like you still have good vision in the other eye, you might also take advantage of a contact lens trial to set both eyes where you'd want them. You might also consider seeing if multifocal contact lenses work for you, or what level of monovision is comfortable if you consider that approach.
I've seen surgeons writing about using the Symfony in cases where they wouldn't wish to risk a monofocal. An accommodating lens like the Crystalens (the only one available in the US if thats where you are, though also usually the one used elsewhere) is a single focus lens so its also an option for many people who can't use a multifocal (though its risk of night vision artifacts in some studies is oddly actually higher than the Symfony, and it has a low but still higher risk of other sorts of complications, more risk of PCO, and more risk of needing readers. Personally I'd still have risked trying the Crystalens rather than a monofocal if I hadn't been able to get the Symfony (or a multifocal) for some reason.
Other options to provide more near are corneal inlays like the Kamra and Raindrop which are inserted just under the surface of one eye to extend its range of focus. They were created for people with presbyopia, though they've been tested for people with monofocal IOLs as well. Unfortunately if you are in the US, I'm not sure whether the FDA has technically approved the use of them for people with IOLs or if doctors can do it "off label". There are also various laser approaches to creating multifocal patterns on the cornea, or I think (not positive) even some exploring extended depth of focus patterns, but I don't know how the various options compare (or if those are available in the US, and again I don't know where you are, many folks here are from the UK or other countries as well as the US).
One thing that would be a little misleading with a contact lens trial and monovision is that if you have any remaining accommodation in your unoperated eye then it'll have more near than it would with a monofocal IOL. Unfortunately since you only mention being nearsighted for "over 20 years" rather than say "over 30 years", I'm guessing there is a decent chance you hadn't yet had much if any problem with presbyopia yet, that you still have some accommodation. Unfortunately I think most surgeons are used to a cataract patient whose average age is mid-70s who have had decades to adapt to the loss of near vision, and may perhaps not always be as careful to talk through the issue of loss of near more with those younger who will be needing to cope with a much greater loss of near vision.
The range of near vision each person gets with a monofocal set for distance varies based on their eye's natural depth of focus, so studies on IOLs only report averages. Some doctors I've seen suggest that with a monofocal set for distance, that things start to get blurry 6 feet out, though a small minority can get some further our reading vision, while I've seen others suggest things at 10-12 feet get blurry (it partly depends on their residual refractive error, if they were left farsighted, or also their view of what is blurry).
I was fortunate when a cataract caused problems at age 49 to have been dealing with early presbyopia long enough to be familiar with the issues, but not long enough to be resigned to it, fighting it off with monovision contacts and then multifocal contacts. The thought of losing my remaining near is what led me to expect to get a premium lens, and to wind up with the Symfony. I figured even if there was a slight risk of needing a lens exchange due to visual artifacts, that since the vast majority of people are happy with premium lenses that it was worth the bet to get perhaps a few decades of more convenient vision with a premium lens.
Even with the Symfony you can get it targeted a bit further in provide a large amount of near.
michael74313 softwaredev
Posted
Hello and thank you all for your feedback. Here's my answers to some of your questions. I live in the US. I decided to do the right eye first because with glasses they could only correct to about 20/50 and I knew it would only get worse over time (left eye corrects to 20/25). By the way, I asked the doctor if I would feel any pain and he said "NO." Surgery was a breeze and I did not even request ANY IV sedation. I was ready to if I needed it but I never did.
Today I can easily read the 20/30 line without glasses with my right eye but the doctor did say the toric lense did shift (I think about 3 degrees). I kind of had a feeling because SOMETIMES it would seem when looking at letters far away there is a slight "ghosting/shadow" like double vision so to speak which you get with astigmatism. I had mentioned this a day or so after surgery and the doc said it would go away. When it didn't a week later at follow up he said the lens has shifted slightly. Again, it's not terrible and I really don't notice it at all unless I'm trying to look at letters at a 20/20 range. I don't think my vision improved much at all from the day after surgery to a week after but I'm healing very well he said. Overall the clarity is fantastic and I haven't seen mid range and distance like this in decades. I can read the computer fairly well without glasses (I think if the toric is adjusted it will be perfect). I don't know if symfony would have been a better choice. It's hard to say given my prior history of corneal erosion set off by a minor corneal abrasion injury. Yes, you are correct, I have used soft bandage lens before for my corneal erosion for healing. I would recommend antibiotic drops to anyone with a soft bandage lens. A prior doctor just gave me lens and no drops after an erosion and I wound up with an infection subsequent to the corneal erosion due to the bandage lens (Iritis). Eventually, PRK cured it all for good.
