Cataract - I Should Have Chosen Near Vision

If your surgeon is not willing to use lasik, what is he suggesting to fix the astigmatism? Changing the lens will probably not fix that!

If the astigmatism is fixed, it may solve some of your vision issues.

If he is willing to exchange the lens (at no cost to you?) to get you the best focus at about 16-18 inches without any residual astigmatism and feels confident about achieving that objective, then I would probably accept his offer.

Otherwise, I will get a second opinion from a LASIK specialist.

Also, please note that all the 3 choices, which I indicated in one of my posts above, depend upon some amount of  monovision

 

Maybe I should inquire into the symfony lens.

I have Symfony Toric lens in my right eye and still have to have LASIK enhancement to correct the error in prescription and astigmatism. Unless you know what the plan is to take care of that, changing to Symfony lens will not by itself fix the issue.

Minor correction in my post above:

I had to (not have to) have LASIK enhancement to correct the error in prescription and astigmatism)

I understand.  I'm not 100% sure why my doctor seems against laser to tweak things.  At this juncture I'm not sure if I should focus on fixing my right eye before doing anything with the left.  He's willing to change out the lens but I don't know if he will consider a symfony.  I've read some complain about the halos with the symfony and I would not want to change out the lens only to again have possible problems with halos and starbursts. Regarding your other post, if you change out the lens with another toric lens then if it is properly aligned then it should fix the astigmatism.  But I understand that all too often it is not perfect and needs adjusting to fix the astigmatism.  Only now am I realizing how difficult these choices are and my near vision is important to me but I'm also getting spoiled with this distance lens so it seems like symfony is something to really consider.

I think that before you take any other step, you need to establish how you are going to take care of the astigmatism in your right eye. If you need to talk with a LASIK surgeon to establish that, you should do that. In our area in USA, many LASIK surgeons offer a free consultation. If you have to wear glasses to get the best vision due to the astigmatism, you need to establish that too.

Then, you should really get a vision test done to see what your current eye prescription is. I would not do anything concrete with that information right now since your vision will probably change over the next month, but that information may help you focus better on the best choices for the next step.

I understand what you are saying. The problem is if I can do a lens exchange for a toric symfony and it stays aligned then there won't be an astigmatism.  Is this correct?  If so, then it would just be a question of whether to do a lens exchange with the right eye with symfony or if it is safer to start with the left.  Sorry for all the posts and questions it just seems like symfony is a better option if one wants to be able to have good all around vision.  I wish I had carefully considered all this before I did my right eye.  But again, you are right, waiting is a good for now since my near vision in my right eye might improve  (not sure though).

I am not saying that you should not get Symfony toric lens. All I am saying is that you should have a clear understanding of your backup plan if you are left with astigmatism after you have your lens change. (I was left with astigmatism and a slight spherical prescription error after getting a Symfony Toric lens, but was lucky to be able to get LASIK enhancement  with no problem). And then you should think about whether that backup plan may be applicable to your current right eye lens.

As a related question, did your surgeon rule out PRK also for correcting your vision in the right eye? PRK has advantages and disadvantages compared with LASIK, but may be worth checking into (just like you should check with a LASIK surgeon to get a second opinion).

I'm not sure yet but I will definitely check what his plan is regarding my astigmatism.  On another note, I have read that the symfony does not provide as "clear" of vision as a monofocal lens does along with the potential for halos.  This makes it harder for me to decide what to do with my left eye.  It's so difficult because it's not something I want to do casually.  I want to give serious consideration as to what lens to choose for my left eye and what plan of action to choose for my right eye.  Thanks.

I think that once you know what the plan is for taking care of the astigmatism (whether or not you have a replacement lens) and what your spherical correction is with the current lens (which will tell you the best focus distance with that lens), it will be much easier to figure out the best next step.

re: "On another note, I have read that the symfony does not provide as "clear" of vision as a monofocal lens does "

It depends on what is meant by that. I have at least 20/15 uncorrected distance vision with the Symfony. They didn't have a line below that to test, and that line was easy to read so it could be better, and if I ever worse the slight distance correction it'd be even better (though I neglected to find out  what the 20/X figure is for the best corrected). Most people find that adequate and its questionable if they'd notice much difference.

