Eyhance help please

Actually all the use of an Eyhance may do is complicate the eyeglasses power selection. The first issue is that when the peak visual acuity is flattened compared to a monofocal which has a higher and sharper peak, choosing the right power becomes more difficult for the patient. They have trouble deciding "which is better, A or B?". And the other part is that with progressives the intermediate and near vision is taken care of by the + Add. There is no need for the EDOF effect.

I don't agree. I have a high degree of natural EDOF due to keratoconus. I can still give very precise and consistent answers to which is better A or B. But at the same time, one pair of monofocal glasses (-0.75 undercorrection) is extremely versatile. They give me sharp enough road signs, a sharp dashboard, my best computer vision, okay phone vision, and okay book reading though for a long session with a book I want -2. I love it.

I can also completely remove the EDOF gift of my weird corneas by putting in scleral contacts, giving me, effectively, perfectly spherical corneas. Yes, the sclerals give me my best vision at a given distance, but only if I have on exactly the right glasses over them. I have 4 pairs of glasses I use with them. This is not a good tradeoff. I'll take EDOF any day over that extra bit of sharpness that also requires an arsenal of different glasses to achieve it.

I find progressives useless for intermediate. They say there's an intermediate region on the progressive lens vision corridor, but I can't find after 30 years looking for it.

Some progressive lenses are better than others. I find the Costco Accolade Freedom 4.0 HD Progressive Lenses to be very good. The other key is to get frames that have a higher than average height to the lens. If you pick a frame with a narrow lens, the height of the intermediate power section is compromised. The issue with progressives is that you have to tilt your head up and down to find the best part of the lens for the distance you want to see. Supposedly 28 mm is the minimum height required for progressive lenses, but more is better... The ones I currently have are 40 mm in height.

Some progressive lenses are better than others.

Indeed. I go to an independent optometrist who has his lenses made locally. He's more expensive than the chain stores, but the glasses I've gotten from him, for over 25 years, have been flawless.

When he made my new sunglasses after my cataract surgery he told me that he had made the intermediate and far zones larger and the near one smaller, since when you're wearing sunglasses you're usually not reading small print (and I wouldn't have the glasses on for reading anyway, given my near-distance IOLs.) The extra $$ are well worth it to me.

The IOL powers would indicate you were moderately myopic before surgery.

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Your eyeglass prescription post surgery is interesting. You have significant myopia in your OD, right eye, and twice as much in your OS, left eye. It is common to convert the combination of spherical error and cylinder error to a "spherical equivalent". This is kind of an approximation of the combined effect of sphere and cylinder error. The method is simple. The sphere error is added to 50% of the cylinder error. In your case:

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OD: 0.0 + (-1.25/2) = -0.625 D

OS: +0.25 + (-2.25/2) = -0.875 D

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This is a mild myopic outcome on average, but with strongly mixed astigmatism. Astigmatism can sometimes help with reading, so that may explain some of your reading vision. The sphere alone is essentially set for distance. So that may explain some of your distance vision. Perhaps mixed astigmatism can give a multifocal effect??? I am not aware of any commercial IOLs that intentionally do that. Astigmatism is a varying power of the lens as you go around the clock in angular position. MF and EDOF lenses typically vary the power in the radial direction. But in different ways they are presenting a mixed image to the retina that spreads the best focus rather than at a sharp consistent point.

before cataracts you wore glasses for distance between -2 and -2.75 sphere. very similar to mine. how did your near vision turn out with eyhance at plano in both eyes?

@Lynda111, I see I made a typo in my response to you. I said:

" You have significant myopia in your OD, right eye, and twice as much in your OS, left eye."

It should be "You have significant astigmatism....."

Wow! For starting so high with myopia and astigmatism your surgeon did an excellent job in lens power selection. I would consider the -0.5 D sphere in the left eye very minor and will contribute some with reading closer up. It is too bad about the PVD. I got PVD suddenly in my first eye about 10 months after surgery. It has faded slightly but is still annoying in certain lighting conditions. I am now about 10 months out from the second surgery and have not (fingers crossed) had the PVD issue in that eye yet...

Indeed, RonAKA, the PVDs are a bit of a pain. I was glad they both occurred well before I'd even started considering cataract surgery. Much is (rightly) made of monovision, which I used well for several years pre-op, but I am very glad to have full binocular vision at distance + glasses for reading with my somewhat dense PVDs. They rarely interfere with both eyes at the same time, so the clear eye can take over seamlessly when driving (or reading), for example.

what power reading glasses do you need?

Hi, soks. I'm still using cheap readers from the drugstore right now. I bought +1.0 for my long periods at my desktop computer (which I set well back on my desk) and if I want extra clarity e.g., at table or for cooking/preparing food, and +2.5 for reading my phone or paperbacks/low light. I grabbed these for the post-op period, rather randomly, but they work fine for now. My optometrist has given me a more accurate reading of +1.25 for intermediate and +2.25 for close reading if I want to pursue varifocals/more precise glasses. Hope this helps! It's a bit of a faff having two pairs of glasses, so I may get varifocals. On the other hand, the readers are really low-cost (10 pounds sterling apiece), while my vision other than reading is good, so I have yet to decide if I'll bother. Hope this helps!

I should add I'm fine on my pc without readers for casual use, but I use the +1.0 for work to get a really crisp view

It sounds like you found a really good sweet spot -- that is wonderful! How is contrast quality in lower light situations? Do you drive at night?

Hi, karbonbee. Indeed, I count myself very lucky. No problem driving at night. There is undeniably a bit of a halo around lights when shone directly into my eyes, but not at a problematic level. I can see both distance and dash (and google maps!) just fine both day and night. I couldn't drive at night prior to the surgery because of the cataracts, but all good now. As for contrast, the lower the light, the more I need reading glasses as expected. A couple of months on from surgery I'm finding the best way of functioning using cheap readers, which work fine so far, though as I've mentioned I may get some progressives or bifocals, so I only need one pair of glasses for intermediate (PC screen, cooking etc.) and close (reading good old small-print paperbacks!), and glasses-free otherwise.

That is awesome! I'm so happy for you. I'm still in the thinking phase, but I'm -13 & -14.65 in my and right and left eyes with minimal astigmatism (it was mostly corrected from years of wearing hard contact lenses), and started developing early onset cataracts in both eyes about a year ago, so I have to make a decision soon as my vision is degrading quickly. I'm a regular night time driver on all sorts of roads and do computer repairs. My prescription though has been fluctuating a lot over the past five years -- I get a prescription filled, and a couple of months later, it's no longer giving me good vision. I'm still trying to figure out the best solution for myself, and feedback from such as yourself who have gone through it helps so much! Thank you again.

If you are still using hard contacts you will want to be sure to stop wearing them at least a month before getting your eyes measured for IOLs. Soft contacts should not be worn for at least a week before measurements.

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That is a significant amount of myopia and you will want to be sure to get your power calculations done by at least a couple of different formulas that are suitable for long eyes. The Hill RBF 3.0 and Barrett Universal II are a couple that come to mind.

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Your prescription changing often is often caused by cataracts.

Yes, there's a lot to plan for. Thanks for the heads up. Unfortunately, I can't drive with glasses -- the depth perception difference is huge -- everything is at least a third smaller than true vision with contacts, so that will present a huge problem. Even walking down the street wearing glasses can be a challenge unless the angles have been calculated properly. My astigmatism used to be a lot higher, but after 20 + years of wearing gas permeable lenses, I was told that it had mostly been corrected (at around -1 right now). I haven't been able to wear soft lenses due to high prescription and dry eyes (they tear, but not always wet my lenses efficiently -- and they have sucked the moisture out of soft lenses in the past, lol). Although looking up the suggestions you made for soft lenses on another post, the technology has definitely changed since I last tried, so I will be looking into that, thanks again.

Apparently my corneas are healthy, despite the high myopia (usually am around -9.25 & -10.75 up to a couple of years ago) because my poor vision isn't hereditary, but a side effect of having red measles when I was seven and going outside into bright light too soon (ten days in a dark room is usually long enough, but not this time). My left eye used to be dominant but about ten years ago, the retina tried to detach, leaving me near and far sighted in that eye. So when filling a prescription for that eye, I've had to back off distance to improve the near (if not anyone within 3 ft of me makes me feel wonky, almost nauseous). I've also had to deal with floaters in that eye, though these days, they're only there when I'm tired -- in general, they don't distract me much. My originally weaker right eye has taken over quite efficiently as the dominant eye though. And although I have and use binocular vision the most, my brain will switch to mono vision as needed (but can cause more headaches over time). As someone else commented, because of the high myopia, I am used to being able to see 4" away clearly without glasses, etc, which is an amazing ability to rely on when fixing computers, etc. So there is a lot to think about -- what am I willing to give up -- what will I HAVE to give up. But it has to be done!

