Final Answer: LAL

I have not asked for a pre-adjustment target, at least not yet.

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I told the doctor I think I would like to end up at about -2.00 D. He said that's overkill, and proposed to target -1.25 D to start. If I like the initial result, we can just lock it in there. If I do want more nearsightedness, it can be added with light adjustments until I'm satisfied.

My -2.00 D goal is post-adjustment, not pre-adjustment.

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I hear that the LAL extends its depth of field when adjustments are made to increase myopia - but not when adjustments are made to decrease myopia. Some surgeons seem to target plano initially, with the intent to add a bunch of myopia to maximize depth of field with the near-vision eye. I was actually thinking of asking my doctor whether we should start at plano for that reason. However, your warning also makes sense - the last thing I want to do is run out of adjustment before hitting my desired myopia!

My doctor uses ORA for lens selection, and says his experience is that ORA is quite accurate. But I am sure you are right that errors still happen and it's best to allow for the possibility of a significant error.

Not sure what the best answer is here... Thanks for the suggestion.

It is my understanding, the extended depth of focus only occurs on the very first adjustment (going towards myopia)

The adjustment needs to be more than .5 diopters for EDoF to occur.

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I am curious what your doctor suggested instead of the LAL?

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My questions are so similar to yours and I appreciate you sharing.

It is my understanding, the extended depth of focus only occurs on the very first adjustment (going towards myopia)

Julie, I think you are likely the source of Phil's understanding.

"It is my understanding, the extended depth of focus only occurs on the very first adjustment (going towards myopia)

The adjustment needs to be more than .5 diopters for EDoF to occur."

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That's interesting. I had not heard either of those details.

In the Mayo Clinic video, Dr. Mahr talks about this. He mentions myopic adjustments greater than 0.50 D or equal to 0.50 D, but does not explicitly say that a smaller adjustment fails to produce a similar effect. He also talks in the same video about controlling EDOF by starting at plano and "creeping" toward myopia. It sounds like he is implying that multiple small adjustments do contribute to EDOF (not just the first adjustment), but again, he does not say that explicitly. He also says that with EDOF, many patients choose only -0.25 D or -0.50 D of myopia for their monovision (near eye).

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Dr Wong on Youtube describes his technique, but is even more vague about the EDOF effect. He says that he targets plano with initial lens selection, and adjusts to a final target of -0.75 D or -1.00 D. Apparently, with the resulting EDOF effect this is sufficient myopia to give patients pretty good reading vision without losing much distance vision at all. It sounds good, and he has a patient experience on one video showing that. But the details are not discussed.

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I would love to know more, and will ask my surgeon. Did you get the info above from your doctor?

"I am curious what your doctor suggested instead of the LAL?"

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• Two doctors suggested the Clareon monofocal lens, mainly because that is the standard lens their group buys in bulk.
• One doctor recommended Symfony OptiBlue, because of extended depth of field, compatibility with small pupils, and compatibility with an eye that had prior LASIK treatment for myopia (which tends to flatten the cornea). This doc said the enVista lens would be terrible for me because of my prior LASIK.
• The other doctor recommends enVista, because of the secondary aberrations in my cornea (maybe a lot of those secondary aberrations were caused by my old LASIK treatment) - he says the enVista lens is more tolerant of such aberrations. This guy says I should definitely avoid the Symfony OptiBlue lens because the nature of my old LASIK (small optical ablation field) would practically guarantee bad dysphotopsia with the Symfony.

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  None of the docs expressed any great concerns with the LAL, it just was not their first choice.

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  I think part of the reason for the varying recommendations is that most doctors have a tendency to not listen to what you want as a patient. And part of it is technical considerations that patients are unlikely ever to fully comprehend. I also question how fully even the expert doctors comprehend all the considerations that go into a good lens choice for an individual patient. Based on my experience, it appears tbat a lot of the doctors' advice is based on a limited set of facts, considerations, anecdotes, experiences, and biases. Even very good doctors seem to be pretty inconsistent in their advice and approach for an individual patient. The docs might say that such things are more art than science. I think it's more accurate to say that they are sloppy in their thinking and that most patients let them get away with that.

Yes, I received that information from my surgeon.

Also, EDOF cannot be reversed.

JDvision has LAL in both eyes and is extremely knowledgeable.

I I'm hoping he will read your post and respond. He is pleased with his outcome.

The LAL + has me concerned. Would my surgeon have implanted the + in my eyes without me knowing? I just had my 3rd appointment with him. I also had 1 appointment with the optometrist who does the LAL refractions. I was scheduled to see the ophthalmologist who does the LAL LDD adjustments (she just implanted LALs in both eyes) but saw the surgeon instead. This surgeon has a remarkable reputation.

Again, thank you for your posts.

I don't think a surgeon would deliberately implant the wrong lens in your eye, but mistakes do happen in surgery and I am sure that the wrong lens has sometimes been implanted in cataract surgery. But since you said your surgeon has a remarkable reputation, I think he implanted the lens you wanted.

You summed it up pretty well in your last paragraph.

"I think the Symfony surgeon is wrong and the enVista on is right. Symfony uses some MF and is generally not recommended for a prior Lasik patient."

I would say the same, based on what I've read. But the Symfony surgeon is himself a prior LASIK patient, and got Symfony in his own eye. He recommends it from personal experience as a patient as well as a doctor. He uses enVista as a surgeon, but does not have one in his own eye.

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Thank you for all your help, RonAKA. My next question is whether to ask the surgeon to aim for some off-label extended depth of focus, as seems to be common for near-vision eyes with LAL. From anecdotal reports and internet videos, my impression is that EDOF works well for LAL mini/monovision patients, with an acceptable tradeoff of slightly lower acuity at the main focal point. I assume there is always some tradeoff, and perhaps for the distance eye, EDOF would not be worthwhile. Any input would be appreciated.

My thoughts on the EDOF claims for the LAL is that I would not depend on it, and target the eyes to get a very accurate spherical equivalent outcome. If you get some EDOF then it would be a bonus. Just my opinion but I would not go overboard with targeting more than 0.5 D over what you want to end up at.

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@JDvision has experience with the LAL mini-monovision. He seems to have come up a little short in the reading vision eye with a -1.6 D outcome. I don't quite understand that. Perhaps I just got lucky with my near eye, with my extra amount of cylinder that has not been corrected.