My unoperated left eye is very nearsighted and I can easily read my iphone 5s comfortably at around 8" but the range seems to be about 5"-12" although I would never choose to read at those ranges in that outer spectrum. I could read the smallest print on my eye drop bottles with my left eye. However, things definitely get blurry without glasses even as little as two feet out. I guess it just never bothered me because I would just wear glasses. My prescription as of 6 months back was:
sphere,cyl,axis
OD: -3.5, -1.25 100
OS: -3.75, -1.75, 70
Add 2.25 for computer/mid range
I'm questioning whether symfony would have been better. Last night while showering, I could not tell which was conditioner and which was shampoo for the same brand bottles and needed my left eye to tell. What am I supposed to do? Get my reading glasses? There are so many things I use my up close vision for that I never really even thought about it until now.
Monovision and/or contacts would only be a temporary solution for me. My doctor provided me with a few "test" soft contact lenses of different ranges to try for monvision. I can read my iphone but it's too much of a struggle when the lens shift my vision out. He gave me -2 and -1.5 test lense for my left eye. It's just too much of a struggle and not comfortable to read with them. I would not want to make it a permanent solution and I don't mind mid range or distant glasses but I would not want to be forced into reading glasses. ANYONE who is nearsighted if they HAD TO they could easily read a computer screen (just move closer - it's not ideal but you can do it without glasses). However, someone with distance cannot read something up close without glasses - if you move the object further away then it can become too small to see. There are just too many reasons why I don't want to be forced into reading glasses.
It seems like at this point my best course of action is to delay surgery on my left eye and see what can be done for my right eye as it heals. I do like the clarity of mid range and distance without glasses but my iphone is impossible to read and even my fingers and fingernails are a blur. I'm a software engineer and logically my brain says "as things get closer, they should be easier to read. Things three feet away should be easier to read than things a mile away." But, my right eye says otherwise.
I'm just wondering after my right eye heals and is tweaked with laser or whatever then if symfony in my left dominant eye will provide me with good near vision but not have to deal with monovision?
Will Symfony allow me to keep my near vision in my left eye? I just don't want to lose that. Maybe I should try a test multifocal soft contact lense if they make them. Thanks everyone for listening and for your feedback
at201 michael74313
Posted
You really have 3 choices now (all of these assume that after your eyes settle down, you will have LASIK to correct astigmatism and get the right eye best focus distance to your selected value.
Choice 1: You get the right eye adjusted to about 16-18 inches best-focus distance, which will let you read comfortably the typical reading material as well as a computer screen without any problem. After that for left eye, you can either get a monofocal lens set for about 32-40 inches (and use glasses for distance) or get a Symfony lens set for distance (which will provide good vision at intermediate distance also, but may cause night vision issues). I would not consider the usual multifocal lenses, because they have worst night vision issues.
Choice 2: You get the right eye adjusted to best-focus for distance. After that for left eye, you can either get a monofocal lens set for about 32-40 inches (and use glasses for reading / computer work) or get a Symfony lens set for 32-40 inches (which will provide good vision at near distance also).
Choice 3: You get the right eye adjusted to about 32-40 inches best-focus distance. After that for left eye, you can get a monofocal lens set for about 16-18 inches (and use glasses for distance) or get a monofoal lens set for distance (and use glasses for reading and computer work).
Your actual choice will depend on what is most important to you.