Right now I'm strongly leaning toward Toric Synergy in my right eye, and either a Toric Eyhance or Monofocal set to mini-monovision in the left (thanks to extensive research of user reviews, videos, etc -- this site has been extremely helpful). Loss of too much contrast is important to me, but so is having a range of vision. I already have had to deal with glare and halos because of my high prescription for a very long time and have just learnt ways to side-step and compensate for it over the years, so it doesn't bother me as much as it might others. Truthfully, if I can end up with at least what I have now with contacts (but a bit sharper), as imperfect as it is, I'll figure out how to live with it. My brain has had to learn to deal with a lot over the years (serious brain injury at the age of 22) and is pretty flexible, considering everything, so I have confidence it will figure out it's part. I have another consultation next week with a different surgeon (Ottawa area) who has experience with Synergy, so we'll see what they have to say. At the first consult, the other surgeon said that I had "interesting eyes" -- I believe the term interesting in that context is considered a curse in some cultures, lol, sigh.

Yes, that is a lot to plan for. I see some significant issues in determining the correct correction power for IOLs. First is just the very high myopia that can be an issue. Second is that you are wearing hard contacts and your cornea is likely to change shape once you stop wearing them. This can be an issue not only with the sphere, but also the cylinder (astigmatism). Normally astigmatism is reduced when the lens which has the cataract is removed and replace with an IOL. That may not be the case for you. You should discuss the hard contact issue with the surgeon and come up with a plan. That may include switching to soft contacts for some time, and then going without any at all for a period of time. The newer silicon hydrogel contacts I found are much better than the older hydrogel only ones.

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Another thing to consider to improve accuracy of power selection is the Alcon ORA System. This method remeasures the eye after the natural lens is taken out and before the IOL is inserted. It is claimed to improve power selection accuracy. On a quick check it would appear that the Herzig Eye Institute in Ottawa has the capability to do the ORA. You could discuss the value of it with them.

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My thoughts would be that considering your eye issues it may be prudent to avoid multifocal lenses like the PanOptix and Synergy. They are probably best used in "perfect" eyes. The one monofocal IOL I would suggest considering is the B+L enVista. It has been designed to work with less than perfect eyes. The problem may be finding a surgeon that uses it. Most clinics use either Alcon or J&J. In Manitoba it is offered as the public healthcare fully covered monofocal. My brother got it in a private clinic in Winnipeg.

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Hope that helps some,

Thanks, I will bring this up. The Herzig Institute is the place I'm going for the consultation, so good to know that they have the right equipment for me. These days, I am wearing glasses pretty regularly, only putting in my contacts when I have to drive somewhere, and then taking them out once I get back home (too much dust here blowing through heating grates and carpeted floors for hard lenses). I arranged to have a drive to the consult so I will be wearing glasses to the appt, and most likely for the days preceeding it as I do know that the contact does change the shape of the eye and wanted to make sure that it didn't interfere with their measurements.

Using only monofocal lenses is not an option for me, as I need some natural close and intermediate and some degree of long vision in at least one eye -- this is not negotiable! I know my eyes and am familiar with their quirks (as in have learned to compensate for), and I know what I need for day to day living, and I'm willing to take the chance on the Synergy giving me that option. I have read multiple successful results with people who are even more myopic than I am, which gives me hope. I've already ruled out PanOptix and even Vivity not just because of the halo/glare effects, which I am already used to, but because of the overall loss of contrast. Many of their users have commented on not being able to see the stars in the sky unless the moon is high -- not for me. I know Synergy has it's issues also, but from what I've read, if placed properly, has a very good chance to give me the balance I need. I'm used to restricted vision in the left eye, so having only a range of vision in it won't bother me, and I'm thinking that a mini-monovision there will help to compensate for any restrictions with the Synergy in the right eye. If I have to wear glasses for driving at night, then I will deal with that when it happens. I will have a better understanding of my options after my consult next week. Thanks again. I will indeed add your suggestions to my list of questions for the surgeon.

Assuming you do not want to wear contacts after cataract surgery I think it would be very important to ensure your eyes have restored themselves to the normal shape before it is measured for IOLs. If they have not fully relaxed to a natural shape then your prescription from the IOL is not going to "hold". It will change as the shape regresses.

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"Using only monofocal lenses is not an option for me, as I need some natural close and intermediate and some degree of long vision in at least one eye -- this is not negotiable!"

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Actually in a mini-monovision configuration one can get the full range of vision with only monofocals. While there is an option called hybrid monovision where an EDOF or even MF lens is used in the nearer vision eye, I am not sure it is really worth the additional risk of optical side effects. I was really close to doing that myself by using a Vivity in my close eye, I backed out of it along with some encouragement from my surgeon to not do it. I have mini-monovision with monofocal lenses only and have no regrets. I can see from about 10" out to infinity very well. I am probably 95% eyeglasses free. I occasionally use some +1.25 readers to see very fine print. Normal print on my computer at 12-14" is just fine without glasses. I can also easily read my iPhone.

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"I've already ruled out PanOptix and even Vivity not just because of the halo/glare effects, which I am already used to, but because of the overall loss of contrast."

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The Synergy is going to have just as much loss of contrast as the PanOptix, and perhaps even more. Both of these lenses distribute a significant amount of light to closer vision which reduces contrast sensitivity at distance. Of the two lenses the Synergy probably diverts more to close vision and will have a larger loss of contrast sensitivity. I have been following this forum for a couple of years or so, and I would say the anecdotal report on them is that the PanOptix provides better distance vision and weaker close vision, while the Synergy has better close vision and weaker distance vision.

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If you were to correct your vision to -0.25 D in your distance eye, and -1.50 D in your close eye, vision correction with glasses would be very minimal. This is what I have and the progressive glasses I have now (but very seldom use) are the lightest and thinnest lenses I have ever had in my life. I would expect with this minimal amount of correction the current issues you are having wearing glasses would be gone.

That's good to know. I will ask the surgeon, thanks again. You said "I can see from about 10" out to infinity very well."... is that in both eyes? And I know I read it somewhere here, but which monofocal did you use?

Right now, there is a +2.50 on the left eye for glasses and contacts to give me some close vision. I'm not sure how that would translate into what you were describing for an IOL setting? With the left eye, using contacts, I used to have really clear long distance, better than the right (good close vision also), but because of the farsightedness now also there, lost the distance to give me some close vision, which is about 6" with glasses but only maybe 19" now with contacts, and distance is restricted a lot. But I don't have a problem making that my dominant long distance eye again. Although i do wonder what about it caused it's retina to almost detach years ago, and whether making it dominant long distance, might set it off again.

The problem I have with a monofocal in my dominant right eye, is that it is/has been my full range eye from near to distance (sharp distance). Now, without glasses, clear from the end of my nose (about 3") to a whole 6", lol. With glasses from about 7" to 20", but distance is comprised because of the strength of the prescription -- everything is so much smaller and pinpointed with glasses. With contacts, until about a year and a half ago, I had 20/20 and could see clearly about 6" out to about 100'. Now I can see about 6" to maybe 75' with that eye but it does blur in an out due the cataracts, I guess.

So if I were to try what you describe, I would probably have to cut more of the distance anyway in the right eye, which is what I was expecting from using a Synergy in that eye. It is tempting though what you suggest for the loss of contrast. From what I've been reading though, the majority of people who went with a Synergy had little loss of contrast, less apparently than Vivity or PanOptix. Not of course as good as a monofocal, but not bad. Though most people don't include context into their experiences, so there is still some conjecture based upon individual experiences.

I have to say that considering that I have been paying a minimum of $1,000 for glasses every two years, and around $300 for contacts every year (depending upon how many I lost), I wish I'd known about this surgery a long time ago. My neighbour was born in Ukraine (she's been here for about nine years) and was born with a prescription of -17 plus in both eyes. When she was 13, they started her with a form of soft contact lens and when she reached 18 there, they performed a lens replacement that cost about $1,000 per eye that has given her perfect full range vision. She's in her mid thirties now, and doesn't have to wear glasses for anything. According to her, she doesn't have any vision restrictions at all. She doesn't remember what they used though, and with what is happening in Ukraine now where her mother still is, it's not a priority to find out, but she said she will when she can. But I wonder why such a thing has not been offered to high myopic people here?

10" to infinity is with both eyes combined. At any given distance I don't know which eye is giving me the vision, as the brain is quite smart about using and blending the vision so I am unaware of it. But from theoretical defocus curves the near eye which is at about -1.4 D (and ideally should be -1.5 D) gets me from 10" to 6-8 feet with excellent to good vision. The distance eye which is at -0.25 gets me from 18" to infinity. So there is an overlap in the 18" to 6 foot range where binocular vision is the best. This is with an AcrySof IQ lens in one eye and a Clareon in the other. Both are optically identical. Clareon is newer, and claimed to be a better material. Both work well for what they are intended to do.

