Consultation on 2nd Eye Completed. Here's the plan.
Posted , 12 users are following.
Hi All,
I've been on and off visiting this forum for a few years since the start of this "journey" or whatever we want to call it. Approximately 4 years ago I had a mono-focal distance lens implanted in my left eye by a clinic in another country where I used to live. Great results--reading some letters at 20/10 in that eye at my most recent consultation. I'm clear at around 61cm and beyond. Inside of that and it's a struggle for reading. Right eye was relatively okay at the time and although I was offered to do that eye as well I decided to put it off. The diopter difference between the eyes was 2.0 (naturally nearsighted in the non-operated eye) and I just barely tolerated it.At the time, the plan in my head was to ultimately go for a mono-vision strategy using another mono-focal lens with maybe a 1.50D targeted offset when my eye got worse. This was until I started reading about EDOF lenses in the past year or so.
Flash forward to this year and my right eye has become significantly worse. Pretty useless, really. I've been to two clinics locally where I live now and both were giving me unsatisfactory advice. One didn't even bring up mono-vision as an option and I had to suggest it. The other told me he'd never seen a patient so informed in his life (thanks to all of you guys and gals!). One suggested a 1.00D offset (after I brought up mono-vision), the other a 2.00D offset. I suggested 1.50D to the latter doc and he was okay with that. Neither doc mentioned anything about an EDOF lens as an option.So I decided to visit my original surgeon recently because I did click with him, he actually listens to me, and he did do a great job on my left eye previously.
I ate the cost of a plane ticket and accommodation and had my consultation with him last week. I've always been intrigued with pursuing one of the newer EDOF lenses for my "near" eye because I didn't want to lose too much stereopsis whilst gaining some reading vision. This was my theory anyway.No sooner than we started our discussion after my tests, he brought up the Rayner EMV EDOF lens which, with a little less than a 1.00D offset, he said should give me what I'm looking for. He wants to use femtosecond laser surgery which could be a ploy to pad the bill I suppose but I'm not sure. Maybe there's some logic or benefit to it, but I don't know. A lot I've read on the subject seems to point to a rather high cost/benefit ratio. Regardless I'm going to trust his judgement and will hopefully get this done in the latter part of September. I'm super excited about finally getting this done with a strategy that makes sense to me in the context of my goals. I'll let you all know how it goes and good luck to everyone on this forum.
IG
1 like, 33 replies
RonAKA indygeo
Posted
It sounds like you have a good plan. I am not familiar with the Rayner lens, but I did consider a Vivity for my near eye. It also would benefit most with a -1.0 target. What you gain with an EDOF over a monofocal for the near eye, is a little bit better distance vision in the near eye. The compromise of course is the risk of optical side effects from the EDOF. In the end my surgeon discouraged me from getting the Vivity, and I went with a monofocal Clareon. It is not perfect, but I am probably 95% or more eyeglasses free.
indygeo RonAKA
Posted
RonAKA, I think you've had an excellent outcome. I last recall you said you might get a laser procedure to eek out a bit of improvement. But honestly, I'd be quite happy if my results ended up similar to yours now. The Rayner is much like all the other EDOF lenses from my understanding with perhaps a few nuanced differences that I'm not expert enough to speak intelligently about. In any case, I'm comfortable with the choice at this point. Quite a few Youtube videos on the Rayner EMV look encouraging.
IG
john20510 RonAKA
Posted
lm going with vivity in a few weeks, why did your surgeon discourage you from vivity
RonAKA john20510
Posted
I had asked him about using the Vivity and what his experience was with it. He responded that he had a "particular" patient that wanted it, and was not happy with the outcome. I believe he categorized me as a fussy patient and was concerned he was going to end up with another unsatisfied patient. We will never know as I went with a Clareon monofocal.
rwbil indygeo
Edited
The Rayner EMV from what I have read falls into the "Premium" Monfocal category the same as Eyhance and Vivity.
And even though it is FDA approved you don't read much about it. I guess doctors in the US are more tied to one of the two major companies.
From the little I have read I think the Rayner EDOF will perform similarly to Vivity, so it seems like -1.0 (D) should accomplish your goals of small amount of monovision and yet gaining some more close up vision.
Keep us informed as this particular IOL Pairing is not talked about much.
indygeo rwbil
Posted
Hi Rwbil,
Yes, I'll definitely keep you all informed of the results. It's a rather rare paring indeed. I've not personally run across anyone really who have had the mono-focal in one eye and the Rayner EMV (or any EDOF lense) in the other, although I have to say there is some literature out there of a study that showed reasonably high patient satisfaction with this arrangement.
IG
rwbil indygeo
Posted
I have mix and match IOLs, but you are right many doctors, actual probably most as most just implant a monofocal, will not do mix and match.
