How to get good vision from reading distance to about 6 feet (or beyond)?

If you mean taking the +1.0 D of hyperopia down to -1.5 D, that seems to be impossible for the Lasik specialists I have talked to. You can find it being done in the literature, but after a consult with two surgeons they are unwilling. It seems reduction of myopia is relatively easy and is done with the more central part of the cornea, but changes to make the cornea flatter is much more difficult and the cuts have to be made at the periphery of the cornea and are less predictable.

Yes, with correction (+0.50/-1.00 lens) my right eye can see better, about 20/25 distance, and with progressive lens (add +2.50) I have good vision at all ranges.

I may not have stated it clearly, but my goal for the 2nd (left) eye IOL surgery is to have good uncorrected (without glasses) vision at all ranges, i.e left 1-6 ft, and right 6-infinity, that was the thrust of my initial question.

I think the reason that +0.50 SPH gives me such poor uncorrected vision is that I also have astigmatism in that (right) eye of -1.00, so between both SPH and CYL errors my right eye can only see 20/40 uncorrected.

I was utterly unhappy that I didn't get plano/plano results, until I read that IOL result errors of up to +/- 0.50 are common, I wonder if that's true????

Some friends who had IOL implants tell me they had 20/20 results...

One friend had an accomodating IOL implanted, and he has excellent vision at all ranges.

Allen, I replied earlier but it got stuck in the moderation queue. I had questions about your 20/40 also but please just ignore what I posted about that when that post shows up. I found out that you only correct to 20/25 or 20/30 which is unfortunate. This is the previous post of yours. https://patient.info/forums/discuss/why-isn-t-anyone-talking-about-technis-eyhance--710285?page=9#3840130 . Your right eye result is mystery for sure. It's needs some explanation from a surgeon so that you can be confident that it doesn't happen with the left eye. Maybe a referral to a Retinologist is needed.

Surgeons typically land within +/- 0.5 only about 75% of the time. It is a real risk.

*"Surgeons typically land within +/- 0.5 only about 75% of the time."

Hence the demand for light-adjustable lenses. My ophthalmologist has offered me that for my left eye, the one with low enough astigmatism to be corrected by toric lenses available in the U.S.If it's really important to you to hit the marks, get a LAL. However, there is no guarantee your vision won't change after the LAL has been locked, putting you back in the same glasses-dependent boat.

Again I would not worry about the 2nd eye until I had clearer answers regarding the first eye. And based on your results I would be looking for Top Opthmalogist in the US that uses the latest machines and getting several measurement on different days and different machines and making sure they are consistent.

Yes it is common for doctors to miss the mark which is why they tend to shoot for the first power that is on the myopia side. This is also the advantage of the LAL, which can be adjusted post op.

I would want several questions answered first before I even thought about doing anything to my other eye.

You state your corrected vision is 20/25 distance, but did not state what your intermediate vision was when corrected and I am not talking about when wearing progressives. Please provide details on exactly what your vision is at all ranges when corrected, without progressives. Looking at the defocus curve I would expect you to have 20/25 vision even with your +.5 D if you had no astigmatism.

Also maybe you stated it somewhere, but I am not sure why your astigmatism is off. Did you use a Toric IOL or some other method to correct for your astigmatism. Sometimes the astigmatism amount cannot be corrected with a Toric IOL.

Q1) Correcting for both refractive error and residue astigmatism, how close can you see comfortable well? I would expect you to get close to 2 foot.

Q2) Prior to having cataracts, when fully corrected what was your distance vision? If not 20/20 what is the reason?

Q3) If the answer to Q2 is 20/20, then why are you only achieving 20/25 vision when fully corrected. Is there an eye health issue or something else going on?

Q4) Have you tried to only correct your residue astigmatism and seen what your results are. I would expect if you just corrected for Astigmatism your distance would be 20/25, which might be acceptable distance vision and you might be able to deal with the Astigmatism via other methods.

Make sure to get your biometry data with the exact target and chosen IOL power from the first surgeon if going to another for your other eye. That should make targeting for your left eye more accurate. IOL powers come in 0.34D steps so the spherical miss in the first eye was only one or two IOL powers off. Some residual astigmatism was likely to happen because a toric lens wasn't used so the surgeon probably targeted as close to plano as possible if factoring that in to get a good Spherical Equivalent result so the miss might actually be only one IOL power. The confirmation of how much the miss was will help you when deciding on the IOL power target for your left eye as it can be factored in.

Good suggestion to get records from my surgeon, thanks.