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It is standard practice to use a +2.5 D add in progressive and bifocal glasses. The +2.5 part of the lens leaves you myopic at the reverse of this or a -2.5 D. This provides very good reading vision, and because it progresses to full distance correction can provide narrow but very good intermediate vision too. In the earlier days of monovision a -2.5 D myopic target was used in the near eye to provide the same excellent close vision as an eyeglass approach. However, this has given this full monovision a bit of a bad name as the 2.5 D differential between the eyes can be difficult to adjust to. And, it can also leave a bit of a gap between the close vision eye and the distance vision where the near eye is not providing good enough intermediate vision. For this reason the current practice has been to switch to a min-monovision approach where the differential is reduced to 1.5 D with the near eye being left at -1.5 D. Obviously this will not give the same visual acuity very close up at the +2.5 Add did. But, I find it is a very reasonable compromise and various studies have found that -1.5 D is an optimum value to target. It does require some reading glasses for difficult very small print in dimmer light. I have some +1.25 OTC reader that I may use once a week or so. My prescription progressives I may use once a month.

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I believe retina detachment is a possible risk in cataract surgery, and also in YAG procedures, but it is very low. You would have to ask your surgeon about risk considering your personal situation.

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With high myopic corrections, an IOL is going to give a better correction than eyeglasses because it is located much closer to the source of the error. The normal practice is to use the dominant eye as the distance eye, but the reverse, called crossed monovison, is ok too. Some believe it may even be better. I ended up with crossed monovision by happenstance. I noticed that the Herzig clinic offers monovision with both Lasik and lens exchange (catarct surgery). So, they should be quite familiar with it and understand what the option is about. Keep in mind that mini-monovision only requires monofocal lenses, and not the premium ones (unless you need a toric). A premium lens can be used, but I think when you consider all the issues, two monofocals are just as good, or perhaps even better. Also be aware that a private clinic may (not always) push the options that give them the most profit. If I understand the Ontario situation which I guess is changing currently, two non toric monofocals should be offered to you at zero cost. But, I see this clinic uses laser incisions which they are likely to charge extra for, and the ORA system is likely an extra charge too. Not sure about the laser incision value, but the ORA may have some benefits for you with the harder to estimate high myopia correction.

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Hope that helps some...

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Edit: Considering your issues with hard contacts and astigmatism you should ask about about keratoconus being a potential issue. It is a thinning of the cornea which can give rise to unstable astigmatism. I was not informed that I had it until after my cataract surgery. It prevented me from getting a Lasik touch up to correct residual astigmatism.

I suspect your friend in Ukraine must have gotten multifocal IOLs. They have been around for a while, and especially in the bifocal versions. More recent ones like the PanOptix and Synergy are essentially trifocals. But, they all have issues. Some adapt to the side effects, and others do not. The big loss for a person with typical vision of doing a lens exchange at a young age is the loss of close vision. This is countered by using monovison or some combination of monovision and MF IOLs. When Lasik only is used monovison is the usual option to retain close vision.

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My thoughts are that with all the potential side effects and issues down the road, it is best to leave Lasik and simple lens exchange until the issue is pushed by the need to deal with cataracts. In some extreme situations like you describe, it may then be better to go early.

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Not sure about pricing in Ontario at private clinics, but where I was at a year ago (in Alberta), the cost of a Vivity or PanOptix per eye was $2,200. A monofocal toric was $1,100. The Clareon extra cost over the AcrySof IQ or Tecnis 1 was $300. These are incremental costs over the cost of a standard monofocal which are fully covered except for the eye drops by Alberta Healthcare.

Once again, thank you so much for such a clear detailed description. I am leaning strongly now to mini-monovision with monofocal lenses. Though I am also considering possibly the Eyhance in maybe just the right eye. Reading some of the results here, it seems to give just enough extended vision with minimal adjustments with fewer of the negatives of the other EDOFs. Once again, once I talk with the surgeon, that might change. Because of my astigmatism, I will definitely go with a Toric version as I'm not interested in finding out after the fact that I should have taken that route to begin with., though I understand from your suggestions that there are ways to predict this quite well.

There is a very long waiting list in Ontario for OHIP covered surgery, it's 1-1/2 to 2 years right now, and although I was put on the list last April, with the constant fluctuations of my prescription, and other health issues have made even another six months far too long to wait for. I've been trying to find out where on the list I am, but have only hit walls. Once your name does come up with OHIP though, you can choose a Toric version or another enhanced lens or even have the surgery done in a private clinic, and OHIP will pay the surgeon the amount of money they would have spent if you'd done the basics through them in a hospital. It comes to about a $2,000 deduction for both eyes of what a private clinic would charge.

I will request the ORA evaluation though -- won't know til I meet with them if there's an extra charge, but it sounds worth it. I was always told that I wasn't a candidate for Lasik surgery due to my high myopia -- the cornea was already thinned out, which made the surgery too dangerous to risk. Regarding using the laser incision method, from what I've read, the old school basic method is considered as good as, or better than, using laser placement, as it requires more attention to the placement of the IOL, with better long term results -- at least in terms of placement -- laser extraction is probably more efficient.

The first clinic I visited (iCare) offered "Traditional Cataract Surgery" covered by OHIP, or "Refractive Cataract Surgery" which was not covered by OHIP, but was included in the cost of buying an enhanced lens and could only be done in their surgical centre as they have the technology while the hospital doesn't. The refractive option added a laser vision enhancement procedure (ultrasound and laser light technology). I didn't see any mention of ORA. They did suggest monovision as a viable option though. They offer the Eyhance but were big on the Vividity and Panoptix for enhanced IOL options. They give you an easy to understand (large) booklet which goes through the surgery and the options, but it wasn't until I started researching on my own, that I realized that the "implied" outcome with any of the lenses wasn't as rosy as presented. But I only had the one consult with them and I also understand that as others here have mentioned, trying to explain the shortcomings to someone who hadn't done any research would be very difficult and confusing on both sides, so I'm not putting this clinic down in any way, I just want a second opinion of what my options are now that I am more informed.

I suspect she had one of the newer light allowing adjustable lenses implanted as she did mention that they did a couple of adjustments after the procedure. I think her surgery was done around 2008, at which these lenses were available in Europe -- they're only just being allowed in NA. According to her, she has absolutely no visual restrictions. She has a full range of vision, and no loss of contrast in any light. She said she doesn't wear glasses for anything. I really, really, really, want to know what they used on her, lol. Though since she was young, maybe the results were better than for someone older.

The costs here for those IOLs are a lot higher here in Ontario. Last April, I was quoted $4,000 and $4,500 each eye for the Vivity and PanOptix respectively. I just reconfirmed those prices as of last December. The Clareon versions use updated materials which don't lend themselves to glistening -- worth the extra $$ if you take that route, I think. When I first had my consultation, I was under the impression that the $4,000 plus price tag was for both eyes with those lenses, but then as I researched and watched videos from surgeons and coaches, I kept reading user comments about those lenses costing $4,000 plus USD for each eye so I called the clinic again and was told that I was wrong. That's a freaking huge amount of money!! I've read that the actual lens costs about $300, so the rest of the money is for running the private clinics. Which considering the cost of the equipment they use, etc, makes sense, but still!!

I forgot to add that my sensitivity to light stems from my extreme fairness, not the astigmatism. Apparently, I'm am borderline albino according to my ophthalmologist. According to all of the available tests, my corneas are otherwise healthy. I was thinking more about the almost retinal detachment in my left eye, which was originally the dominant eye, and remembering back when it happened, I was wearing my gas permeable contact lenses for really long periods of time on a daily basis, so I'm thinking that might have been the causative agent for that.

Wearing glasses has always been a problem for me because of their strength. My clear vision ends at about 4 inches, so not much margin for error. I started having really bad migraine headaches when I was a teenager from wearing them and this continued until I was eighteen and received hard contact lenses, then the migraines stopped. But then I was in a bad car accident and the left side of my head banged in, so wearing glasses for extended periods of time started once again to cause problems, adding to, and enhancing, the headaches I was already having due to the injury, so I started wearing my contacts for a longer period of time, with no obvious problems until the retina went bonkers. I was doing a lot of computer work then also. Then, my prescription was around -8D in the left eye, and around -9.25D in the right one.

I have learned to be very careful as to who cuts the lenses for my glasses, cos there's many a time when I couldn't even walk down a street wearing them without feeling woozy because of a minor error. The depth perception between glasses and contacts (real vision) is so drastic. Although it doesn't take me very long to adjust once the contacts are in -- much harder going the other way.

I was very close to going for a Vivity in my near eye. I think the main advantage of it is that you don't have to target as much of an under correction. My conclusion was that the under correction could be reduced to -1.0 D in the near eye with Vivity. That results in better distance vision in the near eye. As I probably mentioned I decide against it at the last minute with some persuasion from the surgeon. He thought I would not be satisfied with the vision I would get compared to a monofocal.

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For the same reasons I am not sold on the Eyhance. It probably is an extra cost and really does not add much value when you are going for mini-monovision. It introduces some potential for optical side effects which are not there with a pure toric.

