Dr's recommending EDoF/MF IOL.I'm not yet convinced

The post you are referring to is Danish Viking's. He has a Zeiss LARA and LISA so has the benefit of lenses from the same manufacturer. Symfony (Tecnis) and PanOptix are made by different manufacturer and the PanOptix has a yellow tint to. Something to keep in mind. The trifocal introduced by Tecnis also has a yellow tint to it which puts Symfony users in a spot.

It was a very long thread, and I somehow missed that part. I believe it started out as a EDOF lens in one eye and a trifocal lens in the other. I guess I made some assumptions....

Thank you all for your help. @Danish_Viking, I asked the 2nd Dr about minimono because as you point out that would probably address my top priorities best . He rejected it immediately and went to the Symfony recommendation. Guess it's time for a 3rd opinion!

Out of general interest why are you ruling out monovision? You are in an ideal situation to try it out as you already wear contacts, and they could meet all your priorities.

Your #3 priority for no halos tends to rule out trifocals or EDoF IOLs, but you could still experience some of this with monofocal lens. I have trifocals and experience halos/starburst but manage driving in a big city without any difficulty.

An alternative to monovision for your situation would be monofocals set for distance with reading glasses for closeup work (not meeting #5 without glasses).

The measurements taken prior to surgery, by the IOL Master device, are usually pretty good, and you should have this measurement taken where the condition of your eyes will be similar to after the surgery. That is why it is strongly recommended that contacts not be worn for 2 weeks prior as they influence the same of your cornea. If you are prepared to wear progressive lens in glasses then an exact measurement is less critical as the prescription of the glasses will take care of the final adjustments for distance, near, and minor astigmatism.

Finding another doctor would seem to be a good idea.

In general I've rejected monovision for a couple of reasons. Firstly because of concern for depth perception. My wife had monovision done with her lasik and hated it. I could see that when we played tennis she struggled to see the ball as it was coming over the net in that intermediate zone. She had it redone after about a month and has been happy every since. Secondly, I don't mind reading glasses as I already use them for the past 3+ years. I'm very active and depend on my depth perception in a lot of situations. I would rather have my eyes working more closely together over most distances and use readers when needed. My ideal outcome (if there is such a thing) would be to have excellent distance and intermediate vision, the ability to read part of the time without glasses, and readers for fine print and short work.

Having said all that has come before I realize there are a few items I've failed to mention that may or may not be of consequence.

Another reason I'm concerned about photic events and low-light situations is I really enjoy HD cinema, and have researched extensively and invested substantially in a home theater system that me and my wife get a great deal of pleasure from (I know, 1st world problems). Halos and glare are two things I'm familiar with in this setting and are highly undesirable.

Also, I have a small amount of astigmatism in both eyes. Dr. 2 planned to address it with LRI using a laser during the cataract procedure. I don't know what Dr. 1's plan for this was.

Thank you for your detailed reply! This is great information that definitely benefits us all. Thanks also for the article referral. Looking it up now!

Here is another article to have a look at. It is more dated, but it addresses the pros and cons of more and less Anisometropia, and what the optimum might be. It addresses the issues of how binocular corrected distance visual acuity varies with distance, when using 1, 1.5, and 2 levels. It also addresses the issue of stereoacuity which I think is the aspect of being able to judge distances with the same levels of undercorrection. It is one of the tougher ones to read, but I think it has some good info in it.

Optimal Amount of Anisometropia for Pseudophakic Monovision Ken Hayashi, MD; Motoaki Yoshida, MD; Shin-ichi Manabe, MD; Hideyuki Hayashi, MD

An interesting observation on the article "Revisiting monovision..." is the lack of any mention about the potential side effects of MFIOS or EDOF.

My conclusion is the best candidate for any form of monovision is

a. someone who naturally has monovision (rare but a friend of mine has this),

b. someone who already uses contact lenses in monvision configuration, or

c. someone who can spend the time trying it and confirming that they can adapt.

I think the latter requires at least 3 weeks of trial. Considering that you only get one shot at this, a 3-week trial for something that you may have for the rest of your life is not bad. Doing a 2 or 3 day trial and then committing it is more risky, but if it does not work then you are committed to glasses of corrective surgery like LASIC.

i am not sure whether a 3 week trial would be necessary if a mini monovision done. The IOLs shift back and forth on the healing process (6 weeks) before they settle ad adhere. So you could end up .25 diopter either way. That's one of the biggest reasons surgeons cannot always hit target. Most won't aim for plano (usually target is .25 diopter nearsighted). If they aim for plano you could end up farsighted. Each eye with the healing process (even if best distance is targeted) could be potentially .50 difference). A small amount if monovision can be tolerated by most people 1.0 diopter at most.