Not 100% sure why, but I guess it might be there is no or few clinical trials to know the results and there is not a lot of reason for a company to fund such a trial.
indygeo rwbil
Edited
Yes, there aren't many studies out there with the mix of the Mono-focal with an EDOF like the Rayner EMV. My surgeon seems to have a lot of confidence in the Rayner, however and he's considering around a 0.85 offset. What's interesting about the Rayer EMV is it also has some hyperopia "add" which even if you hit a target of, say, -0.50, one can still wind up with 20/20 distance vision. It's a very forgiving lens. He said I'd still retain some distance vision with the lens whilst gaining functional reading ability---perhaps not the tiniest pill bottle print, but yes to a book or newspaper.Needless to say my fingers are crossed for a good outcome. I trust my surgeon as much as I could trust anyone.I'm really looking forward to getting this done.
IG
Myope_PSC indygeo
Edited
I hesitate to add the following to the topic as it seems that you've confidently made your decision and really trust your surgeon. I don't want to cause any second guessing but this public forum is all about getting as much information as we can prior to surgery. It's so confusing and difficult to sort through it all.
Emmetropia is described as eyes that are within a range of +0.50D to -0.50D. My assumption is that a 20/20 score after testing should follow for most people with healthy eyes if they end up with a spherical equivalent in that range. The 20/20 image would be clearer the closer you are plano.
This study might be worth considering: "Laboratory Investigation of Preclinical Visual-Quality Metrics and Halo-Size in Enhanced Monofocal Intraocular Lenses"
It appears that the RayOne EMV at plano has less depth of focus than the ICB00 (Eyhance). They mention a risk of increased halo size. It might also be worth reading about hydrophilic lenses and calcification and PCO to see if any of the increased risk factors apply to you. This is a fairly quick read: "Should We Abandon Hydrophilic Intraocular Lenses?".
As I mentioned, these decisions are so difficult. Trusting the surgeon is a huge part of it in my opinion but at the end of it all, the choices made become our individual responsibilities so the more information we get prior to surgery the better that decision should end up being.
RonAKA Myope_PSC
Posted
My understanding of emmetropia is that it is the best vision you can get. With some standard aspheric correcting IOLs the peak value of the defocus curve can be close to a LogMAR visual acuity of -0.1 which is about 20/15. They typically drop off in both + and - directions to a LogMar of 0.0 at -0.5 and +0.5 D or 20/20. This means you have a 1 D range as a target to hit 20/20 vision or a bit better. BUT, there is a huge difference in closer vision if you hit +0.5 D compared to -0.5 D. You gain a full 1.0 D of close vision when you hit -0.5 D compared to +0.5 D. So I always take it with a bit of a grain of salt when these experts say the lens has a flat landing area, with some even recommending that you target to be in the + side. This to me totally ignores the impact on closer vision.
rwbil Myope_PSC
Edited
I have not researched the RayOne EMV so don’t know how its design compares to other hydrophilic lenses, but in an article in Review of Opthamolgy, An Update On Monofocal-plus IOLs, states the RayOne EMV has an enhanced square edge design to reduce PCO and a study showed a YAG rate of 1.7 percent at 24 months.
As time passes it will be interesting to see more studies of these “Premium” Monofocals and their results.
I also did a quick look at the study you showed and maybe I missed something, but confused by your conclusions.
The study is self was a bit confusing as it compared monocular implantation of the ICB00 to monovision implantation of the Ray One EMV to a standard monofocal. The study also mentioned monocular results of RayOne. Best I could tell the increased halos was when the Ray One was used in monovision configuration.
I will also add the results state Defocus tolerance and when looking at the graph it states, Defocus tolerance of the weighted optical transfer function.
I will put the article results and conclusions below so others can make their interpretation of the results:
Results: The monofocal IOL showed the highest image quality at the far focus. The ICB00's, the AE2UV/ZOE's, and the IsoPure's performance at - 1D was superior to that of the monofocal lens. The monocular defocus tolerance of the RayOne EMV was comparable with that of the ZCB00. The RayOne EMV's intermediate range was improved in a monovision configuration (- 1D offset). This approach, however, yielded the largest halo area, i.e., 53% of the ZCB00's halo, compared to 34% for the IsoPure, 14% for the AE2UV/ZOE, and 8% for the ICB00.
Conclusion: The mono-EDoF models have a clear advantage over the standard monofocal lens by expanded imaging capability beyond - 0.5D. Although the RayOne EMV provided the largest (binocular) visual-range extension, it was at the expense of monocular vision and higher susceptibility to halo. The ICB00's and the AE2UV/ZOE's halo-profile was similar to that of the ZCB00, indicating their low potential to induce photic phenomena.
RonAKA indygeo
Edited
Here is a link to an article from 2018 where "hybrid monovision" was reported to be used in some patients with good success. This is when a EDOF or MF is used in the non dominant eye.
Clinics in Surgery Article 2027 Monovision Strategies: Our Experience and Approach on Pseudophakic Monovision Misae Ito CO* and Kimiya Shimizu
Myope_PSC rwbil
Posted
Wouldn't any monofocal combo give increased depth of focus when one is offset by -1D? That's what monovision does.
ZCB00 is the basic Tecnis monofocal. I read that to mean that the Rayone EMV and a standard monofocal have similar defocus tolerance.
Wouldn't that then mean that using 2 Rayone's in a monovision setup be similar to using 2 standard monofocals in a monovision setup?