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You can't really make an informed decision on a toric until after you have had your eyes measured for an IOL. Then you will know what the predicted residual cylinder will be if you do not get a toric. Selecting a toric or possibly a monofocal Clareon might get you into the private clinic queue instead of the long wait public one.

I suspect your friend that got the LAL lenses must have done monovision.

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Some clinics in the US and possibly in Canada don't give you a credit for the basic cost covered by OHIP for example. If you opt out of the public route you pay the full pop for each eye.

Or from what I've read, she could have had either a Juvene, RxSight or Crystalens IOL implanted. They haven't been used much here, but in Europe, it's a different story.

According to the OHIP website, private clinics are required by law to give you this discount. This is an excerpt from the complete eBulletin...

"The physician, hospital or facility is required to provide the patient with sufficient information to make an informed decision about the purchase of any uninsured service and obtain the patient’s agreement. When a patient makes a voluntary choice to purchase an uninsured lens (i.e. one with features that are not medically necessary), test or other service:

• The physician, hospital or other facility is required to apply the cost of the medically necessary lens against the cost of the elective lens (i.e. to credit the patient for the cost of the medically necessary lens).

• The physician, hospital or facility is required to provide the patient with an itemized invoice that shows the amounts charged for each uninsured service and, if applicable, that credit was given for the cost of the medically necessary lens.

Physicians who sell and charge patients for uninsured services may wish to review their legal obligations set out in Regulation 856 “Professional Misconduct” under the Medicine Act, and The College of Physicians and Surgeons of Ontario policy statements #3-10 “Block Fees and Uninsured Services,” and #3-15“Consent to Treatment”

There's another version at the link below.

(https://www.health.gov.on.ca/en/public/publications/ohip/cataract_lens_surgery.aspx)

I was strongly leaning toward the Vivity, but started to read a lot of reports of loss of contrast. People saying they couldn't see the stars at night unless there was a full moon, or another light source. The same with the PanOptix. Apparently there is less of that with either Synergy or Eyhance.

There's next to no waiting line if you choose to pay the difference for an enhanced lens. I was told It could be arranged within a week or so. I posted a reply to what you said about clinics ignoring OHIP's requirements, but it included weblinks, so I guess it got pulled for review? Here is the jist of what I wrote without the weblink to the source. This is directly from the MOHLTC website.

"When a patient makes a voluntary choice to purchase a lens with features that are not medically necessary, the ministry requires that the patient receives a credit for the cost of the medically necessary lens that should appear on the invoice."

I am somewhat skeptical of some of the claims made about the various lens manufacturers. What makes sense to me is that the loss of contrast sensitivity is directly proportional to the gain of near vision of the lens. In order of loss of contrast sensitivity I would suggest the lenses rank as follows:

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1. Monofocal - Tecnis 1 or Clareon or AcrySof IQ - Zero loss, no gain of near vision
2. Eyhance
3. Vivity
4. Symfony
5. PanOptix
6. Synergy - Most loss, most gain of near vision

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   Yes, on the coverage I have been following the Doug Ford vs Jagmeet controversy on privately delivered health care. I think I saw that exact same quote in one of the articles. That provision makes a lot of sense. I believe that is essentially what we have in Alberta. A PanOptix or Vivity would cost me $2,200 per lens in a private clinic. A monofocal toric was $1,100. My Clareon monofocal which really is only a "premium" lens because it is new, cost me $300. However, it is what got me into the private clinic queue instead of the public hospital queue.

"Juvene, RxSight or Crystalens"

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I believe at least a couple of these are intended to be accommodating lenses, but as I understand it, with limited success.

Yes, from my research, I agree with your rankings, except maybe the placement of the Synergy in the list. I've read some very mixed reviews from people who used it, and it looks like the placement of that lens is extremely important. If it's not exact, then people experienced loss of contrast, blurry vision, halos, etc, but when it works, most people said that the contrast was exceptional. A number of such reviews were from people who had only one eye done, or had used a mixture of the lenses, so had something to compare it to. I read reviews from pilots and truck drivers who loved it and had excellent vision with it in any light. This was one of the reasons I started to lean strongly toward it, and why I ended up contacting Herzig since surgeons there had experience with it.

I find it weird that Vivity has such a poor contrast rating, considering the technology used to create it. The whole idea of using the non-diffractive wave tech was to improve over the restrictions of the diffractive ones like PanOptix that can create gaps in your vision range and reduce contrast. I understand how the light is distributed with the different lenses, but still. Now they have a disclaimer on their website stating that there is a strong probability that there be a significant loss of contrast, especially in restricted light -- which I've read a lot also from quite a few people who used the lens -- and why although it initially was my favourite, but have now decided to not use it.

I based my rankings on the amount of near vision the lens provided, and made the rationalization that more near vision mean less light being dedicated to far vision and as a result lower contrast sensitivity at distance.

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I think the contrast sensitivity thing is way over rated. They ended up having to put that warning on the Vivity because with one eye only the lens was just under the minimum standard for contrast sensitivity at distance. With a Vivity in both eyes it meets the standard, so they recommend using two of them, which of course is good for Alcon! They don't talk about having a Vivity in one eye and a monofocal in the other. I believe that would provide better all around contrast sensitivity than two Vivity lenses.

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If you do a search here I recall there was one lady that got a Symfony in one eye and a Synergy in the other, and was happy with it. I think it was a Jennifer.

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My thoughts remain that mini-monovision with monofocals is a lot simpler and more predictable, with a much lower risk of optical side effects.

i dont think contrast sensitivity is overrated. it is very real and might contribute to overall good quality vision with monofocal even when the acuity drops.. things are not as sharp and fainter than they would be without contrast loss. night times and cloudy days are darker.

I had my consult with a surgeon at Herzig yesterday, and after the initial tests, he thinks the Eyhance would be a good choice for me, and surgery is scheduled early March. At this point, I'm already ten days contact lens free, so I figured I might as well take advantage of that. I will start my own thread here after it's done. He wants to do them a day apart, which I know has pros and cons, but since I'm very sure on what I want to target for, and willing to accept the outcome, I don't mind them being that close. I was going to suggest waiting a week in between, but it doesn't seem worthwhile now. The surgeon will decide the day of the surgery after doing the ORA test, whether or not I need the Toric version. He seemed quite sure that I most likely will need it for the left eye. I decided against using the laser guided placement as it would add another $1,100 per eye for the surgery (it will be $5,100 for both eyes as it is if both need Toric lenses). The surgeon doesn't have a problem doing it old school luckily. Usually they only do that in hospital surgeries.

The surgeon was really pushing for mini-monovision targeting plano for my dominate eye and -1.25 for the other, but after thinking about it even more last night and rereading patient outcomes, I decided to ask for either a -1.0 for both eyes, or maybe, -0.75 for the dominant eye and -1.0 in the other. Reflecting heavily upon what I'm used to and how I used my vision, I'm really worried about losing so much near vision in my right eye, and such a drastic shift of visual responsibility to my left eye, in which I haven't had functional near or even distance vision in for such a long time. The surgeon was willing to make my left eye the dominant one again, which might work out okay, but I'm used to driving down dark roads and looking down the right side of the road, especially when cars are approaching, so it doesn't make sense to restrict that. I'm also worried about potentially increasing pressure in the left eye by making it dominant again, since the retina has already tried to detach twice.

I'm used to a full range of vision in my right eye (with contacts at least), so if necessary, I don't mind wearing glasses or even a mild contact lens prescription for sharper long distance if need be. But reading the patient outcomes here and elsewhere, I'm hoping I might luck out and achieve a reasonable near and distance vision with this setting like some other people have. I didn't have a copy of my contact prescription for the consult and the surgeon insisted that I must have been using mono vision all these years with contacts, and wouldn't believe me when I said I hadn't. He said that with my myopia, that was impossible, so was waiting for my contact prescription from my optometrist for evidence, lol. She sent it to him today, so I wonder if he'll change his mind about the impossibility of my vision, lol. My current optometrist had the same assumption when she first filled a contact lens prescription for me in 2017 and had ordered the lenses in a monovision configuration, but when I put them in and didn't have good vision, she apologized and redid them the way I was used to for full range of vision, in the right eye at least. Most optometrists have been initially surprised at the quality and range of vision I've had over the years with contacts, and most have deduced that it is because my poor vision isn't hereditary.

Using your evaluations on power outcomes for a monofocal vs a monofocal+ (that's what Herzig calls the Eyhance), which were very helpful (thanks), and your research showing that for the best results, there shouldn't be more than a maximum difference of 1D between eyes for the best blended vision results, helped me a lot with my decision. Upon further research, I found that because of the extended vision capabilities of the Eyhance, it was suggested to not go more than 0.75D between the two eyes for best results. And since the targeted outcome might not be the same as the actual outcome, I think that using even the -0.75D and -1.0D strategy will end up putting me within an acceptable range. Scared, but hopeful.