 I've seen one study where the Symfony showed better distance vision than the monofocal control. Usually studies show them as comparable within the margin of error, or at most only a little bit lower visual acuity than a monofocal. The FDA approval data shows a difference of  perhaps -0.2 lines on the eye chart  average better for the monofocal.

In theory an aspheric monofocal might be better, but in actual practice it doesn't tend to be much of a difference. One prominent surgeon has a presentation I saw online of a talk where he said the actual expected average best corrected vision with an aspheric monofocal is about 20/17, and the Symfony is about 20/18, while a spherical monofocal (rarely used now) is 20/20, and a diffractive multifocal about 20/22. Those are averages of course, I suspect being younger than average my visual system was able to get better results. The chromatic aberratoin correction of the Symfony counterbalances and reduction in image quality from extending the depth of focus.

More importantly, you aren't always looking exactly at infinite distance, or at the best focal point of the lens if its set somewhere inwards.  You are looking at some range around the best focal point, and the Symfony provides  a larger range, so as a practical matter the odds are for most places you are looking your vision is actually clearer with the Symfony.

I have 20/20 (plus a bit better) vision at 80centimeters, and 20/25 at best near. At the check when they measured at  40cm exactly they didn't have a 20/25 line, but I was at least 20/30 and read some off the 20/20 line so its likely 20/25 at 40cm. 

Its less clear in the sense it does reduce the effective light slightly, reducing contrast sensitivity, but some studies put it as comparable to a monofocal within the margin of error, so its almost the same even if others put it slightly lower. Its within the range, or better, of those the same age with their natural lens. So dim light vision in theory might be reduced a bit, e.g. seeing a menu in a dimly lit restaurant, but I haven't found it a problem. Low light vision is noticeably better than when I had multifocal contact lenses back before I had a cataract.

In terms of night vision, for talk of the results, google (since they moderate links):

"High rates of spectacle independence, patient satisfaction seen with Symfony IOL"

Overall my night vision is much better than I can recall it being even before cataracts. I am in the minority that see halos, but I've never found them to be a problem since they are so translucent and mild that I see through/past them.  A major reason night vision is better is that I seem to have less issue with glare disability, the headlights themselves are less distracting and I find it easier to see the surrounding environment, which more than makes up for the presence of the halo. I don't know if that would have been the case with a monofocal IOL also, I hadn't researched the issue, or if it relates to the Symfony's optics. I hadn't seen a study on the issue, and unfortunately I gather many people interpret questions about "glare"differently and view it as talking about a visual artifact rather than the glare disability issue. My visual acuity seems better than it was even before cataracts, which sometimes happens with those who were highly myopic beforehand since the correction we wore minified the image, reduced its size on the retina.

Unfortunately  monofocals can cause trouble with driving, including night driving, in a different way if they make it more difficult to read the dashboard and things like maps or whatever else that someone might stuggle to see that draws attention away from the road. People aren't good at assessing the level of risks, they may be more subjectively aware of halo issues , but it may (or might not) be that accidents might be more likely with the monofocal.

Unfortunately it is true there is a slight risk with a premium lens that someone will need a lens exchange due to visual artifacts, though the risk is tiny since the vast majority are satisfied, its still necessary to be prepared for the possibility. Someone winds up being the statistic. With > 480,000 people getting premium IOLs each year, a tiny minority having troubles leads to a fair number posting about them. 

In my case I decided the slight risk of needing a lens exchange was worth i for the benefit of potentially having a few decades of a more convenient range of vision. 

