Conflicting surgeons opinions on suitability of multifocal IOLs

Posted , 11 users are following.

Hello, when i knew i had to have my cataracts removed, i went to the same surgeon who did my Lasik in 2003, because i was 100% happy with those results. He did mini monovision giving me perfect distance vision in right eye and excellent close vision in left eye. Discussing IOLs with him, he specifically told me i was not a candidate for multifocal lenses. For various reasons, i did not get my surgery done with him.

Today (8 months later) i had an appointment with another highly recommended surgeon who said i was an excellent candidate for multifocals. Based on the first opinion, i had gone prepared with questions about monofocal IOLs and mini monovision, but he threw me off-track completely and i left wondering what could be the reason/reasons for such opposing opinions. Where i went today is a multi-surgeon "state-of-the-art" type set-up, whereas the first one was a long-established single owner surgery. Could it be that different and more sophisticated instruments/measurements give different results? Or what other reason could there be? I'm 63 and feel there's been a slight deterioration in my vision in the last 8 months.

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  • Posted

    Both surgeons and opthamologists seems to have strong opinions and be divided right down the line on this topic. You will find some who say they would not put these in there own eyes so would not recommend it for their patients.

    The most significant potential downside from multifocals is the possibility of glare or halos. It is minor in many/most cases but can be bad with a small percentage of patients. This condition is extremely unlikely with monofocals, but not unheard of.

    I think monovision is safest with people who either have this naturally or have adjusted from contact lens or Lasik.

    You did not say how mini monovision is working for you, and what your expectations are for monofocals. There are many trade-off so you need to clearly understand your goals and where you are prepared compromise.

    • Posted

      Infact i have been perfectly happy with my monovision. It is only because of the onset of cataracts in recent years that I'm having to get something done.

      I was trying to understand why one surgeon would flatly refuse to offer a multi focal option while another would say I'm a perfect candidate for it and it's a straight forward case.

    • Posted

      "This condition is extremely unlikely with monofocals, but not unheard of.". You're completely wrong. Many people, including me, expirence huge dysphotopsia. "Unlikely" is just super misleading. I think you should work for an IOL manufacturer, great propaganda.

    • Posted

      Sorry Ad12345 but Chris is right based off statistics. I am deeply sorry you have had a bad experience with monofocals and glare etc. Likely this would have been much worse with premium lenses. There also could have been a miscalculation of power or your pupils dilate beyond the IOL. Statistically monofocals provide better contrast sensitivity and less glare and starbursts than premium lenses but doesn't mean it can't happen.

      Have you sought out other opinions? Perhaps there is a reason why you are experiencing these visual disturbances that can be fixed.

  • Edited

    Let me say that this is a complicated subject and decision making process. It is one I have agonized over and have come to my personal decision. However, it is a personal decision and different people are going to have different expectations and as a result have different degrees of satisfaction with the various choices.

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    I will give you a reference to read if you want to take a deeper dive into the issues around the various choices. This article is written by an optometrist, not a surgeon, and the intended audience is other optometrists. It does not really cover the pros and cons of various options from a surgical perspective, but more from an outcome perspective. Still it is quite technical and requires some effort to read and understand for us laypeople. If you google the following you should find it. We are not allowed to post actual links here:

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    Review of Optometry Picking a Premium IOL for Every Patient Victoria Roan, OD

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    In your particular case I would focus on a few points:

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    1. You say you essentially have monovision now with Lasik surgery. You say you are 100% happy with it. If you are, why would you consider a multifocal or EDOF lens? What aspect of your vision are you trying to improve on? Generally the issue with monovision is that the patient does not adapt to it, but you seem to have adapted... You have a great advantage on most by knowing from real experience what monovision can do for you. But one caution. With the natural lens you can still focus to some degree close up even at age 63. With a monofocal IOL you will lose that ability. But, you still have a pretty good idea what monovision is like, and you could experiment more now using contacts providing you can still see well enough to evaluate different degrees of monovision.
    2. I would ask about any complications that may present considering that you have had Lasik surgery. For example do you have astigmatism? Is the astigmatism symmetrical or irregular. Irregular astigmatism may not be corrected well with a toric lens, and there may be issues with halos and glare especially with the premium lenses.
    3. Do you have any hobbies or work activities that require special vision at a particular distance. Does it have to be perfect, or just OK?
    4. Are you a type A or type B personality? It may be the biggest factor in what type of lens you will be happy with.

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      As I said in the beginning it is not an easy decision, and based on my research there is no silver bullet slam dunk answer. It depends on you and your priorities. My suggestion would be to read and reread that article until you understand what issues are, so you can make an informed decision. I'm sure it will prompt other questions which you will want to investigate further. I hope that helps some.

    • Posted

      Thank you for the resource - all information is helpful at this stage. I suppose I'm wondering, since my cataracts need to be removed and new lens inserted, a) if multifocals might give me a better overall outcome, since that's what he suggested first, before i mentioned monovision and b) since it is being offered as an option now, i should consider it. I have a little astigmatism in both eyes, and he said this could be corrected. I would prioritize unaided close vision( for craft, phone, cookery, and pen-&-paper-writing) and intermediate (for laptop). I'm prepared to wear glasses for distance and night time driving, but would like to be as glasses-free as possible (obviously!) If there's a better outcome to be had, albeit at a higher cost, i think I'd prefer to take it.

