Has Any One Else Noticed this Unusual Vision Issue with Symfony Lens

There is no lens yet that is perfect. The vast majority of people with any lens are happy with the results, it is   the minority with issues that are vastly more likely to post about them. Unfortuantely the results people get depend greatly on things like the residual refractive error (which can happen with any lens, and is usually correctable via laser) or on the existence of other eye conditions degrading visual quality (which impact any lens). People's natural depth of focus varies, i.e. the range of vision from their eye by itself in dependent of the lens which impacts what they would have even without a premium lens, and the same is true of  the range of vision they get with a premium lens. Studies are only averages, some people do better or worse. If someone doesn't have as much near as average  with the Symfony once refractive error is corrected, its very possible they'd have had even worse than average results from a monofocal as well since their natural depth of focus, or their eye's visual potential, is less than average for some reason. 

I have probably answered your question in one of my earlier posts, but to make it easier for everyone, I will summarize my choice of lenses and the related experience et al below:

1. I started using contact lenses to achieve monovision almost 25 years back (left eye for reading and the right eye for distance). It took me probably less than 5 minutes to adjust to monovision. So, staying with monovision, when I had cataract surgeries, was a no-brainer for me, but obviously, it  may not be for everyone.

2. I had my cataract surgery for the left eye about 18 years back. Had a monofocal IOL installed in the left eye at that time. (they had only monofocal lenses at that time. Have no idea about the brand). Did not achieve the desired correction for reading (in addition to having some astigmatism). Used contact lens for many years to achieve good reading capability in that eye. Finally, I got tired of using a contact lens for that eye and had LASIK enhancement for the left eye about 2 years back to have the best focus at about 18 inches. That has worked very well for me.

3. Finally last year, I needed cataract surgery for the right eye also. Based on the glowing reports about the Symfony lenses, I decided to have the cataract surgery done and a Symfony toric lens installed in the right eye about 3 months back

4. The spherical prescription of the lens was slightly off and more importantly, in spite of the toric lens, there was significant astigmatism left over in the right eye. Fortunately, my surgeon provides cost-free LASIK enhancement when he installs a premium lens. So, I had the LASIK enhancement done about 4 weeks back. That helped me achieve 20/15 distance vision in the right eye.

Having done all this,

My day vision is almost as good as I was hoping for. The Symfony lens provides me good vision by itself down to about 32 inches (I was hoping for 26 inches, but 32 inches is reasonably good). The left eye provides me good vision in the 16 to 20 inches range by itself. Together, they provide me acceptable vision in the 20 to 32 inches range also. So, on the whole, I am happy with my day vision. I don't have to use glasses for any of my daily tasks.

As I have said before, I wish that my night vision were better than it is. I was hoping for not having any glare or minor halo issues around bright lights, but I knew that that could happen. However, seeing about 10 concentric circles over a large area around the lights was a big surprise because it had not been highlighted in the published literature.

Fortunately, I don't drive much at night so that I can live with not having night vision issues.

Knowing what I know today, for my living style, I will probably pick up the same lenses combination I am using, but the best choice may have been a little different if excellent night vision were important to me.

thank you for sharing your expericence, maybe just like my doctor said, there is no perfect lens. I have one more question, for the lens, do you notice it has external refection? the mono lens and symfony, like if you look into the mirror, you could see the lens glaring? that is one of my concern.

Glad to have been of some help.

To answer your question about the relection in the mirror, I have not noticed any reflection of either my mono lens in the left eye or the Symfony lens in the right eye.

I am 4/6 weeks out on my eyes.  Very pleased with the over all results.

Only use 1.5 reading glasses on occasion for very small print or in poor lighting conditions.  

I still haven't noticed any improvement in the Glare/Concentric circle issues.  

Other that that, I see much better at night. Still see a soft glow around white lettering against black backgrounds on flat screen TV's in darker rooms. 