I am not so convinced. Another thread here had a computer simulation testing contrast sensitivity. I did the test with the image cranked to maximum contrast and viewed it with one eye at a distance which would give an MTF of 0.45 or a very high value. Then I viewed it with the other eye which should have had an MTF of 0.0. Yes there was a very minor difference, but hardly noticeable. See my response in this thread. I compared my AcrySof IQ lens set for full distance to my Clareon lens set to -1.4 D. I viewed the test pattern from the same distance so the AcrySof IQ was at max MTF, and the Clareon was at essentially zero.

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https://patient.info/forums/discuss/simulating-vivity-and-other-non-monofocal-iol-experience-using-visionsimulations-795952

I think that most of the complaints of loss of contrast is happening under restricted light situations. And then in my experience, a lot of people aren't very aware of the quality of the quality of their contrast vision unless they happen to work in the field that requires it.; such as photography, graphic design and such.

Probably one thing that also has an overall impact in how the world looks is the overall color saturation of your vision.

I've recall reading some some story online where a patient looked at the world through a trifocal like panoptix etc. and in long term felt that the world looked dull through those lenses so they've had a lens exchange to something more vibrant like vivity or a monofocal.

That may the case, but I don't have any easy way of testing it. That computer simulation I tried is at normal monitor brightness. The thing that I don't think may understand is that contrast sensitivity (MTF) and visual acuity essentially track each other. A monofocal has a fairly sharp peak in both MTF and visual acuity at the distance it is set too. If it is distance then both visual acuity and MTF drop off quite sharply as the distance decreases. The Vivity on the other hand has poorer MTF at the peak visual acuity point but it drops off more slowly as the distance decreases at a point the visual acuity and MTF actually exceeds the monofocal as you get closer. So, it is not as simple as many assume. The Vivity Package Insert PDF has good data and graphs that illustrate this.

To be very frank I would be skeptical of those claims. I suspect any IOL is going to look very bright and vibrant compared to a natural eye with a cataract. I recall that when I got my first IOL I had to switch my TV from where it was set (Vivid) to normal. I couldn't take the brightness and saturation and thought it looked very unnatural.

i have definitely noticeable contrast loss with symfony compared to my natural eye. it cannot be corrected with glasses. if monofocal is going to he as bad that is very concerning and i would conclude that multifocal dysphotopsias are definitely worth it.

Is the contrast loss visible both in photopic and mesopic conditions. Does it manifest as dullness of color etc. or what's the best way you can describe the experience. Can you use visionsimulations "loss of contrast" tool to describe the difference with some numeric settings you can provide here, or does that tool even come close?

not much outdoors in daylight. indoors much pronounced during night. sharpness loss cannot be corrected with glasses. it mostly impacts intermediate / near vision. it can cause facial recognition issues on cloudy days.

gray 10. strength of gray 40. its a decent tool. the foggish effect affect sharoer details.

That looks pretty severe to me, scary. I wonder what kind of results Vivity produces.

if that becomes your normal vision in both eyes it is probably less impactful. i have same question about eyhance how much is the contrast loss and if monofocal does the same then i will take the rings.

At least it doesn't look like that at all based on the clinical data. Eyhance is very similar to the tecnis 1 zcb00, just borrows some of the peak to near vision. And the distance vision MTF curve looks identical to sensar1. But it IS a monofocal ultimately.

But definitely choosing a lens is difficult because every bit of data you look at is based on some kind of subjective / anecdotal evidence, even if you can plot it to a chart it doesn't tell you what your subjective experience is like. I'm still grateful that you've been able to give your experiences with the symphony.

here or some examples of contrast loss for me:

• i didnt recognize two coworkers on a cloudy winter day outside costco.
• i turned into the wrong left lane at night.
• the night sky is clearly darker with Symfony
• in an airplane the sticker on back of the front seat that says floatation device under your seat is lacking something. it is fainter. a bit hard to read quickly.
• the ground is less sharper than the right eye while standing.
• mirror reflection is also less sharper. it is clear but less sharp. something is missing.
• tv video quality is not affected at all. it is probably better with the IOL.

vivity is very tempting because you can set it at -0.5 and you would have good near vision and distance isnt really compromised much. however there is a video that says they have recently found that it is creating noticeable contrast loss.

i think for lifelong myopes getting near vision and using mild glasses for far -1.5 should hopefully not be a big deal. also if you are going to wear glasses for -0.5 surgery astigmatism which i will why not add a -1. sphere to it.

I have concerns about Vivity even though people have good experiences with it, but Eyhance could be a compromise that gives a little bit of extra clarity to the already hazy closer vision without having to throw away mesopic contrast, because up here it's fairly dark a big chunk of the year. It's hard to find good comparative data on the issue.

I just need to get over the fact that I need to get used to having to use glasses pretty much for any near activity.

I would argue that one needs to offset the Vivity to -1.0 D to get the equivalent near vision of a monofocal offset to -1.5 D. That is based on the defocus curves in the Vivity Package Insert.

in that case i would set one to -0.5 and other to -1. however i think they best way to see what you need is to use + contacts on the iol eye after doing the first eye for -.25 to -0.75. i prefer that iol trial over the trial with contacts on natural eye because the natural eye is a fantastic thing and still retains the accommodation.

Keep in mind that J&J in my opinion makes some claims for the Eyhance that are a bit hard to swallow. For example suggesting that mesopic contrast is not compromised. Given that they achieve this EDOF effect by varying the power of the lens from the centre out to the periphery, and in mescopic conditions the pupil will open up to include more of this range of lens power, this does not seem possible. From the defocus curves I have seen the Vivity adds about 0.5 D to the range of focus. The Eyhance adds about 0.4 D to the range. This is not a huge difference. The Vivity does just enough to claim it is an EDOF lens, but the Eyhance falls just a bit short. It is a little puzzling that the Vivity contrast sensitivity takes a big hit, while the Eyhance is claimed to lose virtually nothing... And, they are basically getting the extra range of focus the same way. The Vivity does it as a step, and the Eyhance does it more smoothly.

jnj made similar claims with symfony and it is bs unless the contrast loss with their monofocal is as bad as Symfony.

vivity has a step that can contribute to higher dysphotopsias and possibly contrast loss. however it also uses entire 6mm optic surface for refraction which could be beneficial for large pupils.

from the videos it would appear that vivity adds 1D while eyhance adds 0.5D. i havent really seen vivity's defocus curves. the step wouldnt be worth 0.1D gain.

For me it is bit of a moot point. I have mini-monovison of -1.40 D on a spherical equivalent basis with monofocal IOLs. The only issue I have is, of that spherical equivalent, I am getting 1.0 D from the sphere component and the remainder from 50% of the cylinder. I would trade that in a heartbeat for a clean -1.5 D of sphere only and no astigmatism. I made a significant mistake in not selecting a toric IOL.

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To my thinking the best way to get into monovision is to get the dominant eye done first to full distance vision with an IOL. Then with an IOL in the eye you can simulate what close visual acuity looks like with either a contact or reading glasses. Reading glasses lets you switch back and forth more easily while using a Jaeger chart to measure it. This does not test your ability to use monovision though. To do that one would take what you learned from the reading glasses test to get the offset you want in the other eye with a contact. Yes, it will be a bit optimistic as there will be some accommodation in that eye, but you have already selected the power based on the IOL eye test. It is then really just a matter of finding our how well you adapt to getting closer vision with one eye and distant vision with the other. For me it was no problem.

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And to keep things simple I would do it assuming a monofocal lens will be used. If you plan to use a Vivity or Eyhance in the close eye I don't know how you would simulate it. I suppose a MF contact could be used but that opens another can of worms. How close would that MF contact simulate the Vivity or Eyhance? I think you would be back to making a power choice based on the theoretical EDOF gain of the respective lens.

i can see why you would put trial contact in the natural eye to simulate tolerance and continuity of acuity with both eyes together. i would also do monocular contact trial on iol eye to see how much near is gained and how much is the distance conpromised by by the deliberate myopia.

See figures 5 & 6 in the package insert which can be found by googling:

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Vivity P930014 Package Insert PDF

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At a LogMAR of 0.2 I see an extension of vision from -1.0 (monofocal) to -1.5 D (Vivity), or perhaps very slightly more than a gain of 0.5 D.

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Eyhance don't seem to publish the clinical data like there is for the Vivity, but the curves I have seen show an increase of slightly less than 0.5 D at a LogMAR of 0.2.

I thought about doing the contact thing, but didn't want to be bothered trying to explain to an optician why I would want the trial contacts for my IOL eye which has 20/15 vision. Picking up some readers at the dollar store seemed more convenient than trying to spin a tale to the optician at Costco...

i compared your vivity defocis references with figure 4 in "delivering intermediate vision: the eyhance..." this would suggest that acuity difference between eyhance and vivity is only about 0.2D on the near side like you pointed out.