As a side note, while you are trying to use glasses in the interim period, please try not to get glasses with a prescription with more than 1 diopter difference between the two eyes. Otherwise, you may have double vision issues. You may need to use a contact lens in combination with glasses to achieve that.
michael74313 at201
Posted
Hello and thank you for your reply. I'm confused and have a question. Let's say I go with Choice 1 where you wrote, "You get the right eye adjusted to about 16-18 inches best-focus distance." How do I do that? I already have a monofocal Alcon lens in my right eye set for distance. How would it be adjusted to 16-18 inches? Thanks.
at201 michael74313
Posted
michael74313 at201
Posted
Wait a moment - does this also apply if I got a Toric monofocal distance lens (not just monofocal but toric)? I know it is RISKY to go in there and do a lens exchange or piggyback. But, are you saying with a Toric Lens Set for Distance, they could correct that and and set it for around Mid-Range with Lasik in spite of the Toric Lens that is currently set for distance? I'm assuming this would be a LOT safer than going in there for a lens exchange.
at201 michael74313
Posted
michael74313 at201
Posted
I'm assuming Lasik is a lot less risky than going in for a piggy back or lens exchange since that risks the lens capsule bursting. I'm hoping Lasik fine tuning is an option for me. I had 2 PRK treatments about 10 years ago for Corneal Erosion. Perhaps my doctor is being conservative due to my RCES 10 years back. I'm not sure if that will affect how much my cornea can be shaped for perhaps a more mid-range. I just want to be able to read without glasses. I don't mind glasses for distance. One more thing - the cataract surgery has caused no problems at all with any form of dry eyes or any problem. I'm not sure if the Lasik and cornea reshaping could cause any dry eye or other issues. This gives me a LOT to think about. Out of curiousity, how "far" can they go? In other words, if someone has a distance lens, can they reshape the cornea so that the person now is near and can read or is it more mid-range? Similiarly, if a lens is put in to see up close and the person changes their mind, can the cornea be reshaped so that they can see mid range or all the way to distance? Perhaps this depends a lot on the cornea but it gives me a lot to think about. I was set for distance, my toric lens is not quite perfect and I'm seeing about 20/25 or 20/30 but I can easily read my computer mid range. But, up close is TERRIBLE. My fingers are blurred 12 inches from my face. The Lasik sounds like the next step before I do anything with my left eye. Your feedback gives me a lot of hope. Thank you again.
at201 michael74313
Posted
Having had Lasik enhancement in both of my eyes after cataract surgery, I feel very comfortable with Lasik. I have not had any eye dryness issues because of Lasic either. That is not to say that eye dryness can't happen. But on the whole, results of Lasik are much more predicatable than lens replacement.
There is no problem in using Lasik to get better near vision or mid-distance vision even if the lens is toric and was originally aimed for long distance. Your eye may be somewhere betwee mid-distance and long distance right now any way (an error of about 0.5 diopter is quite common in the surgeons' calculation of IOL power).
If you are not sure about whether aiming for mid-distance or the 16-18 inches focus distance is the best choice for you, you may want to aim for the mid-distance first. Otherwise, there will be unnecessary amount of shaping and re-shaping of the cornea.
As I said before, you should wait for a month or so for the eye to settle down and for you to have an actual eye prescription. Then, you should consult a Lasic surgeon to get his opinion for your eye.
michael74313 at201
Posted
That sounds great. Currently I can read my computer when leaning back in my chair about 3 feet away (but it would be even more clear without the slight astigmatism because the toric is off). I'm not sure if I need a lasik specialist or if it is something my Ophthalmologist can do (who also did my PRK years ago).
This is giving me a lot of hope but I also have to consider that my right eye is not my dominant eye. I understand exactly what you are saying. One thing I'm not sure of at this point, is whether I should try to go as far as I can with lasik on the right eye (after a month or so) so that I can try to read up close (since it is not the dominant eye) or if I should just have them try and reshape the cornea a little and go mid range and do the left (dominant) eye in the future for reading. I have a lot to think about but at least I have time.
Thanks.
at201 michael74313
Posted
michael74313 at201
Posted
Thank you again so much for for all the support and feedback. I'll keep you posted. It may be a while since I have to wait for my eye to heal.
Thanks
badsoden michael74313
Posted
Hope you see this since it has been a year or more...how is your vision now? What did you decide to do in the end? I'm facing cataract surgery in a few weeks due to a cataract formed after retinal surgery. So only one eye with a cataract at this point in time. My cataract dr. insists that they never put in an IOL for near vision, only some level of distance and then glasses. I have worn glasses all of my life so don't mind continuing to wear them but my big concern is losing my near vision. I am near-sighted like you and have the same concerns. I'm going to ask the dr. about the Symfony lens talked about in this older conversation. We are able to manage the cost of a premium lens and I want the best possible outcome I can get. Thanks for any info.
wgriff01950 badsoden
Posted
Hi: If you read the old posts, my situation is the same. My left eye was corrected to 20/20 with a toric lens to correct astigmatism. It was and is still 20/20 and has been problem-free. The docs I've spoken with continue to say that this distance correction is the one that turns out most problem-free.
