Cataract Surgery Options

I have a Symfony Toric lens in my right eye for distance and a monofocal lens in my left eye for close-up. With this combination, I have good day vision at all distances beyond 16 inches. However, I wish that my night vision were better, the main issue being the seeing of multiple concentric circles or halos around lights at night time. Many other people seem to have had the same issue. Rather than repeating the details here, I will encourage you to read my post, “Has Any One Else Had This Very Unusual Vision Issue with Symfony Lens?” on this forum. You should be able to find it by clicking on my name and then looking under “Discussion”.

My wife has a Crytalens in her left eye for distance and monofocal lens in the right eye for near vision. The Crystalens focus adjustment seems to vary from person to person. My wife also tends to get reflections from lights on the side due to Crystalens optical diameter being only 5 mm  It also seems to result in Posterior Capsule Opacification much more ofyen than most of the monofocal lenses.

My suggestion will be go with monofocal lenses if having the best night vision is very important to you and the Symfony lens if having a good depth of field (without glasses) in the day time is most important to you. If you are willing to try a little bit of monovision, I will suggest using a monofocal lens for distance and a Symfony lens set for intermediate distance (which will also provide you good vision at reading distances), which is essentially a variation of what I have.

I had the Trulign lens (the toric version of the Crytalens put in my left eye. It corrected my astimatism, but failed to give me good vision near or distance, when it was suposed to accomodate to let me see near and far. Worse I see haloes, rays and have glare from the side. Even worse I had flickering that was even more annoying which only a 3rd operation to put in a piggyback lens diminished, but which created even more glare. I consider choosing the Trulign  was one of the worst mistakes I ever made.

Which you should choose partly depends on your personal visual needs, e.g. is really near vision without glasses more important to you, or is intermediate&distance more important? The Symfony and Crystalens optimize distance and intermediate vision with a chance at good near, the multifocals are bifocals that optimize near and distance with  not quite as good intermediate (and a slight reduction, likely not noticeable, in distance). Some surgeons actually mix 2 different IOLs together depending on people's needs, e.g. for someone who wants a bit more near  the Symfony in one eye and a multifocal in another. If you were outside the US a trifocal might be another option to consider (they aren't approved in the US yet, all the multifocals here are bifocals).

There was a trade industry publication that did a story in March on what   surgeons would choose, since they moderate links, to find it google:

What tools and products would experienced cataract surgeons opt for themselves By René Luthe,

There is a toric version of the Symfony also which corrects for astigmatism, and the Trulign is a version of the Crystalens which corrects for astigmatism. 

re: "but with halos, star burst..."

I'm not sure where you got your information from, but studies suggest the Symfony has a lower incidence of such issues than other premium IOLs, e.g. for one overview of the studies (you can likely get a sense of it even if there is some technical jargon since its a trade publication), since they moderate links here, google:

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

There is no model of  IOL out there, including monofocals,   that doesn't give some people problematic halos or other night vision artifacts. The question is merely the level of risk. There are over 480,000 cataract surgeries a year with premium IOLs, and even though the vast majority have great results, it it is those with problems who are most likely to complain online. It only takes a tiny % to account for many posts, so its important to keep in perspective that its studies that need to be paid attention to and not anecdotes online by people who have trouble grasping they are unusual. Unfortunately even though a minuscule fraction of people have enough night vision issues to wish to exchange a premium IOL for a monofocal (which also might still have issues), its true that *someone* winds up being the statistic so its necessary to be prepared for that. If any risk is too much, then a premium IOL isn't a good option for you. 

In my case I figured being atypically young for a cataract that I'd be living with the results potentially for a few decades, and so the very high odds of more convenient vision for a few decades was worth the tiny risk of needing a lens exchange. 

The Symfony reportedly has  a risk of night vision issues fairly comparable to a monofocal, even if not as low a risk as the best (e.g. the Tecnis monofocal often used as the control lens in studies of the Symfony). Although the Crystalens is a single focus lens, its emphasis is on potentially accommodating rather than on being the best single focus lens possible, and so some data suggests it may have a higher risk of problematic night vision issues than the Symfony. Unfortunately there aren't enough head to head studies to be sure how some of these lenses compare in terms of those issues. Comparing different studies may be misleading because the patient demographics may be different and the exact way they word the questions may be different, and the wording can impact the results. 