I should add that even with residual astigmatism, a Symfony would still leave you with more of a range of vision than a monofocal would. Also I should add that although the Symfony is used in cases where people are hesitant to recommend a monofocal, there is some chance that if the cornea is irregular that might be an issue. Unfortunately some surgeons don't like to go to the extra work of evaluating whether someone whose eye isn't completely perfect will work with a premium lens. Some people for instance with prior refractive surgery are automatically told they can't get a multifocal by some surgeons, while other surgeons have gone on to evaluate the state of their cornea to see it is in good shape and had good luck with even multifocals. The Symfony is more tolerant of issues, but some surgeons are conservative if they haven't tried it since there haven't been many studies published on the issue, though I've seen some recent publications indicating good results with people with other eye issues with the Symfony. (not as good as the results with those with otherwise perfect eyes, but better than with monofocals).

You've made some excellent points about the symfony vs monofocal.  I'm assuming there is no way to simulate what the halos would be like with a contact lens or glasses?

If you were me and decided to try the symfony, do you think I should try it in my left dominant eye first or do a lens exchange in my right (non dominant) eye first?   Why or why not? Right now my right eye has a monofocal set for distance.  The monovision bothers me more "up close" when using my left eye to read than walking around when using my right eye for distance. Maybe the symfony in my left and a lasik correction for the astigmatism in my right will work for me.

Having the astigmatism correction in the right eye and correcting it for distance combined with a Symfony lens in the left will work (that was one of the three choices suggested by me in one of my posts above).

However, if you plan to use this approach, you will have to figure out the best combination of glasses or contact lenses for use until you have a cataract surgery in the left eye. Will suggest using monovision with glasses with this approach because if you tried to get the left eye prescription for distance, there will be too much of a difference between the 2 eyes prescription, which will most probably cause double vision.

If I go that route do you think it is best to first lasik correct my right eye and then consider symfony in the left or do the left with symfony and then follow up with lasik in the right or both eyes to fine tune?  I'm thinking it makes more sense to first consider lasik in the right which might give a better guide as to how to set the symfony in the left  (ie: gear it more to near or distance based of the right eye).

I agree with you that it makes more sense to get the right eye adjusted first to get rid of asigmatism and fine tune it to the best focus distance of your choice. After the right eye vision has stabilized completely, it will be a good time to make the decision for the left eye.

I would ideally suggest being sure a surgeon has examined your corneal surface and has no concerns about a premium lens. 

Unfortunately there isn't any way to simulate the halos, especially since not everyone gets them. The halos with the Symfony are due to light scattering off the diffractive rings since it uses diffractive optics, which no contact lens currently uses as far as I can tell. Multifocal IOLs also use diffractive optics, but for different purposes. So although multifocal IOLs can get that sort of halo,  the major cause of halos in multifocal IOLs is due to having unfocused light from the other focal points, which is a lot more light energy than the unintended edge scatter. Unfortunately its the sort of thing where you really do need to just decide upfront that you would be comfortable with a lens exchange if you decide you need it. 

Halos and other visual artifacts can have many causes, in fact I was surpised to see this info below (to avoid the moderated links, google the text to find the article):

"The study, titled Needs, Symptoms, Incidence, Global Eye Health Trends (NSIGHT), surveyed 3,800 spectacle and contact lens-corrected subjects, 15 to 65 years of age, from seven countries (China, Korea, Japan, France, Italy, United Kingdom and the U.S.) to better understand the eye-related symptoms that vision-corrected patients experience. The NSIGHT data provided valuable information on how often patients experience halos and glare and the degree to which they found them bothersome. 

About half of the spectacle and contact lens wearers surveyed reported suffering from the symptoms of halos (52 per cent and 56 per cent, respectively) and glare (47 per cent and 50 per cent, respectively) more than three times a week. More than four of five patients who experienced these symptoms found them bothersome (84 per cent and 89 per cent for halo and glare, respectively). " 

I would suggest it makes more sense to use it for your unoperated eye first, to decide whether you'd really need to do a lens exchange for the other or if you can live with the combination. Then again, although the odds are good they can do a lens exchange at any point, it is easier if they can do it within the first few weeks of getting a lens.  

