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.
0 likes, 35 replies
RonAKA shel53548
Edited
Here are my thoughts on conflicting opinions. But, let me warn you up front they are based on very limited data; that is my personal experience with one surgeon, and a friends experience with another surgeon. We are both in Alberta, Canada, and the issues may be different in the US, assuming that is where you are?
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My friend got into the cataract decision about 2 years ago. She agonized over the choices but decided on a multifocal PanOptix (tri focal) lens in both eyes. The surgery was done in a private office kind of like you describe -- state of the art. While she was initially happy with the results and expected the side effects would improve with time, they actually did not. She now thinks she made a mistake in going multi focal. Here main issues are halos around lights at night to the point she will not drive at night, and reading especially in lower light. Even with brighter light she uses +1.75 readers for reading. While one could conclude that perhaps they "missed" on the correction, it would seem odd that they missed with both eyes. This said, if you search here you will find many posters who have had PanOptix and are very happy with them. This is just a sample of one.
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I was next and we live in a different city and I was referred to a different surgeon. In Canada we really do not have much ability to "shop around" for a surgeon. I recall I waited 10 months just to see the surgeon for a initial assessment appointment. He is a university professor in ophthalmology and does all of his work out of a hospital that has a large eye specialist department. A number of different independent ophthalmologists use the same facility and equipment. I was referred to this guy by my optometrist who said that he would offer premium lenses if they were suitable. When we discussed the options after he reviewed the detailed measurements, he said multifocal options were available but he had a hard time recommending them to patients because he would not put them in his own eyes. I was somewhat prepared for this and had investigated multifocals and concluded I did not have the right personality for them -- a bit of a perfectionist I am! We moved on to toric lenses and he said that I did not have enough astigmatism to use them. He suggested that non toric lenses were best and if they did not achieve the vision I wanted then he could do some correction with Lasik to correct any residual error. From there we moved on to the issue of glistenings that the Alcon AcrySof lenses are said to be susceptible to. He said that in his practice he had seen them but they had never been significant enough to be a optical concern. He also claimed Alcon had made QA improvements that had significantly reduced the incidence of them. He has been a paid consultant for Alcon in the past. But, he said if I was concerned he was quite prepared to use the Tecnis lenses which are claimed to be free of glistenings. In the discussion he said that the glistenings issue in his opinion had been overstated by some in the industry. He went on to "talk out of school" about some of his peers in the city that operate out of their own offices with their "own" equipment. He basically suggested in so many words that their full office equipment had been supplied free of charge from Tecnis and that they were a a little bias in what they recommend for lenses, and were liberal in their criticism of AcrySof.
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My point in telling the story is that there are things going on behind the scenes having to do with the economics of a practice that may have some influence on the recommendations the surgeons provide to the patient. To be frank, there is more money in prescribing premium lenses than standard ones. I think an ethical surgeon would provide all alternatives with their associated pros and cons and let the patient decide which way to go, with eyes wide open! I suspect some do, and some may not. It is kind of a buyer beware issue.
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My thoughts in your case if it is feasible would be to get a third opinion from another surgeon that perhaps would not be so polarized in choices. In your case, I think monovison would be a safe choice, and the questions is whether or not multifocal would offer a benefit to offset the potential risks of it. It is not an easy choice.
soks RonAKA
Posted
your friend's scenario is what i worry about. i have also seen in here someone with synergy say that they need enlarging mirror for make up.
i wonder if this is a case where your friend would need a much larger reading correction with a monofocal than required by general population.
with symfony i definitely need 1.25 readers for computer and 2.5 readers for closer HD quality. also my side effects never got better if at all anything they got worse in 2 years.
RonAKA soks
Posted
I really can't explain it. My friend is not an extreme type A personality, but is certainly a perfectionist. I think her expectations for the lens may have been too high, and she is having trouble adjusting to the reality. That said, personality types really do not explain why one would need +1.75 readers to read in daylight with the PanOptix. I just don't understand it. I know she has prism issues and has always had issues with getting good eyeglass prescriptions, but, I just don't know. I know I share her perfectionist issues and have concluded this is not the road for me.
