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first eye Vivity emmetropia, second eye?

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Pascal111
Pascal111

Hello everyone, I would like to know your opinion, maybe get an idea how my second operation should proceed.

March 2020 I received the Vivity in the remote dominant eye. Now the right eye is on. In good light I can read from about 35 centimeters. From 50 centimeters I can read well. However, mainly use fonts with good contrast, such as .B smartphone. Newspapers, fonts with poor contrast, are difficult even in good light.

I would very much like to get a few centimeters more closeness. My 3 main focuses for the 2nd operation: 1. No strong optical phenomena, no risk of a failed neuroadaption. (which means that multifocal lenses are excreted) 2. The widest possible range and thus freedom from glasses. 3. The best possible visual acuity. I realize that either way it's a compriss. I am looking for the most suitable, best possible compromise for me.

I am seriously considering 2 options so far, possibly a third party. Do you have a more suitable idea?

  1. Vivity on emmotropy. - This should not cause me any optical disturbances and allow an almost perfect visual acuity from about 50 centimeters to Far (as it succeeded in the 1st eye)

  2. Vivity with -0.5 diopters - This should give me a few centimeters more closeness without losing binocular appreciably distant. With only -0.5 diopters, neuroaddaption should not be difficult and I should get a uniform picture. Or what do you think? - On the other hand, I have the (small) concern that this mini-monovision will lead to further loss of contrast. And a few centimeters more closeness won't do me any good if the contrast nearby is so bad that I still can't read well nearby.... (these thoughts are pretty much my biggest question)

    2b. Eyhance to -1.0 - Should give me less loss of contrast. However, the mini-monovision would be larger, so probably the binocular image would be more difficult and I would lose some distance - therefore probably not an option for me.

  3. A bifocal lens, focal points near and far. - This is where I know the least. Is there a bifocal lens with wavefront technology? All other technologies provide halos and co., right? What would make for less interference and the larger range and the better overall picture: mini-monovision with the Vivity or a bifocal lens?

I am very curious about your opinions and experiences, thank you very much! And all the best to you!

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  • mathdoc
    mathdoc Pascal111

    Edited

    Congrats on your excellent outcome with the Vivity in your LE. Your LE monocular defocus curve came out better than that in Vivity/FDA clinical study. Which IOL formula did they use for power calculation? Your astigmatism had perfect mirror image symmetry (corneal astigmatism: -0.93Dx169◦ RE, -0.93 Dx11◦ LE), and nice to see that your cylinder dropped to -0.25D (and sphere to 0DS) post surgery! Your monocular VA of ~0.35 logmar at -2.5D/40cm is better than FDA report VA at that vergence, but it drops off steeply to ~0.72lm at -3D/33cm (FDA defocus curve stops at -2.5D, so no data there). The starbursts & spiderwebs & halos are somewhat worse than I expected (though tolerable) for the Vivity, though.

    Please check what predicted refractions you get for your RE biometry & Vivity (using the same power formula as in LE), for IOL powers 21D (~emmetropic), 21.5D and 22D. The values shoud be (my guesstimate) approx. 0, -0.35D and -0.7D, respectively (are they?). Then, you can use your own LE defocus curve to see what monocular VAs you can expect in your RE, at those power values. For example, with 22D power Vivity in RE, if ~ -0.7D is the refraction, your monocular near vision could be: 0.175 lm @ 40cm & 0.275 lm @ 33cm (0.175 lm @ 40 cm is roughly 20/30 Snellen = Roman N5 = Jaeger J2). Binocularly, I'd expect close to N4 @ 40 cm (=0.1 lm) with this choice.

    Please share your thoughts & questions, and correct me if I've made any errors in the above.

    • Pascal111
      Pascal111 mathdoc

      Edited

      Simply WOW! Thank you very much for the deep input! However, this overwhelms my knowledge to a large extent. I read out that the result LE was excellent and nearby better than expected. Which in turn tells me that with the same conditions in the RE, for more proximity, the MiniMonovision can be low...? (Lower MiniMonovision = lower risk of vision problems/disturbances/loss of contrast... right?)

      The starbursts & spiderwebs & halos are somewhat worse than I expected (though tolerable) for the Vivity, though.

      I don't have starburst and halos at all... After 4-5 weeks only a small capsule algae has formed, so that since then I unfortunately see two diagonal stripes through lights/sun/moon... however, this does not really bother the vision at all. it looks like this character "/" by a "0"

    • RonAKA
      RonAKA Pascal111

      Posted

      Keep in mind that MTF (contrast sensitivity) has a bell curve associated with it. See the Vivity Package Insert PDF. When you move the curve to the right with under correction you actually increase MTF and contrast sensitivity at closer distances, at the cost of a small loss (in that eye only) at distance. This effect should result in the ability to read more easily in dimmer light. That is when most people start reaching for reading glasses.