Just to add to my post - if at all concerned - mixing a monofocal with an EDOF would help as there is seamless vision with the range of an EDOF IOL.

Just more to think about - good that you are thinking about all this prior to surgery. Helps you come to a solution that is best for you.

It seems to me that one of the considerations of a monovision solution is that glasses are always there as a plan B. Even in the case when the monovision is perfect, there is no reason other than cost that one could not have prescription progressive glasses to correct for any distance and near reading. They could be used for night driving and reading in dimmer light or very small text. However, if one is having glare and halos at night with a multifocal or EDOF, I don't believe that can be corrected with glasses. I think realistically that with monovision or the multifocal solutions one is going to end up with at least reading glasses. Same with full distance in both eyes, for sure one will need reading glasses.

Ron - maybe I am misunderstanding - but, your are right, halos and glare can not be corrected with glasses.

When it comes to near vision, a lot of people are free of reading glasses with multifocals, and some people with monovision are also free of reading glasses.

In a forum like this, you will mainly find posts from those who are not satisfied with their result.

A lot of people are very satisfied with their lenses, but they don´t spend their time on a forum like this 😃

Chris said: "An interesting observation on the article "Revisiting monovision..." is the lack of any mention about the potential side effects of MFIOS or EDOF."

Yes, she seems to be assuming that a monofocal distance lens with a MFIOS or EDOF in the other eye, will result in the monofocal distance eye suppressing issues like halos and flare at night. I am not sure that is a good assumption. I have had experience with -1.25 monovision with contacts, and now I kind of have monovision as I can easily read this computer screen with my good eye, while suppressing the total blur I get with my cataract eye. But, I have no experience with whether one could suppress halos and flare. I do recall there are contributors here that have that solution.

Great discussion. Thank you all for your thoughtful comments. To address some of the questions brought up here:

**

Considering that you only get one shot at this, a 3-week trial for something that you may have for the rest of your life is not bad*

Unfortunately I don't think this is an option for me as my LE is completely clouded with the cataract, which is what drove me to see my optometrist in the first place. Having said that, I'm finding it's bothering me less and less and my dominant RE is taking over in distance and driving situations. Yesterday driving in good light with glasses I was surprised to find my vision was really good and did not suffer the blurring/haze of the LE. In reality my eyes have always been a little different even with correction. My RE has always been superior for distance.*

I think realistically that with monovision or the multifocal solutions one is going to end up with at least reading glasses. Same with full distance in both eyes, for sure one will need reading glasses.

I'm completely ok with reading glasses. I would like to see relatively well in the 18" - 20" range to read my bike computer (Large/medium font) and GPS watch (Medium/small font). However, there are reading glass solutions for cycling glasses that are acceptable options.

assuming that a monofocal distance lens with a MFIOS or EDOF in the other eye, will result in the monofocal distance eye suppressing issues like halos and flare at night. I am not sure that is a good assumption

Agreed. I think I would be very disappointed if I made that assumption and it didn't work out. I'm just not sure what my ability to neuro-adapt is. Although yesterday's driving experience was encouraging, I will be be closely monitoring how this plays out over different scenarios and lighting conditions over the next few weeks.

Still going back to Dr. 1"s office next week to have my eyes measured. Hopefully I can discuss some of these observations with him, as he initially suggested a monovison approach. Still trying to decide who to reach out to for a 3rd opinion as it's hard to discern who does what well from their websites, and it's expense out of pocket ($350 for the consult with Dr. 2)

There is an interesting youtube video that is focused on adaptive training for monovision, but it also touches on dealing with glare. Search for the title "How to get the best from Monovision". It is by wellingtoneyeclinic, and seems very logical. I wonder how many people with monovision IOLs were given this guidance.

Yes seeherenow has that set up with a monofocal in dominant eye targeted for best distance and it does suppress halos / concentric circles that he sees with EDOF Symfony lens in the non dominant eye.

Your brain will normally choose the better vision. Currently I am experiencing blurry vision out of LE (new experience - a change from result had after cataract surgery). With both eyes open I see clearly - it is only when I close RE that things are blurry.

That is a good video. IF, and I would suggest that is a significant "IF", this works, then it could conceivably work also suppress glare and halos with a multifocal or EDOF lens in the reading optimized eye too. However that might be a touch more difficult.