0.5D iol power translates to only 0.35D acuity so one may end up giving up -0.35D more of distance to match or exceed the vivity near acuity by tiny bit with the eyhance.

now is that vivity step creating that much of a problem in terms of dysphotopsias or contrast?

I've looked at several papers online that suggest that the mesopic contrast sensitivity is very similar between the zcb00 and icb00, some of those were sponsored or partially sponsored by J&J. It's hard to wade through this information.

Vivity does spread the power further down the near vision than eyhance does. If eyhance goes to MTF0 around -1.5d mark while vivity still has mtf at -2.0 that would explain the difference pretty well.

The binocular visual acuity of vivity also seems to stretch to logmar0.2 at -2 according to the package insert document.

I have never really understood the reason for the Vivity step. They talk about wavefront manipulation, but at the end of the day it seems like it is the lens power that really counts.

I am suspicious of the MTF values claimed by J&J both on the Eyhance and their monofocal lenses.

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On the defocus curves you have to look at the extension of vision of the Vivity compared to the monofocal curve. Yes, on a binocular basis it is a bit more than 0.5 D extension, but not a lot. Some of the sources play a bit of a game with the numbers in that they talk about the depth of focus being 2.0 D and not mentioning that the depth of focus of a monofocal is almost 1.5 d on a binocular basis. It is a more fair comparison to always compare to the monofocal control group.

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And if one is to get very precise about it the defocus curve of the Tecnis 1 due to the correction to zero asphericity is going to have a steeper drop off than the AcrySof IQ which leaves some asphericity. Comparing the Eyhance to the Tecnis 1 is not the same as comparing the Vivity to the AcrySof IQ lens. But, I think that is a very minor effect.

This is definitely making me more anxious, i thought I already had a reasonable lens picked. But if their overall curves compared to their own lens which is the one they use in the public sector then at least it's some kind of an improvement to a decent lens. I need to still check how it compares to the clareon monofocal i suppose.

I still see mostly positive outcomes with the Eyhance lens even on this forum so it maybe still a good option to go with. Even though the one draw-back is that it's just a partial optic and not the entire 6mm.

But there's no equivalent available in the market unless i go with the Vivity treatment, which scares me even though it's probably over-proportion since people do pretty well with multifocals that have even less contrast. The optometrist that I was talking to had Panoptix in both her eyes and she was really happy with them and had no issues driving at night. But also it appears to me that panoptix has a lot more distance MFT than Vivity does. But it's been difficult to get graphs that are scaled the same way.

Everything I have seen indicates that the optical performance of the Clareon is essentially the same as the AcrySof IQ. The material is made slightly differently, and the edge design is slightly different, and the light transmittance is higher for the Clareon. The sharper edge design of the Clareon has a slightly higher risk of dysphotopsia and slightly lower risk of PCO. Have a look at this study report.

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Comparison of Visual Outcomes and Patient Satisfaction Following Cataract Surgery with Two Monofocal Intraocular Lenses: Clareon® vs AcrySof® IQ Monofocal Smita Agarwal1, Erin Thornell2

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And there is this document which shows the improved light transmittance, but I really have not waded through the rest of the data. Don't see any defocus curves on a quick look, and most of the document seems to be about the toric versions.

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Clareon P190018 Physician Labelling PDF

"Even though the one draw-back is that it's just a partial optic and not the entire 6mm."

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Where did you get the information that the Eyhance does not use the full 6 mm of the lens? I recall seeing somewhere that one lens, and I don't remember which, reduces the useable optical diameter, but only at very high powers - I recall only for lenses over 30 D, which would only be needed for someone that is very hyperopic.

It's supposedly ~5mm out of the 6mm. I have no reason to doubt that, as he's frequently using both in cataract surgery. the zcb00 has a similar characteristic. I suppose it's a design choice to make the haptic easier to work with? Less dysphotopsias? Can't say, this is beyond my understanding.

I found some material on the IQ Monofocal, but i'm not sure that will do much to change my mind on this lens option anymore. I think i still prefer paying for the icb00 surgery over the zcb00 they give at the public healthcare, but obviously since it's a monofocal i'm not expecting a miracle despite the heavy marketing otherwise. I need to make a choice and if there's any chance i get a bit of improved range while maintaining image quality i might take that.

I feel that Vivity scares me too much, probably disproportionately so.

i saw that video too where he said Vivity uses the full 6mm so is better for those with large pupils. tecnis has a border for all their lenses. however the PanOptix js only 4.9mm. i am going to see him end if this month. what are you currently leaning towards?

When you say that you made a mistake in not getting a Toric lens in the one eye, was the ORA test you told me about not used to gauge it? And if it was used, did it not suggest the Toric version?

The surgeon I'm going with said he's going to wait til my eye is open, run the ORA test, and then decide if I need the Toric. He's pretty sure from the initial tests that my left eye will need it, but I'm wondering if I should ask for a Toric in the right eye, no matter what the test indicates? I've already factored the possibility into my budget, so for the difference of $300, maybe I should just insist on it?

My first eye was done in the public Royal Alex hospital in Edmonton that serves many ophthalmologists. The surgeon I had is a professor at the University of Alberta. The hospital has very good equipment and facilities. This eye was measured two ways for astigmatism, and I believe an IOLMaster 700 and Pentacam was used. Not sure now which was which, but the surgeon said one method predicted 0.0 cylinder and the other predicted -0.4 D. Neither was high enough to merit a toric, so I went with a AcrySof IQ pure monofocal. I had the surgery on this eye, and while initially I tested at -0.75 D cylinder, it has since come down to -0.50 D. With my sphere at 0.0 D, I have 20/15 vision so it turned out very well.

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At that time my other eye was measured too, and there was not much discussion about exactly what was predicted, but the surgeon raised a caution flag that I had "irregular astigmatism" and while it was higher, a toric lens may not be suitable for me.

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About a year went by and I got a referral to the same surgeon for the second eye. My second eye was measured again, but this time at the surgeon's private office. This surgeon's father was also an ophthalmologist, and in the interval had passed away and left his son the office and equipment. My observation was that the equipment in this office was a downgrade from what was used at the Royal Alex. After the measurements he was initially recommending a toric for the eye. I reminded him that when he measured the eye previously at the Royal Alex that he was unsure that a toric was suitable due to the irregular astigmatism. He abruptly stopped the consult and said he did not have the information to discuss it further, and would have to call me back by phone from his office at the Royal Alex. He obviously did not have access to my previous measurements from his office and probably was not able to take the same measurements with his older equipment. When he did call me back at home we had a discussion on options and he was very iffy about recommending a toric. The issue with irregular astigmatism is that the astigmatism is not symmetrical in the eye. Rather than being hourglass shaped, it is all on one side of the eye. He told me that we could go ahead with the non toric and if there was too much residual astigmatism it could be corrected with Lasik post surgery. I went with that. His prediction was that I would end up with -0.75 D cylinder, which is on the borderline for needing a toric.

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After surgery, which this time was done by the same surgeon but at a private clinic, Visionmax Eye Centre, I ended up with the predicted 0.75 D cylinder and unlike my first eye with 0.50 D cylinder I was getting a drop shadow on letters. The surgeon suggested Lasik and did some referrals. The first place I went to, Lasik MD, flat out refused. They said they could reduce the astigmatism, but I would lose my near vision ability. That was a no go. The second place, Eye Q Premium Laser, said the reason for my irregular astigmatism was most likely keratoconus and they would not touch the cornea with a laser as they said it was so thin the results would be unpredictable. Another dead end. However, they did a full eye test exam with a Phoropter. The tech showed me the difference between what a had in this eye for vision and what vision would be like with astigmatism correction. It was a night and day difference. The light bulb went on for me at that point. A toric lens would in fact have worked very well. I still resent to some degree that the surgeon did not give me better advice. A toric would have worked, and Lasik was not really an option.

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Long story, but back to your question. This surgeon never offered ORA, and at the time I was not even aware what it was. I just checked now and I see that Visionmax does have the ORA system, but I would have to assume my surgeon does not know how to use it, or does not have the use of it in his agreement to use the facilities in the clinc. And, I do not know if it would have provided any more clarity on whether or not a toric would have worked for me, as my case is fairly unusual.

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This all said, I still have very good vision in this eye, which is the close vision eye in a mini-monofocal configuration. I do know now that it would be better if I had gotten the toric. But, I read normal font easily on my computer, and on my iPhone without glasses. The only time I have a bit of an issue on the iPhone is when it is white text on a black background. For some reason that shows the double image drop shadow more than the reverse.

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I guess one thing with the ORA system is that depending on the sedative used for the procedure you leave the final choice to the surgeon to decide what lens will be used if you are not aware enough to think clearly... My hospital experience was with an IV sedative and I was definitely not in a clear thinking condition. My clinic experience was with Ativan. Not really sure how clearly I would be able to think, but I certainly was much more aware of what was going on.