  • Pascal111
    Pascal111

    Posted

    The following should perhaps be noted:

    • The eye test on which the results and the Defocus curve are based took place under perfect conditions: Brightly lit room, illuminated panel with black writing. Better contrast is not possible. Therefore, good results. However, these lighting conditions are extremely rare in reality. Therefore, the real result in everyday life is not as good as the test result.

    • For the operation, I bought the femto-second laser. Thus, the calculations for the capsule cut are even more accurate.

    • Unfortunately, I have had permanent vitreous opacity since the first Biontech vaccination. This permanently disturbs vision and concentration (through hundreds of dots and "floating mosquitoes" in front of the eyes)

    • My eyes are extremely dry due to the Lagophtalmus. I drip 12x hylocomode gel into the eyes a day. Dry eyes increase the risk of refractive errors. In January, I have the measurements taken on 2 different days.

    Thank you for your time and input! I appreciate this very much!

    • RonAKA
      RonAKA Pascal111

      Posted

      Sorry to hear you have had these issues. I had perfect vision with my IOL for 10 months and then I got hit with a posterior vitreous detachment (PVD), that has resulted in me having a fuzzy spider like object in my semi peripheral vision. It appears it was brought on by age, and not the surgery though. There is always something!

  • Pascal111
    Pascal111

    Posted

    Hello everyone,

    today I had the first measurements for the 2nd operation as well as eye tests. This showed new aspects:

    • With the operated eye I saw far 100% (clear vision I had up to 80%. Towards 100% it became blurry/uncomfortable, albeit flawless). With the eye not yet operated, it was 40-50%.

    • We tested the change in the operated eye with lenses -0.5D. The result frightened me: I only came to 60% distant vision (and this only blurred). Close-up visibility to 40cm improved from about 35% to 60%.

      (The test with -0.75D was even worse, this probably doesn't make sense in my case. The optician brought a difference of -0.25D into play)

    • If I combine this, I can expect a binocular remote vision of almost 80%. And a close-up visa up to 40cm of about 45%. Of course, I wonder very much whether it is worth it or whether I should not also aim for emmotropy. Then I will have an almost perfect long-distance and intermediary view... but little closeness (which is also important to me...)

    • After the examinations, however, the following thoughts came to me that would still speak for a mini-monovision: 1. Because of the large cataract, we could only simulate on the operated eye. This is the remote dominance. Probably an undercorrection with -0.5D in the non-dominant eye is not as serious for distant vision as in the dominant eye...?

      1. When I walk around or watch TV, I am binocular despite the restriction to 40% in the 2nd eye, satisfied with the distant vision. Therefore, a distant vision after the operation should be better with 60%, as my current visual acuity...

    Thank you for your time and interest! I appreciate this very much!

    • RonAKA
      RonAKA Pascal111

      Edited

      "Probably an undercorrection with -0.5D in the non-dominant eye is not as serious for distant vision as in the dominant eye...?"

      .

      I think the impact will be similar for a non dominant as for the dominant eye. The cataract however, will be having a significant impact on the unoperated eye vision of course.

      .

      I am not familiar with these % vision numbers. What would be most informing at this point would be to know the residual refractive error in the operated eye. Where did it end up? For emmetropia the standard target is to be -0.25 D (slightly myopic). They don't want you to end up in the + zone. If for example the surgeon hit this right on, then you would only need a +0.5 D lens applied on top of this to simulate -0.75 D mini monovision. Monovision close vision is not determined by the difference between the two eyes, it is determined by the absolute myopia of the near vision eye. And of course if the surgeon missed on the negative side and you ended up with -0.5 D myopia for example in the distance eye, you would only have to add a +0.25 D lens to this eye to simulate -0.75 D myopia and monovision.

      .

      At least that is the way I see it. Does that make sense?

    • Pascal111
      Pascal111 RonAKA

      Posted

      Thank you Ron. first short answer. According to the optician's statement today, the surgeon had targeted -0.09 and hit exactly -0.09D

    • RonAKA
      RonAKA Pascal111

      Posted

      That is insignificant, and needs no compensation then.

  • Pascal111
    Pascal111

    Posted

    Hello everyone, I now had my preliminary examinations at the University of Heidelberg and the conversation with the operating Professor Khoramnia, who also performed my 1st operation and wrote the case report. According to the optician, there are several factors for lens size. In my eye, the lens strength at -0.16D would be 21.5 at -0.48D 22.0. With the professor I agreed on -0.48D/-0.5D as a refraction target. This was also my desired value after the eye tests. The professor did not want to risk a larger difference.

    since the cataract has clouded the posterior shell (Cataracta subcapsularis posterior), the prof insists on general anesthesia. I wanted to avoid this because of my risk of anesthesia due to myotonic dystrophy. Furthermore, since the booster vaccination I have mild heart problems and an increased troponin level.