Pretty sure that the wider the pupil dilates the worse the Glare/Circle issues are.  Perhaps it's why not all people have this issue....  Less dilation at night.  I can stare at a bright light close up at night and quickly look away at a light that casts the Glare/Circle issue and it is almost nonexistent for a second or two until the pupil adjusts to the darkness, then it's back.  Not scientific, but seems to indicate that the more open the pupil the worse the glare/circle issues.  Again, the Doc says that this will improve over a few months....

I doubt it, but time will tell....

Even with no change, and it is annoying, I'd still reccomend the lens, but with a much stronger warning about these effects.  I suspect that the Docs are making significantly more money when they sell these lenses and therefore downplay the possible negatives.

I am sorry to learn that you also are havinng the night vision issues due to seeing multiple concentric circles around lights.

Since seeing the circles is due to the inherent design of the lens, I doubt that it will get better. Howeve, we all get used to living with the bad things such as this issue, by not paying attention to them or looking away from the lights.

Based on my personal experience, seeing the concentric circles depends on the ambient light (dark or low light), the intensity of the light and the distance from the light. For me, if I am within 20-30 yards, the usual glare of or starbursts from the lights drown out the concentic circles, at a little longer distance (30 - 100 yards distance) the concentric circles are most noticable, at a longer distance the circles become less noticable except for the very bright lights.

I find it very interesting that your doctor has offered to replace your Symfony lens at no cost and has stopped recommending the Symfony lens to the new patients due to the night vision issues.

Regarding the best course of action for yourself at this stage, if you can live with the night vision issue (without assuming that it will get better) and your day time vision is reasonable good, then you should probably leave them alone. But, this is something which you have to judge for yourself.

 

In terms of doubting the halos will improve, I don't have any statistics for the Symfony offhand in terms of how they improve over time, but a search shows some statistics for trifocals regarding how many perceive halos (note that most do not consider them a problem, the issue is whether they perceive them) and it reduces over time:

I'll see if they find this post ok. The fellow I've been in contact with went to Dr. Peter Novak at The Refractive Centre Prague, Ltd. (Refrakcní Centrum Praha s.r.o.), for a toric Symfony.  

"Regarding the perception of photic phenomena, 90% of patients reported to perceive halos at 1 month after surgery, although 80% of these patients described these halos as not disturbing. At 3 months after surgery, the perception of halos decreased to 50%. ...

This perception of halos decreased in all patients at 3 months after surgery. Law et al. [5] also found a reduction in the perception of halos over time, decreasing from 80% at 1 month to 40% at 6 months after the implantation of the same trifocal IOL."

The % the who see problematic halos with the Symfony is lower than with trifocals, fairly comparable to the % who experience it with a monofcal (some monofocals are better than others). The same is true of issues of glare and starburst. Glare and starburst issues can arise for reasons unrelated to the IOL choice, but related to things like wrinkles in the lens capsule, PCO, dry eye issues, etc. 

Some people seem to be skeptical regarding the reality that people can neuroadapt to phenonenon over time because they personally find the phenomenon so vivid. In reality the brain is fairly flexible and can adapt to some things its hard to image. For instance some famous experiments demonstrated that people wearing glasses that flip the world upside down see their brains eventually some days later flip the world right side up again. Google: neuroadaptation upside down

 

Studies show the incidence of these phenomenon for various lenses, and competing lens manufacturers make sure that the results are likely to be accurate since. If competitors seems to have flawed studies regarding the incidence of halo&glare, it is in their interest to have a study that calls the result in to question. Oddly some people who think of greed as a potential reason for bias neglect to face the reality that their competitors are also greedy and have incentive to route out any flawed claims, so on balance studies tend to be credible. Doctors don't wish to ruin their reputations by reporting flawed results since they get paid regardless of what brand lens they work with. 

 

As I've already noted, some visual artifacts  can be caused by things unrelated to the IOL itself, but due to e.g. a wrinkle or scar on the capsular bag, dry eye, etc. Also most visual artifacts improve over time, even from the 3 month to 6 month period there can be a decent reduction, and some more up to 12 months, or even beyond. 