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Hope that helps some,

That is very helpful, thank you! But, wow, that is such a let down, what you ended going through. Especially since you did so much research and work to try and get the best results for your own situation only to be undercut in the end by a surgeon you thought you could trust. Interesting also, the state of the equipment in the private practice, as usually they are more advanced than the hospitals. I'm sorry you got so blind-sided after all of your hard prep work. It's good that you were able to figure out some workarounds at least, if not perfect, but a bummer that you should have had to.

I have arranged to do the surgery with the Eyhance early March, and posted a reply regarding that on the other thread, but because I attached a copy of my contact lens prescription (which I've only gotten my hands on), it's being moderated so probably won't show up until Monday.

I did the basic prelim tests last Thursday and they will do the more extensive work-up in the pre-op assessment near the end of February. They said for sedative, they're just giving something to relax me, not put me completely out, which considering your experience, is sounding better by the moment. So, it's likely I'll be able to respond to whatever they find with the ORA.

My general astigmatism is -1 in both eyes right now, but from the initial consult, the surgeon was pretty sure that I'd need a Toric in the left eye at least. For my own peace of mind though, I think I will ask him before the surgery, that if in any level of doubt, to just go ahead with Toric in both eyes. It's not going to hurt my outcome, and yes, $300 is a fair amount of money, but worth it if it will offset some the potential problems that people like you are going through after the fact.

I'm too afraid of the contrast loss of Vivity even though you are more likely to get reasonable computer vision with it so Eyhance is now my top consideration. There's been a lot of positive experiences with it, but I'm going to need glasses very likely and there's no guarantee of any range.

Then again, i think glasses are inevitable for near and probably computer anyhow to get a pin-sharp image regardless of my choice. I'm just hoping i get adequate function with eyhance so i don't need to have glasses for all kinds of mundane things at arms length that don't need precision.

It's a dice-roll regardless.

You have an interesting history with your very high myopia and detached retina issue. Without those issues I would agree with the surgeon that with the Eyhance targeting plano in the dominant eye and -1.25 D in the non dominant would be ideal. An outcome of -1.5 D in the near eye is ideal with a monofocal. I am not sure there is a hard limit on 1.0 D differential between the eyes. With monofocal lenses I would say 1.5 D differential is pretty standard. it is also normal to target -0.25 D in the distance eye for safety which reduces the differential to 1.25 D if all targets are hit. But at the end of the day it is your choice as to what you want to see without glasses. With what I know of the Eyhance you should get good close vision with a range of -1.0 to -1.25 D, and in the distance eye, going to -0.25 D is fine, but as you go more myopic than that you are losing distance vision.

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You are putting a lot of trust in the surgeon's accuracy in power prediction by doing them one day apart. There will be no indication at that point what the outcome was on the first eye. I always suggest 6 weeks between eyes so you know exactly what you got on the first eye, and can make any necessary adjustments to the calculations and targets for the second eye. My surgeon said he always learns something on the first eye that he can use in the second eye. But on the contrary side you will have a very large differential between the two eyes after your first surgery. That could be difficult to handle for 6 weeks. The normal practice would be to use a contact in the non operated eye. Without ORA being used that should be fine as the measurements of both eyes will be taken before the first surgery. But, with ORA being done in real time during the surgery I am not sure how that would upset the ORA measurement if you have been wearing a contact between surgeries. If it does then wearing a contact in the non operated eye is not a good idea.

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Not sure what is meant by laser guided placement, but with a toric you get the angular part of a toric correction by placing the lens in the correct angular position. My wife had torics and the surgeon used a manual method of simply marking the eye with what sounded like a Sharpie felt marker just prior to surgery. It seems to work. I think the big trick with torics are to make them stay where they are initially located and supposed to be.

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In any case I think you understand the issues and risks and if you are prepared for potentially needing eyeglasses for the very best vision there is not much to worry about.

I think I just got caught up in the transition my surgeon was making in his practice to go private vs public. The instruments were not antique in his inherited clinic. He had a IOLMaster 500 when the best is currently the IOLMaster 700. You probably should make note of what they are using when they measure your eyes for real. You should also ask for a copy of the IOL Calculation sheet. It will have the required power of IOL and the predicted residual outcome of surgery for each. With your high myopia getting the power correct is not a given. The calculation sheet will also show the power calculation formula they are using. With your high myopia I would expect the Hill RBF 3.0 should give the best results and the Barrett Universal II also a good comparison. If the results of each match, you are good to go. Then of course you have the ORA for a final check. If you have the calculation sheet from the IOLMaster you can compare what ORA predicted in comparison and what was actually used for power.

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Be aware that there is no safe option to use a toric when it may not be necessary. You kind of need it or you don't. Not sure on the Eyhance but the Alcon torics come with a minimum cylinder power of -1.0 D. The effective outcome at the eyeglass plane of that power is about -0.75 D. So if your predicted eyeglass outcome is -0.75 then a -1.0 D toric is a perfect match. If you predicted eyeglass outcome is -0.50 D, then it is too much correction. The problem is that if it used it will "flip" the astigmatism by 90 degrees. Say you are at -0.50 at 70 degrees, and use this toric. In theory it would flip your angle to 160 degrees with a cylinder of -0.25 D. This sounds good as cylinder is reduced, but the problem is that now it is at a totally different angle that your brain is not used to. My optometrist tells me that for this reason astigmatism should never be over corrected. But, I am sure your surgeon is well aware of that. The point is that there is no safe option to use a toric when it is not indicated.

I like the marker comment, lol. The idea of having to go for yet another month without being able to wear a contact in the un-operated eye is really difficult for me -- would actually add a lot more stress to my life -- a lot of organization to have to work through. I don't live in the city, so it means that once again, I'd be dependent upon others for anything needing a car for, which is actually a lot these days.

I hear what you're saying about trusting the surgeon and (hoping) that they learn from the first eye, etc, but in actuality, other than learning perhaps the ideal power settings etc, that philosophy seems to be have been somewhat of a crapshoot for both yourself and others who have posted here and elsewhere. And there seems to be a high incident of people experiencing the "second eye syndrome" who have waited. The surgeon's reasoning is that doing them right after each other usually lends to a better binocular result. I think that doing one eye right after each other might give him better information second time around. I know when I take computers apart, even though I might take notes, etc, It always goes smoother when I get it all done immediately rather than starting something else and then going back. I'm not the only person he's operating upon, so whatever drama he finds with the first eye, I think will be easier to compensate for the next day, then over a month later when he's seen many people in between.

I do know that if I don't have usable near and intermediate sight and somewhat distance in my right eye for going about daily business, that is also going to cause undue stress to get used to. Over the past year, I've had more headaches than usual because of the blurriness in my left eye (intermediate and distance), so even creating mini-monovision with that eye I think will not end well. And I think in the end, it will be easier to fine tune my vision overall if both eyes are somewhat close. I think targeting -0.25 is too much of a risk for me for either eye in case it ends up at plano. Even if -1.0 for the Eyhance ends up -0.25 either way, I think I will end up in a reasonable position. With any luck, I'll end up like Mary27273 who took that route and has quite a reasonable range. When you have a brain injury, you need to keep the variables to the minimum, partly because of the extreme amount of energy and focus you need to generate in order to just exist, but also because it and the body don't always exactly listen closely to each other any more and that is not a good thing when you're going down stairs even with perfect vision, lol.

Got you, regarding the astigmatism corrections. And I have added your suggestions regarding the tests and asking for a printout in my notes for them. Thanks.

From what I've been reading about the Eyhance, and not just from J&J, is that the haptic design of the Toric version has made it extremely stable compared to other Toric lenses. A number of independent surgeons (ie no affiliation with J&J) think that it's design will end up being the standard for Toric lenses in general.

The Toric spec sheet states:

OPTIC CHARACTERISTICS

Powers: +5.0 D to +34.0 D in 0.5 diopter increments

Model Numbers: DIU150 DIU225 DIU300 DIU375 DIU450 DIU525

Cylinder Powers – IOL Plane: +5.0 D to +34.0 D in 0.5 diopter increments

Cylinder Powers – Corneal Plane: 1.03 D 1.54 D 2.06 D 2.57 D 3.08 D 3.60

Diameter: 6.0 mm

Shape: Biconvex, continuous higher-order polynomial aspheric anterior surface

Material: UV-light absorbing, hydrophobic acrylic

Refractive Index: 1.47 at 35° C

Edge Design: ProTEC frosted, continuous 360° posterior square

BIOMETRY:

A-Constant: (CONTACT ULTRASOUND) 118.8 // (OPTICAL) 119.3

AC Depth: (CONTACT ULTRASOUND) 5.4 mm // (OPTICAL) 5.7 mm

Surgeon Factor: (CONTACT ULTRASOUND) 1.68 mm // (OPTICAL) 1.96 mm

HAPTIC CHARACTERISTICS

Overall Diameter: 13.0 mm

Thickness: 0.46 mm

Style: C, Tri-Fix haptics offset from optic; 1-piece lens

Material: Soft, Foldable, UV-light absorbing, hydrophobic acrylic

Design: New squared and frosted haptic design

Edge Design: ProTEC frosted, continuous 360° posterior square edge

They had a link on the spec sheet for a Toric calculator. I don't know how to use it, but it looked interesting. It only has J&J lenses to choose from.