Chris53317 RonAKA
Posted
Ron: I am "going out on a limb" here, please excuse me. I have the ultimate respect for you and all the contributions you have made to this forum from your extensive research.
However, your ongoing reference to your friends situation seems like judging the viability of a product based on a single patient. I am not in denial of her issues, but the more information you post on her seems to indicate that she was either not a good candidate for a multifocal lens or more likely failures by the surgeon. Failures in pre-op assessment and measurement, and failures in post-op remedial actions.
Yes, there is a small percentage of patients with poor outcomes, with any lens, but that should not deter someone from making an informed choice for that lens.
Feel free to use me as a reference as a second point in your statistics. Type B personality but also a perfectionist. 20/20 vision with my trifocals and can thread a needle without glasses. Completely glasses free even with residual .25 & .75 astigmatism. Mild halos with LED car lights, day or night, but quite acceptable.
I have no reservations in recommending this lens along with my surgeon to anyone. Maybe some other lens would have been just as good or even better but there is no trial option, so I will never know.
All the best to you and your upcoming procedure!
Sue.An2 Chris53317
Posted
Agree with you Chris. One cannot assess a lens or anything on anecdotal examples. Had this same argument with a family member over vaccinations.
That being said it is not a comfort to the 5% who end up in the small statistics of those with poor outcomes. My Symfony ho e me good near vision although when reading in low light or extended periods of time (small print) I do have readers +1.25.
My friends would consider me with perfectionist tendencies too. Not sure I am classic Type A though or as one gets older you tend to have to live with many imperfections.
I still do see huge concentric circles around some lights but they are light and now it's been 3 years since surgery my brain tubes them out. Glare is minimal. I drive at night regularly - have to from Oct to Feb with less daylight hours
RonAKA Chris53317
Posted
I am just reporting the facts as I know them, and did condition them with the fact that it was only one data point (well two, if you count both eyes). And, as for my surgeon, again I am just repeating what he told me. It is just information to think about. My ongoing point is that one should not get the impression that a so called "Premium" lens is better than a standard monofocal lens. It is a different lens, with different pros and cons. They may be more appropriate for some, while a standard lens may be more appropriate for others.
Sue.An2 shel53548
Edited
Shel53548 You will find most surgeons have a bias or their go to lenses. I would not push one to go with a lens not in their wheelhouse. There are pros and cons / trade offs to every IOL. Best you decide what compromises you want to live with. If you have cataracts that require surgery you'll find your vision vastly improved after successful surgery no matter the lens. Forums tend to be more on negative side as people do a search if not all is well. People with successful surgeries rarely post unless they were on the forums searching prior to surgeries and even in that you'll find both success and unsuccessful experiences.
Do your homework on IOL selection, seek out several consults and then trust that surgeon.
I had my surgeries 3 years ago now. There are always better lenses coming onto the market. I live in Canada and at that time symfony EDOF lenses were new on the market and no trifocal was available. I went with these and all worked put well.
Now is the time to read up and then decide what trade-offs you can live with. My own surgeon (as I was younger at 53 for cataracts) said older patients gain something but the younger you are the more compromises you need to make.
Wishing you the best.
RonAKA Sue.An2
Posted
I have to agree with what Su.An2 has said about surgeons having their personal preferences on what lens they like to use. In my case I was quite aware of the multifocal option early on, but my research on it, even when my friend was at that point still positive on the PanOptix, was that this option was not the one for me. I had pretty much dismissed it before I went to the first visit with my surgeon. Since I had dismissed it, there was no real issue when he also dismissed it as a good option. However, if I had been really determined to get a multifocal lens, I am not sure what I would have done at that point. He did not say he would not use a multifocal. He only said he had a hard time recommending it. But, then would I have trusted him to do a good job, when he was not recommending the lens? At that point I probably would have gone to another surgeon to get another opinion. If you are in the US that is a reasonable thing to do. In Canada it would be difficult.