    • Posted

      My opinion is that multifocals are different, but not necessarily better. I would look at them as an option to be considered, but like monofocal lenses they have their issues too. Have you had your eye measured by a surgeon? The error in our eyes that needs to be corrected with eyeglasses is a sum of the error in the lens and the error in the cornea. The errors can combine to make the total worse, or they can offset each other. Currently your Lasik surgery has changed your cornea error so that it offsets the error in the lens. When the lens is removed in cataract surgery the new lens no longer has to correct for the lens error, just the cornea error. Once the lens is removed you may or may not have sufficient astigmatism to correct for. They can only tell you that when they measure the topography of your eye. My thoughts are that if you have enough astigmatism to correct with an IOL ( 0.7 D or more) and it is symmetrical, then a toric lens is a good choice. The other option is more Lasik to correct any residual astigmatism if it is small.

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      Whether or not go to go multifocal is a more difficult choice. I would suggest it is almost certain you will have optical side effects from them. The question is whether or not you can adapt to them. Night driving with a multifocal probably is the worst situation with halos and flare from headlights and street lights. But if you never night drive, then it is not an issue. Or, if you can adapt to driving and ignoring the optical effects it is not an issue either. The next issue is likely to be close vision in low light. Same thing there. If you always have bright light and don't do really fine work, then that may not be an issue either. And there is always the option of using reading glasses. This is where the type A or B personality thing comes in. A type A perfectionist may not adapt well to having less than perfect vision. From a surgeon's point of view I have seen it stated many times is that the key step for them is to screen their patients, and ensure they fully understand they are not getting a perfect solution, and what the compromises will be. Their worst nightmare is having the patient come back and want to have the lenses exchanged because they can't stand them. Responsible surgeons will do their best to screen those people out rather than push them to get the premium lens.

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      As far as being glasses free most of the time, if you can adapt well to monovision, then it may be a toss up between monovision and multifocal. The advantage that a trifocal may have is better intermediate vision. To a tennis player "watching the ball onto their racquet" that could be an advantage. The advantage to monovision is that you are more likely to avoid the optical issues like flare and halos.

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      Hope that helps some,

    • Posted

      i have come to a conclusion that unaided great quality close vision would only be possible with a trifocal. of course i talk about this only for myself. setting symfony at -2.5 would give me great close up but literally no intermediate and far. monofocal would be worse than symfony for this approach. the trifocals will come with the nighttime glare possibility.

      setting monofocal or symfony for -1.5 would give me workable near vision bu5 not great near vision. when i saw great i mean hd video on an iphone.

      again this is for myself only based on my one symfony exoerience.

    • Edited

      In today's political scene, Trump would be a Type A for sure. Hard to find Type B's at that level, but Biden would be closer to a type B. If you have seen the movie Caddy Shack (my favourite movie) there are some good examples. Ty (Chevy Chase) and Carl the greens keeper (Bill Murray) are obvious type B's. Al (Rodney Dangerfield) and the Judge (Ted Knight) are clearly type A's.

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      "personalities that are more competitive, highly organized, ambitious, impatient, highly aware of time management and/or aggressive are labeled Type A, while more relaxed, less 'neurotic', 'frantic', 'explainable' personalities are labeled Type B." from Wiki

    • Posted

      It is so true about personality traits and how they influence how a person perceives the outcome of the surgery. When I was deciding on lens options I read somewhere that a surgeon's worse patient is a type A who is an engineer by trade that wants to see a gnat on the back wall of a theatre, has astronomy as a hobby and a Jewish Lawyer for a brother-in-law.

    • Edited

      I'll chime in here as someone who took the old-fashioned monofocal route and who also wanted near vision prioritized. I've been quite nearsighted my whole life (-8 in both eyes before surgery), and didn't want to lose the close vision that I've always been used to.

      I had -2 Alcon Acrysof IQ lenses implanted in both eyes just over a year ago, with the final result (as of February - no doctor visits since then) being -2 in my dominant right eye and -2.5 in my left, i.e. mini-monovision. I deliberately didn't want to aim for mini-monovision, since I knew from reading (especially this forum!) that there are no guaranteed outcomes, and didn't want to wind up with too great a discrepancy between my eyes.

      Long story short...I am delighted. I spend most of my day reading or on the computer, and only put glasses on to watch TV or when I drive. I don't mind wearing glasses (I have progressive lenses) at all, but find that I just don't need them most of the time.

      At night I see slight haloes around car headlights, but they are as nothing compared to when I had cataracts, and don't interfere with driving. I haven't had any dysphotopsias. Oh, and I'm a Type B perfectionist. 😃

    • Edited

      That would be me, except I do target shooting instead of astronomy, and don't have a Jewish Lawyer (Yet...).

  • Posted

    You should take a hard look at the RxSight light adjustable lens. Search youtube. I don't think people realize what a game changer it is. Alcon, J&J, and especially Lensar want to keep it that way. You get to dial it in exactly how you want it.

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