In terms of vision in "dim light", the Symfony also seems to have better contrast sensitivity,  better low light vision, than multifocal IOLs that split the light into different focal points. The Symfony corrects for chromatic aberration which allows it to have decent contrast sensitivity despite extending the range of focus.  Although the newest generations of IOLs seem to have fairly good contrast sensitivity, the Symfony seems to be almost as good as a monofocal. Some studies report contrast sensitivity comparable to a  monofocal, while others show just a slight drop, but indicate contrast sensitivity is within the range of age matched test subjects who have their natural lens still. (though contrast sensitivity reduces with age, so I'm unsure how  it compares for those younger than typical cataract age).

 I haven't seen a head to head comparison with the Crystalens regarding contrast sensitivity. Anecdotally (though this doesn't mean as much as actual study data if it were available, it may be an accidental fluke) I know someone about my same age with the Crystalens and he has a noticeable drop in his near vision in dim light. We met in a well lighted auditorium after a lecture and he had a near vision chart. He showed me that holding a file folder over it to cast a shadow was enough to reduce his near vision some lines, but with my Symfony implants it didn't make a difference.

 I used to wear multifocal contacts before my cataract,  and there was reduced vision in dim light (though it didn't bother me), but noticeably better dim light vision with the Symfony. If it were ever an issue, though it hasn't been, I could always use the light from my smartphone, there are even mangifier apps that use the light to let you read in dim light. 

The Crystalens due to its possible movement has a slightly higher risk of complications like z-syndrome (though the newest model is much improved, I hadn't seen data on the issue) and a higher risk of PCO due to its edge design (a clouding of the lens, which is a minor treatable issue).  Although some studies show a reasonable range of vision on average with the newest Crystalens, it seems that a certain percentage of patients don't seem to see any benefit above a monofocal, that it doesn't accommodate for them. Also since it requires the eye to accommodate to see near, just as with someone older with presbyopia struggling to read near, there it seems there is a difference between what someone can see temporarily struggling with an eye chart, vs. what they are comfortable reading and exerting effort to accommodate (just as those with their natural lens may in theory be able to read near off a chart, but still want readers for reading much text). So I've seen indications surgeons say more people need readers with the Crystalens than with the Symfony, regardless of what in theory the data shows about near (though unfortunately I haven't seen any head to head comparisons studies).

 The multifocals have a higher risk of night vision artifacts than the Symfony, though the newest low add ones aren't too much different. The issue is that those multifocals you mention are bifocals which tend to have a drop off in intermediate vision, though less so thatn the older high add bifocals. So the multifocals might have slightly  better near than the Symfony, with not quite as good intermediate, and not quite as good distance. I saw a presentation where one prominent surgeon suggested that real world average results suggest the average distance vision you'd expect with an aspheric monofocal is 20/17, with the Symfony 20/18, a spheric monofocal (rarely used now) 20/20, and a multifocal 20/22. Though those are only averages (and he lumped all multifocals together, some are better than others),  some studies show a bit better results. I have at least 20/15 distance vision with the Symfony (that line was easy, and they didn't have a line below it to test).

In my case I figured that most of my visual needs, e.g. desktop computer monitors and social distance, are at intermediate rather than really near. I preferred to focus on getting better intermediate&distance, and to risk needing glasses for some near. Though I wound up 20/25 at near, and its rare that I need to thread a needle or do some other really near task where I can't see things without readers.

 

I chose the Symfony Tecnis. I had quite a astigmatism in my left eye, nothing too serious in my right eye. My cataracts were to the point I had to have them removed. So in February we did the left one first, and about three weeks later, the right one. My right eye has been perfect from the day of surgery. We have some tweaking done with the left one... and all distances are better than before I wore glasses. All laser tweaking for post astigmatism correction was included in my Symfony package. There is a bit of halo & glare/starbursts or whatever, but it lessens as time goes by. Not having to wear glasses is a big plus and I don't mind the little extras that came with the territory.