RonAKA Myope_PSC
Edited
The defocus curves in the article below show that the RayOne EMV provides a wider range of defocus than the Tecnis Eyhance. Neither one holds 20/20 at +0.5 D but the EMV is better. The Eyhance holds 20/20 at -0.5 D but rolls off more quickly after that.
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RayOne EMV and TECNIS Eyhance: A Comparative Clinical Defocus Curve White Paper
.
It would seem that the EMV is more comparable to the Vivity than to the Eyhance.
rwbil Myope_PSC
Edited
I cannot believe my reply went into moderation so I will just try a simpler reply.
Frankly I do not 100% understand that chart, but from clinical studies and other articles I have read the RayOne EMV Visual Acuity is better at intermediate vision than the Eyhance, which is better than a monofocal.
Myope_PSC rwbil
Posted
Ron - the chart in the paper you linked to shows the EMV (Enhanced MonoVision) as being at -2.5D defocus at 0.2 logMAR.
The chart in the study I linked to also shows the EMV (Enhanced MonoVision) as being at -2.5D defocus at 0.2 logMAR.
The chart you linked to shows a single curve for the EMV "solution". The chart I linked to shows it takes two IOL's to get to that -2.5D defocus point. Two IOLs with one significantly offset from plano = monovision.
Rayner describes a bilateral plano targeted solutions as "duets" and bilateral plano IOL + offset IOL as "monovision"
The EMV is listed on their site as a monofocal IOL. They clearly show it as being a 2 IOL solution to get -2.25D defocus. From their site:
Dominant / Non-dominant / depth of focus
0D 0.00 D 1.25 D (~80 cm)
0D 0.25 D 1.50 D (~66 cm)
0D 0.50 D 1.75 D (~57 cm)
0D 0.75 D 2.00 D (~50 cm)
0D 1.00 D 2.25 D (~44 cm)
Another way to look at this type of info:
Ron recently posted that he can see from about 10" to far distance with his monovision setup.
1M=39.4"
39.4"/4D=9.85"
Ron has almost 4 diopters of defocus using standard monofocals in a monovision setup. It's probably not at 0.2 logMAR at 10" but I'd be pretty sure that he exceeds 2.25D to 2.5D of defocus at 0.2 logMAR and he's using standard monofocals.
RonAKA Myope_PSC
Posted
That would seem to be very deceptive on the part of Rayner to show a defocus curve appearing to be a single lens that is really two lenses in a monovision configuration. Also the defocus curve does not seem to show that. If for example they split them by 1 D then I would expect to see a maximum LogMAR peaking at -1 D and at 0.0 D. They just show it peaking at 0.0 D.
rwbil Myope_PSC
Edited
First in full disclosure, I have done no real research on RayOne EMV.
If I understand you correctly you are saying Ray One EMV is a standard monofocal and only achieves EDOF by using it in a monovision configuration. In other words, Ray One EMV is posting monovision results to achieve EDOF.
So let look at Ron’s Article chart at -2.5 (D) which is around 16”. I will round to make things easier and please let me know if I am off. From Ron’s article chart VA (decimal) is about .6 which is around 20/32 and Tecnis Eyhance is roughly 0.3 decimal or 20/63.
But you are saying those results are only obtain with Ray One being used in a monovision configuration.
OK, I am not sure what to say if that is the case, as it is comparing apples and oranges and one heck of a Scam IMHO.
If your statement is accurate then has Ray One done something to make their EMV IOL work better in a monovision setting than any other standard monofocal.
If all this is correct, then this IOL does not really fall into the category of "Premium" Monofocals, but into some new category of "Improved" Monovision or something. I am now completely confused.
Myope_PSC rwbil
Edited
Yes, an apples to oranges comparision sums it up well from what I see.
Defocus tolerance for single IOL plano target could look something like this:
Monofocal 1D (~100 cm)
Rayone EMV 1.25 D (~80 cm)
Eyhance 1.50 D (~66 cm)
Vivity 2.00 D (~50 cm)
rwbil Myope_PSC
Posted
When RayOne EMV first got FDA approved I read articles that came out comparing it to Eyhance and Vivity and putting it in the same category.
I have no interest in Ray One EMV so I have not done any real research o it.
But if they are comparing bilateral implementation of Eyhance and Vivity set to plano to a Ray One EMS set to monovision (whether it be -1 D or -1.5 D) that is IMHO a meaningless comparison.
A more meaningful comparison would be to compare the Ray One EMV to other monofocals set to the same amount of monovision, it order to show it has some superior monovision than other monofocals.
Again in full disclosure I know very little about Ray One EMV and don't see many doctors in the US using or discussing that IOL.
Hopefully someone that know a lot about this IOL can shed some light on the subject.
RicG rwbil
Edited
The initial idea (by Graham Barrett) behind that lens is to use an aspheric lens for the dominant eye set to plano, and a lens with positive spherical aberration set to ca. -1.5D in the non-dominant. He didn't intend to use two identical lenses in a monovision setup.
You can look up Graham Barrett's Patent if you search for Patent WO2013018379A1 which explains the concept.
I find the defocus curves that Rayner issued confusing. The one on their website lets an 2xEMV monovision look inferior to an 2xAspheric monovision.