 

I've read a lot about making sure the eye is healthy with a premium lens.  What can happen if there is a problem with the corneal surface and a symfony is used?  Is it halo and glare could be more of an issue or something else?

Regarding what you wrote about a lens exchange, I read that when it has been years it's better to do a piggyback due to fibrotic healing and it being more difficult to remove.

The Symfony seems to be more tolerant of  post-refractive surgical eyes. Since they moderate links, google: "Symfony IOLs in challenging cases" for one article on the topic. An article on the issue of multifocals post refractive surgery, which mentions the Symfony can be found from googling "Odd Couple: Multifocals And Post-refractive Eyes".  

The reason for concerns with those who have had prior laser surgery getting a multifocal is the issue of aberrations causing a reduction in contrast sensitivity or visual acuity, though likely also artifacts at night. I don't know the degree to which those would impact the Symfony also, the small studies so far suggest it may not be a concern and that surgeons are likely in part being cautious.  They should be able to test your eye to see how much of a concern such things will be by seeing the level of aberrations.

 

Hello - a few things.  My doctor said that getting rid of the astigmatism could make my near vision worse.  I'm not sure, but I will say that I can easily read my computer when I sit back comfortably in my chair about 3 feet away.

Now, here's the interesting thing I just discovered.  I did a test,  I took my hand and closed it to make a VERY small peek hole  (like looking through a straw with a very small diameter).  I was able to see the letters a LOT more clearly on my phone.  I could read letters on the home screen.  Does that mean the astigmatism could be affecting my near vision?  Or does this not have anything to do with my astigmatism?

I'm starting to really appreciate my intermediate/distance vision in my right eye more and getting more used to it.  I'm just wondering if even more can be done as I'm around 20/30 right now in my post cataract eye.  Perhaps correcting the astigmatism might improve my distance all around.

Last, I've been experimenting with a soft contact in my left unoperated eye for some monovision (but not too extreme).  But, monovision has a lot of drawbacks from what I have researched.  So, I'm wondering if I'm not quite done with this right eye just yet.  Any thoughts?

?

Having astigmatism is never good. Depending on your prescription, if you get rid of the astigmatism, your near sight may be slightly worse, but the distance vision will be a lot better.

The basic questions remain:

1. What procedure does your doctor recommend for getting rid of the astigmatism? If your surgeon does not give you a clear advice, you should consult another doctor.

2. What is your needed spherical and cylinderical prescription for the best distance? (it will probably change a little over the next month, but it may be useful to get your thinking started ahead of time)

Once you know the answers to the above two questions, then it will be time to think about the relative merits of the 3 choices which I indicated in one of my answers above and decide on the best plan of action.

 

For #1 my thought is why do I need to get rid of my astigmatism if my vision is slightly better than 20/30?  I can always use distant glasses if I need them which I don't mind.  I would probably rather do that if my near vision will be slightly better.  I think I'm going to wait it out a few more weeks to see where my vision settles to in my right eye.  Overall, I'm very happy with my distant vision since I also have good intermediate vision.  I can "sort of read" up close but it's too much of a strain.  I guess for all of us it's like that oversized carpet in a room.  You make it fit perfectly in one corner and it jumps up in another.  You just gotta figure out which corners are best for you so to speak.

The decision is really yours. If you are satisfied with the vision which you have with the right eye and are willing to use glasses when needed, you don't have to take any more steps at this time. My suggestions (including getting rid of the astigmatism) were assuming that you would like to end with very good vision (without glasses) at least at some distances.

Yes - I understand what you are saying.  Thank you again for all your feedback.