The issue with learning from the first eye and applying it to the second is that it takes 3 weeks minimum of healing to find out where the first eye ended up.

Indeed. In my case (UK) the surgeon operated on my second eye only 8 days after the first, because of my (relatively) high myopia and the imbalance between operated and unoperated eye. I covered one eye during the week (using old glasses and tape, and removing one lens; I had one pair with the operated eye side taped and one with the non-operated eye taped, so I could use one for distance, one for reading), but it was a massive relief to get the second eye done, and it was a fairly miserable week - I couldn't wait. Increasingly bilateral surgery on the same day is becoming more usual in such cases here, it seems. As an aside the surgeon used a kind of augmented reality system when rotating the toric lens into place, with the screen overlapping correct alignment according to his computer over my eye as he rotated the lens, though he marked up my eye with a market old-school-style, too.

That is interesting. so did you, or do you, think anything could have been done better by waiting longer between the surgeries? Both of the consults where I am (Ottawa, Canada), wanted to do the surgeries close to each other. What Ron suggests about convenience (and profit) for them as being the main reason for this makes sense, but I have read a number of articles, etc, which say that by doing the surgeries close to each other ended up in a better long term result, in particularly with respects to the success of binocular vision.

For myself, as you said, I think waiting another six weeks would be complete hell for me with my high level of myopia and create far too much stress for my already overloaded brain. Yes, I could remove the lens of my glasses, but I wouldn't really be able to drive (I can't drive with my glasses as it is, only with contacts). I really do not think the end result of waiting between the eyes is going to end up changing much of my choice of targeted vision.

Anyway, I am going with the current arrangements, and hopefully it won't end up being a "lesson for us all", lol. (What can I say, I have a dark sense of humour -- it's saved my sanity more than once.)

I have tried the one lens out method and did not like it. With your much higher myopia I agree it is not going to work well at all. A contact lens in the unoperated eye would likely be the only tolerable solution. However it may contradict using the ORA system on the second eye.

I looked up their advanced diagnostics package (what I'm getting) and it states, "Our Advanced Diagnostics Package includes several measurements: Anterion, Pentacam AXL, Lenstar, corneal topography and Optical Coherence Tomogrophy (OCT) (if required). These advanced measurements will assist your surgeon in selecting the best intra-ocular lens power".

Do any of these translate into any of the measuring technology you've been referring to?

Regarding the extra laser package I referred to before that costs an additional $1,100 per eye states, "The Catalys laser that combines state-of-the-art femtosecond laser and advanced 3D OCT imaging to complete many of the critical steps of surgery that are traditionally done manually with hand held instruments. Using a laser to complete these steps increases precision, makes the surgery gentler on the eye and improves safety on some types of cataract".

I can't afford that so this surgeon better be really good using his hands, lol. Granted if the surgery was done in a hospital, he wouldn't have access to this tech anyway. He's also a corneal surgeon. He said he didn't have a problem not using the enhanced tech.

I am familiar with some but not all of these. The Pentacam is used in cataract surgery to measure the 3D topography of the cornea for purposes of quantifying astigmatism. The Lenstar is the main measurement tool for determining primarily the length of the eye, but it may also quantify the astigmatism. It is the competitor for the IOLMaster that is commonly used for the same purpose. I believe the OCT is used to determine the condition of the retina.

Thank you once again.

I found the 8 days between the two surgeries quite stressful. As RonAKA says the single-eye option does not work that well, and certainly rules out driving. I should have had a soft contact lens made up, I guess, which would have been easier. From my own experience I had great binocular vision immediately on removing the shield on the day after surgery, with no period of adjustment whatsoever. I think my surgeon just went for the 8 days gap because of my (relatively high) prescription (-9.5, -4.0). I chatted to another patient in the reception area, and she had a six-week gap with the same surgeon, and had just cataracts, with little need of any prescription. I've just picked up some progressive glasses for around the house, and they are great.

Hugs, has your visual experience with the eyhance been positive overall. Any issue with sharpness or other weird phenomena at any situations. I'm being targeted for -0.25 on my dominant eye. It's likely the distance will hit just a tad under logmar0.0.

Your other eye was pared back by -0.5, probably it's a lot more compromised there probably.

I'm still trying to get confirmation that I will like these lenses having had excellent vision my whole life at all distances.

hi spoo

u need to get a copy of your iol master. in my case -0.25 for my right eye will be plano with 16D IOL. 16.5D will set me at -0.6 and 15.5 will set +0.10.

someone can very well be plano at -0.1 at which point you are safe to go with -0.45 so as to not end up hyperopic.

of course you can be spot on with lasik after surgery.

Hi, spoo. We are coming at the process from different directions in a way, since I've had poor (myopic/astigmatic) vision all my life, and my vision now is (compared to that) absolutely amazing. Objectively, though, the one point I would raise is that I certainly have a "halo" or misting around lights when shone directly into my eyes at night. This doesn't trouble me when driving, for example, though I can understand it might irritate/disappoint others. My night vision in traffic is not crystal clear (never has been though!). The -0.5 in my left eye is not noticeable in daylight, since my brain seems to use the clearer image and fills out the rest (I used to use monovision, but am loving my return to binocular), while it enhances my glasses-free intermediate vision (for the same reason as above), so it's worked out well. The -0.5 is a little more noticeable at night, but not (for me vs. prior) in any meaningful way. I would also add that I have opaque post PVD floaters, and they contribute to the haloes at night when they wander into view, but optical trickery probably is part of the story though. I have no other distortions (though as mentioned elsewhere immediately post-op there was a fair amount of dysphotopsia with bright lights). Indoors or outdoors closer up, the world starts to get out of focus closer than a little beyond arm's length (I'm not that tall, though!), as I mentioned. Inside arm's length I am more comfortable with corrected vision, and I most definitely need corrected vision for extended reading, or indeed reading the small print on food labels etc., as was intended when setting me for distance vision. I am not like some who appear to be good at all distances with Eyhance, I guess one thing was my surgeon was careful not to over-promise, while I had weak vision before surgery. I have just picked up a pair of progressive glasses (distance, intermediate, close), which are great for, say, sitting at table and clearly seeing my food/the menu, or glancing down to read my phone). I hesitate to offer any advice, since my tolerance for blurriness etc. is probably higher than many owing to my lifelong use of not-always-perfect glasses and contact lenses. There is a Tecnis Eyhance vision simulator (you may have seen it) online. Selecting Toric II Eyhance (my lens) with astigmatism and the night view, and then comparing this with what I ended up with, (1) fuzziness/mistiness in a halo around headlights/other lights at night is noticeably greater than that shown on the simulator (2) my dash-distance vision is FAR better than on the simulator - I can see my dash perfectly, including google maps on a mobile phone mounted on the air vents. I have no idea if the two are connected, though! Comparing the daytime scene, my distance vision is uncompromised and super-clear, my intermediate vision is a LOT better than the simulator shows, and my near vision is also better, particularly my slightly undercorrected left eye vision. Hope this helps.

Thanks, this is helpful and it's indeed hard to find an exact comparison to my vision.

Obviously when replacing one of my lenses with an IOL will reveal potential issues with my natural eyes that i've become used to over time. Still, i am concerned that my tolerance for blurriness, especially uncorrectable blurriness maybe lower than someone with pre-existing eye conditions.

The vision simulator is marketing oriented as it doesn't visualize things like contrast loss etc and the differnece there between eyhance and monofocal is supposedly "nothing", but the light distribution curve does look more funky.

But if you are able to experience sharp / ghostless vision at the optimal focus points that's already a good thing, because it means it's actually possible to correct the vision in case there are issues with it.

What is your ultimate prescription after the lens implant or is that question still evolving?

Do you have any hypothesis to why your night vision has issues even if they managed to hit the corrected targets? Does this include both eyes or just the -0.5 one, and does the situation change at all using glasses?

Hi, Spoo. I guess there is an awful lot of optics going on between the light hitting my irregular cornea and finally reaching my retina, and my experience is probably not that relevant (and may be misleading) for those with less complex prescriptions. I started out at Sph -9.50 CYl -4.0 (R) and Sph -10.0 Cyl -3.50 (L) and landed at 0.0 and -0.25 (R) and -0.50 and -.25 (L). Both eyes experience a degree of haze around direct light at night, which could be due to the high prescription, I guess, and may be within expected parameters. It doesn't bother me in the slightest, though, and may be to do with my eyes rather than the lenses, though this is hard to say! YMMV as my daughter says! I live in the countryside, and lights are isolated, so my pupils are widely dilated outside at night. I have not spent much time at night in well-lit environments since the op. Perhaps this is factor?