Chris53317 RonAKA
Posted
I understand and agree with your thinking. My eye doctor was strongly opposed to multifocals, but after examination and testing my surgeon said that I was a good candidate for them. In Toronto we are fortunate to have access to lots of surgeons/clinics. I think I was referred to the best by my eye doctor. I would likely not have gone for a third opinion if the surgeon was against them for me.
Sue.An2 RonAKA
Posted
I think in Canada as this surgery is covered under medicare most the surgeons do more the these surgeries with monofocals. In recent years my friends in Quebec let me know that province now covers premium lenses and more are opting for them.
Chris53317 Sue.An2
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In Ontario only the basic surgery with basic lens are covered.
RonAKA Sue.An2
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In Alberta they cover the full cost of either the AcrySof or Tecnis aspheric lens. My surgeon says the cost of the Tecnis is a bit higher, but they still cover it. So far my one lens has cost me $70 for the eye drops and dark glasses kit. A toric lens would be an extra cost, as would the multifocal. We never went down the toric road, but I believe the extra cost of it is in the order of $500-$1000 per lens. I was quite prepared to pay that, but the surgeon said it was not suitable for the small amount of astigmatism I have. I've kind of forgotten now, but I think my friend paid about $5,000 extra for the PanOptix. She also seem to get stuck with some very expensive eye drops before and after the surgery. No idea what they were.
Sue.An2 RonAKA
Posted
Interesting here in NB I only paid the difference between the premium lens I chose and a monofocal which was $900. I was credited the $300 for the monofical as the Symfony lens was $1,200.
Surgery was covered regardless. If you went private though I am not sure it would be covered at all. must be done thru the hospital and cataract has to be bad enough you wouldn't pass vision test for driver's lic. Ron perhaps your friend didn't have a cataract bad enough or went private - no way it should cost $5,000 in Canada.
Quebec is now covering total cost no matter what lens you choose.
My drops weren't covered by medicare but my insurance plan thru work covered it.
Sue.An2 Chris53317
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Are you credited the cost of a basic lens and pay the difference? We are here in NB
RonAKA Sue.An2
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In Alberta we have a mixture of surgeons working out of the hospitals, and private offices. Not totally sure of how much there is of each. There is a current move to increasing the number of cataract surgeries done in private facilities to try and reduce the cataract surgery backlog. I don't believe it makes any difference to the basic costs whether or not it is done private or in hospital. It is covered up to the basic aspheric monofocal lens level, and you pay the differential above that. Not sure to what extent the extra costs of premium lenses is regulated. You certainly can for Lasik type surgeries, but not sure about a full IOL operation.
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For sure she had cataracts and just could not correct her vision with eyeglasses any longer. I am not sure that you could just pay for cosmetic IOLs not needed for cataracts.
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It is a little irritating that we send Quebec $12 billion a year in charitable equalization and then they provide Cadillac health care plans with it.
Sue.An2 RonAKA
Posted
Having lived in Quebec many years do appreciate they are far more socialistic than rest of Canada. Daycare at $7 (might be $13 a day now) was awesome. Daycare here can cost as much as your mortgage pymt.
I am not a fan but yes people do clear lens exchange (cataract surgery) to rid themselves of glasses. Often called Presbyvision. 100% not covered by Canada's medicare.
Chris53317 Sue.An2
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After measurements and assessment I was presented with a fee schedule for the six package offering ranging from the free basic lens & surgery procedure (OHIP covered) to the combinations consisting of aspheric, premium, mutifocal, and laser assisted surgery. The clinic claims to basic cost from the government and the client pays any additional costs.
The fee schedule is per eye with no reduction if both eye are operated on. It would be possible to mix and match packages by eye.
It is not clear is post surgery fine tuning procedures would be covered. There was no charge for the PCO procedure that I subsequently needed, but I suspect that was covered under the provincial health care plan.