In my case the glare with the Symfony vs. my vision pre-cataract is noticeably better. It always seems like  headlight glare bothered me more than friends/family all my life, and it is very noticeably less bothersome with the Symfony than I can recall it being before (though of course memory of such things can be flawed, I did have a problem cataract for 2.5 years or so before surgery, though the other eye was fine). 

For a general discussion of the major studies with the Symfony, including problems with night vision issues, search for:

"High rates of spectacle independence, patient satisfaction seen with Symfony IOL"

I have to wonder how many test cases this doctor has done to decide about the glare issue since anecdotal tests often involve issues of confirmation bias after results based on accidental selection of a patient that might have had problems with any lens. Its data from actual studies that should be relied on by default where possible. Unfortunately there aren't many direct head to head comparisions between the Symfony and low add mutlifocals, most were done outside the US where the comparisons were with trificals not available here since they tend to be better options than the bifocals the US is stuck with due to the FDA's problems.

The actual study data I've seen  suggests the older Restor lenses have rates of night vision issues that are higher than the Symfony, with only  the newest low add   (which has some new design features compared to their higher add IOLs, and due to a low add has a lower risk of problems) +2.5 may be somewhat comparable in terms of the risk of visual artifacts.  Its hard to know for sure based on the the FDA data isn't directly comparable since questions are often  to be asked differently (in terms of how they phrase the description and categories of descriptions) and perhaps at different time points and different patient demographics, and they often don't include the margin of error.

For the fairly unambiguous question of "no glare" the +2.5 Restor is 39.9% and control Alcon monofocal is 49.9%, with the Symfony at 42.8% and the Tecnis monofocal at 57.4%. The Restor has a "severe glare" rate of 3.3% with the Alcon monofocal at 3.8%. The Tecnis study terms it "very bothered" and has it for 5.5% for Symfony and 3.4% for the Tecnis monofocal control. That is slightly higher but likely within the margin of error and given the studies may have different patient demographics, etc.

 

oops, I seem to have accidentally pasted in a reference to a clinic I made in another post (I was using another  window to keep some draft text in and  grabbed older text). They really should let you edit posts.

 

I am so sorry to learn that you also have the night vision issue of seeing multiple concentric circles around lights. As you noted, these are due to the multiple circular “diffractive echelette design” in the lens. My surgeon was not surprised that I am seeing these circles  because when he looked into my eye to check the lens, he could also see those circles.

If you noted the blog from therave3154, his surgeon has stopped using Symfony lens due to associated night vision issues with his patients.

Based on my experience over the last few months, I don't expect this vision issue to go away. We will, however, learn to ignore this or work around it.

Its unusual to start seeing halos only after a couple of weeks, rather than from the start. That suggests that your visual system managed to tune them out for a while, which suggests it can learn to do so in the future, though its puzzling they would appear for a while. Refractive errors tend to increase the risk of halos.

Many people see halos the first few weeks with any lens, even monofocals, while people adapt to the lens. So most studies on the incidence of halos only report results after the first 3 or 6 months. The FDA study for US approval shows only 7.5% report moderate halos at 6 months, and 2.7% report servere halos of the sort you are describing, which is about the same range as many monofocals (even if not as low as the best). The New Zealand study showed only mild halos, none reported as moderate or severe,  and the largest study in Europe reports 6.6% moderate and 3.1% severe.

I haven't seen any data on how quickly go away with the Symfony, but I found some recent stats on trifocals (they moderate links, so google part of it to find the link):

 "Regarding the perception of photic phenomena, 90% of patients reported to perceive halos at 1 month after surgery, although 80% of these patients described these halos as not disturbing. At 3 months after surgery, the perception of halos decreased to 50%. ... 

This perception of halos decreased in all patients at 3 months after surgery. Law et al. [5] also found a reduction in the perception of halos over time, decreasing from 80% at 1 month to 40% at 6 months after the implantation of the same trifocal IOL." 

As it mentions, those are only how many perceive halos (and more do with multifocals than the Symfony), most don't consider them a problem if they can see them.  I see through/past them, and bright lights are less distracting than they were preop so overall my might vision is better.