I would like to report an update.  First, and MOST IMPORTANT, being near sighted for over 20 years, you start to get into some really ingrained habits.  For example, I would wear my distance glasses everywhere and it never bothered me.  When watching TV I could easily just slightly lift up my glasses or just glance below them to read my phone (or read anything). Now, all of the sudden I'm thrusted into a world when watching TV where am I supposed to put reading glasses on and take them off constantly to read something?  It's a pain having them at the end of my nose; I hate that.  Then, I discovered bifocal reading glasses where the top part has NO correction.  I had NEVER heard of this.  So, in theory I could wear them exactly as I had always wore my distance glasses.  I would not have to constantly take reading glasses off and on and off and on.  I realize I could easily wear contacts after both surgeries to make myself nearsighted or any way I want but the default is what I'm trying to decide on.  If this works out with these bifocals available on amazon really cheap then I just might go monofocal distance for both eyes.  I'm also experimenting with a contact to simulate monovision.  But, again, I would prefer my eyes to work together as I've read too many problems can happen with monovision.  I had never heard about bifocals with no correction for the top part (why should I since I'm nearsighted)?  What an amazing idea. I hope it works out as the glasses are due to arrive later tomrrow.  Also, my vision for near is no longer that bad.  I could read if I had to but it's a strain and not worth the effort.  Mid-range and distance are just awesome so if I can, I would like to correct the second eye to distance.

Multifocal contacts are even more useful since unlike bifocal glasses you don't even need to change where you look since it focuses multiple distances at the same time onto the eye and the brain sorts our which to pay attention to.

You can also get progressive/varifocal lenses where there is no distance correction. (they are essentially no-line bifocals or trifocals , but with varied shapes for the distance and near correction, and the transitions in between). Regardless, over the net if you have a mild prescription you can get dirt cheap prescription glasses compared to what you'd usually pay (e.g. <=$20-$30 prescription readers), if you don't mind waiting a few weeks, though I don't know offhand how much prescription bifocals or progressives run.

 

It is great to know that your vision is getting better and that you need glasses for less number of daily activities.

Just couple of minor comments / suggestions:

1. Since your distance vision is not as good as it can probably be with glasses, why not have the correction for distance (instead of "no correction" on the top part of the bifocal len. Just be sure that the difference in correction between the two eyes is less than 1.0 D to avoid double vision.

2. Don't make any decision about the left eye until your right eye is more stablized and you know the right eye prescription for distance.

Thank you both for your replies.  You both make very good points and I should definitely wait a while after the surgery before considering bifocals for distance but I think the correction at the top would be so little but it's somethng to consider.

Here are my questions:

1.  Regarding #2 above, if I know I want distance, why should I wait for the right eye to stabilize more?

2.  Do any of you use bifocals or pregressives when working on a computer?  I read that it's not easy to do because you need to use all the surface area on the glasses due to the close proximity of the computer screen (if that makes sense).  In other words, what is your solution when you are on the computer and you have to glance at your phone every so often  (do you have to take glasses off and on constantly or is there a better solution)?  Do progressives or bifocals work well at the computer?

3.  This is kind of off the topic but I always wondered why it is that they have all these options for diopters on the positive side but not on the negative side?  In other words, if someone has say 20/40 or 20/30 in both eyes, why can't they get mild glasses (over the counter) with a slight negative amount of diopters?  Is it an insurance thing because they know you would most likely drive with them?

 

In answer to your questions:

1. If you wait a little more time until your right eye stabilizes before you make a final decision regarding the left eye, you are in a better position to make the best decision for the left eye. For example (even though it may not happen), if your distance vision with the right eye is good enough for seeing at distance (requiring glasses only at limited times for distance), you may choose to get the left eye done for intermediate distance (with mono or Symfony lens). In addition, you are also going to be trying types of glasses which you are not used to, which may affect your decision regarding the distance range for which you will prefer not having to wear any glasses.

2. Before cataract surgeries, I mostly used contact lenses with monovision and thus did not use glasses. I think that I tried bifocals as a backup for a short period, but had to take them off for the computer work. Fortunately, I could see the monitor well enough without the contacts or the glasses.