As I have kind of dismissed EDOF and MFIOL lens solutions, I have to admit I have spent much more time on the monovision option, as well as the pros and cons of different monofocal lens materials and designs. With respect to the monovision option I have found a couple of graphs in that Optimal Amount of Anisometropia article the most useful in understanding what they can and cannot do. The first graph of help to me is the binocular corrected distance visual acuity (CDVA) graph shown below. First I find it surprising that the three (1, 1.5, & 2) had such a small impart on distance. I presume that is because the distance eye is doing the lions share of the work, and the poorer eye does not compromise it very much at all. All options meet the 20/25 minimum standard. Second it becomes obvious in the 0.7 to 3 meter range, the -2.0 anisometropia solution compromises visual acuity the most, with the -1.5 also compromising this mid range but to a lesser degree. And last the -1.0 option provides the best, and virtually uncompromised mid and distance vision. However it comes up short of the 20/40 minimum standard set for 0.3 meters or 1 foot set for close reading.

My vision requirements in order are:

1. Reading text on a 24" computer monitor, probably at about 0.4 meters
2. Watching TV at 2 meters
3. Driving, mainly in the daytime, and only occasionally at night

It would seem that a -1.0 anisometropia would meet all those requirement, and a -1.25 almost for sure.

The second issue you mentioned was being able to judge distance which I believe is stereoacuity. That would be the ability to hit a tennis ball as close as 1 meter away. A -1.0 solution would seem to meet that for just visual acuity. The first article I posted seems to suggest that a reduction in stereoacuity of 50 or less is acceptable. This graph suggests that even in the worst case in the range of outcomes, the -1.0 meets that requirement, while the -1.5 probably does, but the worst case would fall short.

At least in my case, all of this seems to be pointing me toward a -1.0 to -1.25 monovision solution. My plan is to test those with contacts, providing my good eye is still good enough, and the litmus test would be the lowest one that still lets me use a computer without glasses. I would accept I will need reading glasses for the real fine print.

If I can't do a contact proof test, then I think I would guess at a -1.0 solution at this point. This factors in my age of 70 years, and that I have reduced maximum pupil size, which probably improves my depth of field. If I was younger like you, I think I would lean toward a -1.5 solution.

Just some more of my ever evolving thoughts on the subject, and hoping that they may be of help to someone else -- or at least stimulate some thinking...

Sorry, but 20/40 is not comfortable reading vision.

People in general need at least 20/32 to feel they have sufficient vision without glasses.

Monovision with 1.0 will in many cases require reading glasses for the 40cm distance, unless you have exceptional good vision.

When manufacturers put out these things, you always need to deduct quite a lot.

A trifocal have a 3.3 focal point for covering the 40cm distance, you won´t get there with a monofocal set at 1.0, unless you are one of the lucky few.

Sorry, but if it was that easy to give people reading vision at 40 cm, the multifocals and edof would never have been invented.

And edof gives you about 1 diopter more than a monofocal, so the edof covers the same range up close, as a monofocal set at 1.0

With two edof´s you have the bonus from binocular summation (means a lot), and still many people with edof uses reading glasses if they want to look at 40 cm, or they have two edof with slight monovision at 0.5-0.75 to give a little bit more close up vision.

Please search this site to supplement all the stuff you have read already 😃

blog/symfony-or-trifocal-intraocular-lens

Those are the things I will determine with my monofocal contacts trial experience. The proof of the pudding is always in the eating. My recollection is that -1.25 worked OK, but that is a few years ago. I will need to see if my increased age now with lower maximum pupil size improves that. Currently if I close my bad cataract eye, and just use my "good eye" without glasses which provide a -1.5 spherical correction, I can see the computer screen very clearly from 15 to 30 cm. The sweet spot almost seems to be about 20 cm and too close to the screen for comfort. -1.25 would likely be better, and -1.0 might be just fine. This assumes that at age 70 my natural lenses are providing no adaptive adjustment for close vision. That is something I have to investigate further. Can you judge what an IOL will do compared to a natural lens with a contact?

I suspect there is a lot of good information at this site, but I have not found the search capabilities to be that user friendly.

I am sorry, but those numbers are far from what most people can expect with iols.

The optics in the eyes are very mechanical, I guess you already know this with your engineer background. The closer things are to the eye, the more power you need to focus the image on the retina.

To see clear at 80cm you need about +1.5 added to plano.

To see clear at 40cm you need about +3.0 added to plano.

This is all mathematics, and have to do with the way the light needs to be concentrated in relation to distance to whatever is displayed.