~
Now, it sounds like you have a similar situation to me--lifetime of nearsightedness, now the chance to see well at distance in one eye and be nearsighted in the other eye. My "weak" eye couldn't tolerate glasses with just one lens. I saw a ghost images.
~
In desperation, I tried my old (20yo) RGP contacts and that solved the problem of double vision. I figured this would be temporary and my other eye would be operated on shortly; however, the doc said the cataract in my right eye (I'm 71 yo now) is small and "off to the side." In other words, she didn't want to operate on a perfectly healthy eye and told me I'd figured out how to live with monovision on my own.
~
I went back to my optometrist and got two new RGPs--one that corrected me for distance and the other to walk around with monovision. Later, I talked him into prescribing a multifocus contact as well.
~
Nothing worked as I anticipated. Yes, in driving with the distance lenses, I could see all signs and the like but, especially at night when your pupils dilate, reading dashboard wasn't the great. However, with the distance lens in place, I could wear a pair of +2.50 cheaters and work on the computer or read quite comfortably.
~
The lesser RGP Rx turned out to be nice for "daily living." I could read the program at church, menus at a restaurant, gauges in the car. As for the multifocus, it landed somewhere in the middle.
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I found the Distance and multifocus RGPs to be comfortable in my eye; the monofocus tended to get scratchy after 6 or 7 hours.
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I have a friend who searched for a doc who would do multifocal (symphony) implants. He's "happy" with them, but they're not perfect, either, much like my multifocal RGP. Sometimes he'll wear glasses when watching TV so he can read the fine print in the "crawl" at the bottom of the screen that updates news and scores. I also think he doesn't read as much as he used to because it's not as comfortable.
~
Bottom lines, in my humble opinion:
1. Our brains adapt to our situation.
2. There is no one surgery that fixes all situations, especially for nearsighted people who always have struggled to see clearly.
3. The distance fix seems to have the best chance at what my doc (at Harvard U) calls a "good" outcome. Her "good"=my "excellent."
4. Opting for a less than 20/20 final result, which will keep you in glasses, is very much worth discussing with your doctor, especially if you (like me) wore glasses for many years and wouldn't mind continuing to wear them. However, you'll have to ask others on this forum about that solution. When I was active in posting here, it was with 4-5 others going through "the process" and comparing notes.
Best of luck. As always, the best result is to come out with a healthy eye, good (ie, correctable) vision, and the patience to find what works for you.
BG
badsoden wgriff01950
Posted
Once again I'm hearing that the monofocal set to distance IOL is the best choice. I'm really hoping my surgeon is very familiar with the Symfony IOL so we can discuss both options. Funny how you figured out how to fix your vision issues. Sounds like what I'd do to try something to fix something that was bothering me. Thank for your reply.
susan44499 michael74313
Posted
You say you wonder if Symfony would've been better but you had said you weren't a candidate for multifocals I thought?
wgriff01950 susan44499
Posted
Hi Susan:
Dunno about being a candidate. My doc isn't willing to implant multifocals. She's firm in belief that correcting for 20/20 is the best choice.
That's what she did with my left eye, and the result is excellent. She says my right eye is perfectly healthy with just a small cataract off to the side and she doesn't believe in operating on a healthy eye, no matter how small the risk, unless it's necessary to balance vision.
Her opinion is that I adjusted immediately to monovision (though I have RGP options to correct right eye to 20/20 or to use a multifocal).
I kind of bounce among the three options and find monovision works best for daily living, 20/20 oddly works best (with cheaters) for long computer stints, and the multifocal RGP is somewhere between.
Question for the Forum: The 20/20 correction and multifocal RGPs usually feel more comfortable than the lens I use for monovision. Does it have something to do with a larger curve and less contact with the cornea?
Anyhow, that's a long answer to say "I don't know if I'm a candidate for multifocal," and "each of the 3 RGP options has both pros and cons and there isn't a one solution is perfect for all situations.
Good to hear from you again and hope you (and everyone here) gets to a good place with their vision.