    However, he says that the posterior turbidity increases the risk during surgery that the lens capsule could rupture or retinal problems occur. I now hope that the Minimonovision with -0.5D is the best choice in my case and I survive the anesthesia well. In addition, the "Mouches Volantes" have strengthened significantly since the booster. No matter how well the operation succeeds, these "floating mosquitoes" and dots in front of the eyes will probably always affect me.

    • RonAKA
      RonAKA Pascal111

      Posted

      A 22.5 D IOL should leave you at about -0.8 D then. That would be my choice to increase the probability of good reading vision as -0.48 may be marginal. Your anisometropia with the 22.5 D lens would be about 0.7 D. This is a very small amount and would be in the micro-monovision range. Up to 2.0 D anisometropia has been used in full monovision.

      .

      In any case I wish you good luck with the surgery. It is always a risk on what the power outcome will actually be. Since it is the second eye, I would think his estimation should be pretty good.

    • Pascal111
      Pascal111 RonAKA

      Posted

      Thank you Ron! I am aware that with -0.5D I probably do not have good reading, but only a "better" one. However, I shy away from the risk of more. The surgeon also said that he could not guarantee the fixed point. Let's say there is a deviation of 0.3D. With a target of -0.5D I end up either at -0.2 (very good long-distance and intermediate visa, less proximity, but more than currently) - or at -0.8D (remote vision okay, intermediary very good, proximity good).

      But if we aim for -0.75D and it ends up at -1D... the proximity can be too bad.

      In my eye tests, the distance was too blurred for me with -0.6D. With -0.5D it was okay. And in addition to proximity, intermediate with -0.5D was even better than 100%.

      Was this article here from the forum? Tests with Vivity saw -0.5D as the best distance for a Vivity minimonovision. But of course, everyone has slightly different priorities.

      Definitely for the intensive exchange Ron, I appreciate this very much!

      PS: My surgery is not yet scheduled, probably mid-February

      *“One of the interesting things about Vivity is that it has a big plateau of 20/20 or better vision from +0.5 to -0.5 D on the binocular defocus curve,” Dr. McCabe says (Figure 1). “It provides this ‘flexible and forgiving’ plateau of targeting for postoperative refractive error. Because of that forgiveness around plano, Vivity patients had slightly better uncorrected distance visual acuity than the monofocal patients.

      “In the US trial we had to choose the target closest to plano, but in the OUS trial they could choose first minus, if they wanted to,” she continues. “With that flexibility in targeting, there were a number of patients who had at least a half diopter of difference between the two eyes, and in that subset of patients they did have an improvement in one line at intermediate and near. Based on that, it seems like mini monovision would be a strategy that would allow for a little enhancement of intermediate and near vision.

      “In my practice, I’ve been targeting the dominant eye for plano and the nondominant eye for -0.5 D,” she says. “I’ve had a few patients who ended up slightly more myopic, but I think the sweet spot is around -0.5 D. We’ll have data to back that up when the investigator-initiated trials conclude.”

      She adds that because of the plateau around plano, it’s important to push plus in refractions postoperatively. “You can think they’re a little more myopic than they actually are,” she says*

    • NeluG
      NeluG Pascal111

      Posted

      That's exactly what I have now: Vivity in both eyes, one for emmetropia and the other one for -0.5D.

      For distance I scored 20/15 with one eye and 20/20 for the other one.

      I no longer use glasses for reading, for laptop work or for my phone.

      I would still need glasses for very close up work, especially when light is scarce.

      For me the only annoying thing is slight halos at night around some lights, in very specific conditions but that doesn't affect my night driving in any shape or form.

    • RonAKA
      RonAKA Pascal111

      Posted

      "In my eye tests, the distance was too blurred for me with -0.6D. With -0.5D it was okay. "

      .

      Yes for sure you are going to notice under correction in an eye test of one eye at a time. To do a test fairly I would do it binocularly. In other words under correct the one eye to say -0.75, while looking at the chart with both eyes. That is a more realistic test of what your real world vision will be like with mini-monovision. Monovision is about optimizing each eye differently so the summation that the brain does with the two images together is optimized.

    • Pascal111
      Pascal111 RonAKA

      Posted

      Sure, you're right, that would be a better test. but my cataract is too strong, I can no longer do tests with it. I only had the option to test on the operated eye

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