Unfortunately your results suggest you were left farsighted, hyperopic, which reduces your near vision. The lens power inserted was too low. Unfortunately lens power can't be determined using an exact formula, it an estimate based on statistics from past patients. For people with low prescriptions before surgery it usually tends to be fairly accuate (but not always), with more of  a chance its off for those with high prescriptions. They can correct that with LASIK or PRK after the vision stabilizes if you'd like to get more near vision.

2.5 feet is within the range where the average person with the Symfony lens still sees 20/20. For instance one study shows that at 66 cm=2.2 feet (note logmar 0 is 20/20 and 0.1 is 20/25, UDVA=uncorrected distance visual acuity, UIVA =uncorrected intermediate visual acuity,UNVA=uncorrected near visual acuity):

" Symfony IOL: Binocular UDVA of 0.02 log-MAR or better was achieved in 95% of patients. Mean binocular UIVA at 66 cm was 0.01 log-MAR and UNVA at patient’s preferred distance was 0.01 log-MAR (J1-J2). Night driving visual disturbances was reported in 6 out of 46 patients (13%), only 2% of patients reported halos."

And the US FDA study showed at 66cm: 

"Additionally, as shown in Table 22, there were clinically significant improvements in favor of the Symfony IOL with 76.9% (113/147) and 70.1% (103/147) of Symfony eyes achieving UCIVA and DCIVA of 20/25 or better, "

and the chart shows 98.6% had at least 20/40 vision at that distance. 

 

Also I'll note that    that my case illustrates that neuroadaptation can continue even well after surgery. Again the halos have never been a problem for me, but I have seen them, but at just over 2 years postop I've started to see them finally go away. Some lights where I consistently saw them no longer have halos at times.  I suspect I had spent less time than typical outside at night the last couple of years for various reasons (working in home office on a new company) so perhaps my adaptation has been slow for that reason. You adapt faster when you use your night vision more to give your brain a chance to learn how to tune it out.

Thank you for all the statistics. I'm afraid the data is above my comprehension. I was extremely near-sighted prior to surgery. And, as I mentioned, I'm now far-sighted. My doctor is now proposing that I have the right lens exchanged for a mono-focal lens so that I use the right eye for reading, etc. and the left eye for distance - similar to those people who use contacts in the same way. Has anyone else tried this?

Having good distance vision is different from being farsighted. Farsighted doesn't mean having better distance vision, actually it may be not as good as you could have the way this lens works. Ideally should be corrected via laser enhancement if possible since its a waste since it reduces near.

However, that said, if you target your other eye to be a bit nearsighted to get more near, then that may work well enough that you don't need to bother with a laser adjustment of your first eye if you don't wish to spend the money and go through the hassle. One of my eyes wound up slightly farsighted, which reduces its near, but the other eye was on target and makes up for it (so I have 20/25 at best near, where I hold the near chart wherever I can best read it. Its  at least 20/30 at 40 centimeters, that chart didn't have a 20/25 line so it might    be 20/25 in as close as  40 centimeeters).

I have a Symfony toric lens in my right eye for distance and a monofocal lens for reading in my left eye and am very happy with my day vision at all distances.

However, before you jump into this replacing the lens in the right eye, you should first consider other solutions to get similar results.

If there is no other reason to want to change the lens in the right eye other than adjusting the power to read, I would suggest getting this done not by a lens replacement, but by LASIK which will provide you more predictable results.

But before you even go for LASIK, you should try wearing a contact lens (adjusted for reading)  in the right eye. If required, you should also wear a contact lens for getting the best distance in the left eye. If you have not worn contact lenses in the past, this will also require getting used to the contact lens for a while. But this will let you know if you are comfortable using monovision. You can't do this monovision test with glasses instead of contact lens, because with glasses, due to the signifcant  difference in prescriptions, one will tend to have double vision.

What are your current prescriptions (after surgery) for the 2 eyes? Those will probably continue to change a little. Any way, if you can share your current prescriptions, we may be help you a little more.

Following up on my post about 15 minutes back, depending on your presciption, you may need only one diopter or so difference in the glasses prescription for the 2 eyes to check out monovision. In that case, that may be an easier way to check if you are comfortable with monovision.