Some people have better vision than others, and off course, if you see two lines better in a vision test compared to your neighbor, you can "afford" to loose two more lines than your neighbor and still have same vision as he have. So some people get more out of lens than others because they can afford to loose more than others.

Some also have more adaptive brains than the general population, and they can also get more vision from an out of focus image on the retina, for some strange reason.

But the big majority needs +1.5 for 80cm, and +3.0 for 40cm.

If we all could get reading vision at 40cm with a monofocal set at 1.0 nobody would ever choose a trifocal, there would simply not be a marked for trifocals and edof´s.

Iol power and glasses power are not the same, there is about a 1/3 difference, so this detail can make it all more confusing as well.

I would say that your eye must have some accommodation left, or there must be something else that is making you see well that close with that little power.

When people start to need reading glasses, 1.0 is really what people start with in their mid forties, in the stage where they still can function without, but feel more comfortable with the 1.0, in the stage when they only have very mild presbyopia.

With the iol you get full presbyopia, that will be a lot different than the mild presbyopia people have in their mid forties.

After I went to bed last night, I got to thinking that my crude test was not valid. Yes, my spherical correction in my good eye is -1.5, but I also have astigmatism correction at -1.0. I recall back years ago when I wore non toric contacts they would more or less add the spherical and cylindrical corrections to get a non toric single correction. With this method my test was really done with a rough equivalent of -2.5, which is probably why my range of focus is so close - too close. I guess I will have to wait until my contact lens trial to decide what I need for sure.

Your numbers seem to differ from what is actually being used today for monovision. Most are using mini monovision, or even micro monovision. Some base what they use on maximum pupil size and age, which are of course related. And in patients younger than 60 some do use MIOLs in the near focus eye. Wrapped up in that of course is the need to wear reading glasses at some point. My own personal experience from a few years ago was that -1.25 worked for me -- computer good, but fine print needed glasses.

Well, my own surgeries are over, and I am really only trying to help, I am not trying to win any arguments 😃

I am just a little bit afraid on your behalf, that you go into this with a very fixed mind about the outcome, and it will be very different from you expect.

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The numbers I am mentioning is exactly what are used today in multifocals, but there is a difference between the best focus point and the range of usable vision in monofocals.

You need to look at the defocus curves, then it makes better sense.

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When I say you need +3.0 to see clear at 40 cm, this is really what is needed in the majority of people, no question about it, this is why multifocals are made like they are.

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But on both sides of the focus point of a monofocal iol, the focus fades off slowly, so you will have some range on both sides of the focus point, where the image gets more and more out of focus, but still delivers something useable within a little bit of range.

This means, that a monofocal set for plano, will have some useable vision fading off the closer you get.

Useable vision is considered to be 20/32, two lines under 20/20.

A monofocal will normally give you useable vision in the range -1.0 to +1.0, fading off both sides of optimal focus point.

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You still set your far vision eye to plano if you can, because it does fade off, so if you don´t set it for plano, you will not have 20/20 far vision.

So the far monofocal set for plano, will give you useable vision to 1.0, with 20/20 vision at plano, fading off to 20/32 vision at 1.0.

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Then the monofocal for near, you set somewhat closer.

If you set the monofocal for near at 1.0 you will have the benefit that it give useable vision from -1.0 to +1.0.

This means a near monofocal set for 1.0 will give you useable vision from 0.0 (plano) to 2.0. This is why you don´t see any gap between the lenses with 1.0 monovision.

The near monofocal will normally by doing this give you 20/32 vision at plano, 20/20 vision at 1.0, and 20/32 vision at 2.0.

2.0 equals within arms length at 60-70cm.

Closer than this you will get below 20/32 vision, if your best vision is 20/20.

And this is really how it is in the real world, and it is confirmed in outcomes in all real life studies.

But humans factors always come into play, there will always be some that have results that varies from the majority.

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And still, the correction you use on the outside of the cornea, is not the same as the iol power that is on the inside of the cornea. The cornea is making up for about 2/3 of the focusing power of the optics in the eye, the natural lens or iol is only 1/3 of the focusing power in the optics.

So you can not transfer your power calculations from your glasses or contacts directly into iol power.

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Edof have double the range of a monofocal, so an edof set at plano, will give you useable vision to 2.0, instead of the 1.0 from a monofocal set at plano.

So one edof gives you same range as two monofocals with a 1.0 spread.