3. A large no of people have good vision until they become older and need glasses for reading only. They usually don't have significant astigmatism. So, the reading glasses with positive spherical correction work just fine for them and are thus available over-the-counter. Rightly or wrongly, the perception is that people with distance vision problem need not only spherical prescription but also, usually, cylinderical correction for astigmatism. Thus, the laws (in USA) have been tailored to ban sale of over-the-counter prescription glasses with negative power for distance

Thank you again for your input.  I don't think my right eye will get better for distance and I'm okay with that.  I don't see myself doing my left (dominant) eye for intermediate distance when my right eye already sees great at intermediate.  I'm seeing my brain start to adapt to distance rather than near.  One thing that does help is "going outside more."  At this juncture, I see myself going for distance and as long as I continue to feel that way over the next few days and don't have doubts then I'll be ready.  The real challenge now will be finding out if the bifocals work at the computer.  Otherwise, I'll find myself constantly putting on and taking off my reading glasses all the time.  One more thing I notice, sometimes I seem to get a little dizzy or a feeling of vertigo for a few seconds when the reading glasses are on.  Is that because they are the wrong power or I'm not used to it or the "cheap quality" or something else?  I've read different things on the internet but I'm not sure yet what might be causing it.  Thanks again for your feedback.

A possible reason for you having a little dizzy feeling with the inexpensive glasses is that there is no astigmatism correction in those. Getting glasses with the astigmatism correction should help with that.

Also, when you are using a power to read reasonably well with the right eye at about 16 inches, your left eye can barely see at that distance. However, please be aware that if you get the best power to read equally well with both eyes, the difference in prescription of the 2 eyes will probably cause too large a difference in the sizes of the images for the brain to handle easily, causing possible double vision. Thus, you may need to get the left eye correction for reading at about 16 inches and not have a difference of more than about 1.0 D between the equivalent spherical correction for the 2 eyes. Looking at your old prescription for the left eye, it will probably mean that you get  the best reading prescription for the left eye and only the astigmatism correction for the right eye. Thus, you will essentially have monovision at that time, but your brain may be able to handle that better than the large difference in sizes.

re: "Do any of you use bifocals or pregressives when working on a computer?  I read that it's not easy to do because you need to use all the surface area on the glasses"

There are many different models of progressive glasses which devote different percentages of the surface to different distances, e.g. some are termed office progressives. Unfortunately some of those are the more expensive ones you'd need to get by prescription from a local provider since they rely on a number of measurements. I hadn't had reason to examine the over the counter options, but it seems likely some of those also have designs that emphasize different distances. 

If you had readers focused at computer distance, I'd even seen "stick on" reader lenses on Amazon that appear to be tiny lenses you can stick on single-focus glasses to provide just a tiny bit of area to let you occasionally make use of a stronger near correction. 

 

In terms of using a phone while at the computer, there are also various applications that will tie your phone to your computer for various things so you have less need to look at  your phone. They usually connect via bluetooth or USB but sometimes wifi. (and there are cheap bluetooth USB adapters if your computer doesn't have bluetooth). I hadn't had reason to play with them so I don't know their functionality. 

There are some non-prescription adjustable glasses that seem to get very mixed reviews that let you adjust the lens power of each eye seperately, and include corrections in both positive and negative powers (some only provide varying reading powers). 

The lack of over the counter low fixed powered glasses for distance is likely because most people who are nearsighted benefit from getting a custom prescription. Glasses with the same fixed power in each eye won't be as useful to as many people. In contrast, everyone who gets old enough develops presbyopia and so everyone with good distance vision in both eyes (either without correction, or with contacts) can make use of  over the counter readers so the market is much larger.

I don't think the issue is insurance, but it may be also related to driving safety, or at least that might be an excuse used for any legal restrictions on such glasses without a prescription figuring that the correction wouldn't be as accurate as a custom prescription is for most people (I'm guessing some legal restrictions  may exist in some places, though I hadn't checked, or it may be the threat of such restrictions is obvious to those who consdier the market).. Its important for public safety for people to have good driving vision and so a more accurate custom prescription for distance impacts others and not just the patient, and of course ensures eye doctors get more revenue. I was surprised to discover the adjustable glasses that correct for myopia, but it sounded like they have limited fields of view (in addition to not being esthetically appealing) so they likely aren't viewed as something people will wear driving, or only for emergencies.