I'm mystified by the concept of Spherical Equivalent (SE). My eye surgeon who gave me post-op error of +0.50 / -1.00 (which results in distance uncorrected vision of 20/40) keeps telling me that my outcome is perfect, because my SE is zero (SE=SPH+1/2CYL).

Using this logic would lead one to say that a person with SPH +3 and CYL -6 has perfect vision since SE=0, which seems wrong, as I think a person with these numbers would have terrible vision.

What am I missing, and what's the usefulness of SE?

My surgeon maintains that my post-op astigmatism of -1.00 is actually good because it neutralizes or compensates for SPH of +0.50.

Can he be right about this?

You have it right with SE. It is a very rough estimate and really only is intended to be used when you use a non toric contact when you have a small amount of astigmatism. If you are -2.0 sphere and -0.5 D cylinder, you would use a -2.25 non toric contact. I have done it, and your vision suffers a little as a result.

Seriously I am liking your doctor less and less. How about asking if SE is so great why do I see 20/40.

As far as I am aware that is a calculation that is used for contacts when you don't want to use a toric contact, as they might be less comfortable. So it factors in astigmatism to give best correction when no toric is used, but it is not a great correction. And certainly not some goal to reach as acceptable for after cataract surgery.

Actually the IOLMaster program lists SE for each toric lens that is input. I have a data sheet from my brother's readings. His surgeon seems to input toric lenses with zero cylinder when he is intending to use a non toric lens. The program then seems to select the lowest SE outcome as the best power lens. He does not have enough astigmatism to merit a toric.

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The program has selected a lens power that resulted in -0.17 sphere, +0.31 cylinder, and indicates a SE of -0.01 D.

I use to think of 1.0D of astigmatism as minor, but read more and more they try to correct it especially if using a diffractive IOL, which is not this case.

I know most toric begin at Power 1.5D, but I thought 1.0D could benefit from a toric IOL. And if too little of Astigmatism for a Toric IOL, would they do an LRI.

I know outcomes are not guaranteed to hit the mark.

The odd thing to me is I don't think his doctor discussed this with the patient and was shooting for that Refractive Mark and Astigmatism to hit the SE. I am pretty sure if he got his residue astigmatism to zero he be better off than some SE equivalent.

Not an Astigmatism expert, but I would think this is something you might do if you have just a little bit of Astigmatism and don't want to or don't qualify for a Toric or don't want to do an LRI, to give you the best vision possible under the circumstances (without using Astigmastism correcting glasses or contacts).

Now that I think about it my Astigmatism was around .9 D and they used a Toric IOL. Just off the top of my head; if I remember correctly the 1.5 D Toric IOL was either 0.75 D or 1.0D at the cornea plane, thus eliminating most of my astigmatism.

You got me curious. Is there a chart showing SE Vision Quality as Astigmatism increases. Just in the Poster example if he corrects for residue refractivity and Astigmatism he see 20/25, but using SE of Zero he sees 20/40.

Thanks everyone for addressing my questions. One of the things I'm learning from this discussion is the importance of presenting your information clearly and completely. I think I've been unclear and incomplete when first asking my question, so here's my re-cap:

RIGHT EYE (RE)

BEFORE surgery SPH -3.50 CYL -1.50 corrected 20/20 with glasses

AFTER surgerySPH +0.50 CYL -1.00 corrected 20/25 with distance glasses , 20/20 with progressives for intermediate and reading

UNCORRECTED 20/40 distance, 20/70 intermediate, 20/100 reading. The above acuity number are for using ONLY my RE.

However, when I use BOTH eyes, I can see UNcorrected 20/30 distance, which is why I can drive and hike without glasses if I need to. For example, when it rains hard, it's nice to hike or bike without glasses.

IOL is Eyhance model DIB00 +13.0D power implanted April 2021.

The surgeon never told me that even with his use of Femtosecond laser assist (for the LRI incision) and ORA technology my results may not reach the target of plano for both SPH and CYL, which was the goal. When I tested CYL -1.00 afterwards, he said LRI is not reliable, and having it at -1.00 is actually good because it gives me SE=0 by balancing the SPH of +0.50. He then sent me to see other specialists to find out why I can't see better than 20/40 uncorrected with the RE. But no one has a definitive explanation, other than my refractive error of SPH +0.50 CYL -1.00 is the culprit, even with SE=0.

If he had informed me that LRI wasn't reliable, I would've chosen a toric IOL. I had high hopes for perfect outcome for my right eye, and was devastated when it wasn't.

At this point, because it's been 1.5 years and I had YAG on that eye, IOL extraction and replacement isn't worth the risk, considering that my uncorrected vision is merely less than good, but not terrible. LASIC isn't worth the risk either, the improvement will be too small to justify the risk of dry eye and missing the target, which may happen with LASIC. I'll just have to live with this imperfect right eye.