My right eye is +14.5D SE

Left is +15.0D SE

Unable to use contacts - due spinal damage I no feeling in my fingertips.

I am sorry that i was not clear. I was not looking for your Symfony lens prescription. I was interested in knowing whar your eye glasses prescription would be for distance and reading right now (even if you are not planning on wearing the eye glasses). Your doctor should have done your vision test to determine that.

Sorry to learn that you don't have feelings in your fingertips. That has to be hard on you!

Your experience sounds identical to mine. I was very near-sighted. The Symfony lenses were implanted during cataract surgery. The distance vision is amazing. Probably because I couldn't see anything two and a half feet away without glasses.

Surgeries went well.  However, the halos, which started about 2 weeks after the second surgery were so bad that I had stopped driving at night. I started listening to audio-books since reading was almost impossible. I couldn't hold a book far enough away to see the print without wearing 2.5 readers. After numerous exams and conversations, my doctor strongly recommended that the Symfony lens, in the right eye, be replaced with a monofocal one. That surgery was done on March 16. 

The halos are much more tolerable. Yellow traffic lights seem to be the most challenging. Reading has improved some. 12 point font & higher, or bolded print, is easy to see. Anything smaller, or in light print, is a problem and I see ghost images most of the time. The monofocal lens is a 2.5. My doctor was horrified to learn that I'm using 2.5 readers for most of my reading which results in a much higher strength.    

The doctors have determined that the refractions are correct. Laser enhancement won't work. I'm not able to use contacts. At this point, I believe I'll live with the results.  

I am glad that after replacing the Symfony lens by a monofocal lens in the right eye, your halos are much more tolerable.

However, I am puzzled by your need to use 2.5 readers for reading the fine print. Something is not the way it should be. And whatever is the cause of that issue needs to be fixed. You should not have to live with such a vision issue for the rest of your life.

I know that your right eye vision will take some time to stabilize, but you may be able to answer some of the following questions anyway for me to understand your situation better.

1. What is the smallest print you can read with just one eye at a time? Also, what is the distance at which you need to hold the reading material to read that size print? This distance is probably not in the 16 to 18 inches where you normally read. For the right eye, it may be as low as 8 inches. For the left eye, it may be in the 25 to 40 inches range.

2. What makes the doctor say that "refractions are correct"? Has he/she checked your glasses prescription to get the best distance vision? If so, what is the prescription of the needed glasses? And what was the best you could read with each eye individually on the eye chart when using using lenses with that prescription?

3. What is the reason for saying that laser enhancement won't work?

re: "started about 2 weeks after the second surgery'

That is extremely weird, to say the least. That suggests the possibilty that perhaps a lens dislocated or something, since almost everyone who sees halos sees them from the start, it isn't clear why they would suddenly appear unless there was some change.  

You say: "I couldn't hold a book far enough away to see the print without wearing 2.5 readers."

That is what you would likely need with a *monofocal* lens, unless you were left very farsighted, to a degree that is very unlikely to happen. You noted above a claim you were farsighted, but then in this post claim the "refractions are correct",  which implies you weren't farsighted, which doesn't make sense. Did they tell you what your exact prescripton was for each eye with the Symfony, your refraction? Did you get a second opinion?

If you were left that farsighted, that may have been the reason for the halos, and laser enhancement would correct that (which questions why you calim they "won't work". 

 

The "monofocal lens is a 2.5" is ambiguous, it isn't clear if you were so myopic its an actual 2.5D lens (unlikely) or focused in at -2.5D (also unlikely since most doctors wouldn't go for that level of monovision). 

After four years: How are doing with your implants concerning the concentric rings? What did neuroadaptation achieve?

I'm strongly suffering from concentric rings/spiderwebs even 9 months after the surgery with diffractive-trifocal IOLs. Night driving is a nightmare. It's the optic of the lenses. No dry eye, no wrinkles in the capsular bag, no PCO, no decentration or any other issues. There is only explantation left for me. The whole thing now depends on neuroadaptation. Therefore my question.