2.0 is still not real reading vision, and this is why, even with edof´s, many surgeons are making micromonovision with the edof´s with 0.5-0.75 spread, to stretch their reach into the 2.5-2.75 range. But because the edof´s almost covers the same range, you get binocular bonus a lot of the way, binocular summation gives you 25% more combined vision, equal to one line in a vision test, and normally 40% more contrast, so this setup with edof´s will give you stronger midrange and somewhat more close up vision than monovision with monofocals.

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Trifocals have 3 focal points. If we take Lisa that I have, it have plano, 1.66 and 3.33 in an attempt to cover all the way from plano to near. I can absolutely assure you, that I would not have reading vision without the 3.33 focal point.

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I am not saying people should choose edof´s or trifocals, side effects are not for all, you have to have a personality that allows you to forget about stuff like side effects. And not all have a mind that can do that.

I am happy with my result, but I fully understand why people choose monofocals.

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I rest my case here, I wish you the best of luck with your surgery, and I hope you make the choice that is right for you, and that you become satisfied with your result.

Cheers

Christian

My review of studies have conclusions that are somewhat mixed. Without going down the rabbit hole of detail, there are a good number of studies that show monovision provides equal satisfaction and eyeglass independence across all ranges of distance as does EDOF and MultiFocal solutions. There are probably an equal number of studies that find EDOF and MultiFocal may provide slightly better near vision. One could cherry pick to prove one option or the other. All studies seem to agree that side effect like halos, flaring, night vision driving, and reading in low light is worse with the EDOF and MultiFocal solutions. Nobody seems to contest that.

For that reason and my surgeon's advice, "I would not implant those lenses in my eyes", I have dismissed the EDOF and MultiFocal solutions for myself. The original poster is much younger than I am, and I am not lobbying for a monovision solution. It certainly is an option, but if I was much younger, I would also evaluate the option of multifocal in the closer eye and a monofocal aspheric in the distance eye. I am convinced it is a better solution than multifocal in both eyes. But that is just an opinion based on personal priorities.

Money was not a factor in my decision making. But I have read that some professionals believe that much of the interest in multifocal and EDOF solution is exactly that -- money. The industry is somewhat regulated in North America in how much they can charge for a monofocal solution, but they can charge what the market will pay for the so called premium lenses. My surgeon is obviously not in that category. However, one needs to consider that there may be other motives for recommending a certain type of lens. I had a bit of a discussion with my surgeon on glistenings and the use of Tecnis lenses instead of AcrySof (his recommended type). He said he has never had a bad experience with AcrySof but he would use Tecnis if I insisted. Then he went on to say that the choices are a source of controversy in the local profession. He quite surprisingly said that certain surgeons, who he did not name, had their offices fully equipped at no cost by Tecnis. He is a university professor that works out of the local hospital eye specialist clinic. Short story is that there can be other factors at play...

Haven't posted in this thread, but just to add a few comments. I was probably one of the first to post about my experience with PanOptix since it's been available two years earlier in Canada than in the US (it's on 2nd page now - Cataract Surgery Just Completed - Sharing my Experience PanOptix ).

I am conservative with my eyes. Never opted for laser vision correction, never even considered contact lens. I also had concerns about multi-focals, in particular contrast sensitivity. Despite my risk averse nature, I opted for PanOptix and am very happy with the results.

Some random thoughts:

• Satisfaction depends on expectations going in. Monofocals underpromise, and can sometimes over-deliver. Premium lens, if not explained fully, may result in too high expectation.
• many of the articles about issues with multi-focals are from the US, and the US experience with multi-focals until last fall has been with older bi-focals.
• you will get different opinions from different surgeons. Many US surgeons influenced by the so-so results that their patients got from older generation bi-focals, have negative opinions on premium lens. But many others, seeing the good results in Europe and Canada do recommend premium lens like the PanOptix for the right patients.
• my surgeon (also quite conservative) used to discourage premium lens options, but has been very happy with results her patients are getting with PanOptix.

Premium IOLs are not the right choice for everyone, but they have improved a lot. Do your own research, and based on your priorities pick what's best for you.

Hi Charles and Ron:)

Yes, I have the monofocal IOL in dominant eye set for best distance and Symfony in non-dominant eye set for very slightyly more near. This setup has resulted in nearly complete suppression of the halos/spiderwebs - I almost NEVER see them and when I do, they are faint and no problem.

It did take some months to reach this point of complete suppression, but it was good enough within a month after the 2nd eye (Symfony) surgery to be no problem at all. The eyes/brain can continue to improve even a year after surgery! As SueAn mentioned below, the brain will automatically choose the best option if you let it.

Best wishes for a great outcome!