This is why I now have high hopes for my LEFT EYE (LE), which is why I posted my question here. My LE is currently SPH -0.50 CYL -1.75

If I understand correctly, a good option for me would be to target my LE for SPH -1.50 with a toric IOL to rid my LE of the -1.75 astigmatism.

I have several questions about this for my LE:

1. Would I be able to see well for 1-6 ft range with post-op SPH -1.50 and zero (hopefully) astigmatism?
2. How would my binocular vision be, uncorrected and corrected, with post-op:

   RE (OD): SPH +0.50 CYL -1.00

   LE (OS): SPH -1.50 CYL plano

   Is it going to be problematic having SPH difference between my two eyes of 2.00D?

I appreciate the opportunity to ask my questions here and get feedback, as this will help me communicate with the new surgeon I'm scheduled to see late October, and understand her answers.

Thanks all,

Allen

The minimum AcrySof toric is 1 D of cylinder which is about 0.75 D at the lens plane. I am puzzled as to how surgeon use SE. I was surprised to see it on the IOLMaster IOL Calculation sheet.

My surgeon also says LRI is unreliable in his experience and refused to do it. I think your surgeon should have used a toric in this eye rather than LRI. One other option for your right eye is a piggyback lens. It may be able to correct your +0.5 D error, and reduce your astigmatism.

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My only concern about targeting -1.5 D in the left eye is that the anisometropia will be 2 D plus 50% of your astigmatism so a SE of about 2.5. I would try to simulate the -1.5 D in your left eye with a toric contact. If my mental gymnastics are correct you would need a +1.0 sphere, and -1.75 cylinder toric contact to do it. The contact trial should give you a reasonable idea as to whether or not you can handle the -1.5 D (net) in this eye.

Again I am not an Astigmatism expert, but with 1.5D of astigmatism I don’t understand why the doctor would do an LRI over using Toric IOL. I could understand LRI for low astigmatism that a Toric IOL could not correct for or if there was no Toric IOL or your Astigmatism is so great they combined a Toric IOL with LRI, but 1.5D is getting into the Medium Astigmatism range and I would think a Toric IOL would be weapon of choice.

Before I can advise you on your Left eye, IMHO you have to decide on what you will be doing on the right eye if anything. For example if you are going to try and address the astigmatism and not refractive error or if you are fine the way it is and want to be glasses and contact free most of the time, in that situation I would not suggest shooting for -1.5D target in the left eye. That is 2.0 D difference in the eyes and as you well know the doctor can miss the mark and you end up with >2.0D difference.

I am a big fan on micro monovision. I first suggest you decide 100% what you will do if anything regarding your right eye.In fact if it was me I would fly to see one of the top Ophthalmologists in the country and see what options you have for your right eye. If I mention names I go into moderation, so I can PM you ideas. I am still also concerned why before surgery you could correct to 20/20 and now cannot.

Once your right eye is 100% done and you have achieved your desired solution, then I would try contacts to simulate monovision. It will do a good job of simulating distance monovision and you can cheaply try different amounts of monovision to which you like the best. Keep in mind you natural lens still accommodates and changes shape for close vision.

If you forced me to give an answer right now, I probably would suggest looking at Vivity and using much less than 1.5D monovision, especially in your case. But again it depends on everything else I mentioned.

I'll definitely pursue a toric contact to test my brain's ability to deal with two different eyes' optical powers, thanks for the tips.

I think there's help on the way to alter existing implanted IOLs to correct errors, try searching online for "IOL power adjustment - ESCRS" and "IOL Power Adjustment by Femtosecond Laser".

I hope this will happen soon enough for us to have a chance to enjoy close to perfect vision. One paper I read said that even toricity can be added to a non-toric IOL.

I also read about a surgeon who does manual LRI after cataract surgery to correct residual astigmatism, if I can find a guy who does it I'd go for it, as LRI is a low-risk low-cost procedure.

Also another promising technology called LIRIC, search for Feb 2022 article "LIRIC: A Novel LVC Treatment" in Review of Ophthalmology.

You may want to have a read of this article. Piggyback lenses are not considered as good as Lasik or an IOL exchange, but they still can work when those methods are not an option. I have not researched them enough to know if they can correct astigmatism as well as sphere. They may.

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Secondary Piggyback Intraocular Lens for Management of Residual Ametropia after Cataract Surgery

Zahra Karjou, MD, Mohammad-Reza Jafarinasab, MD, Mohammad-Hassan Seifi, MD, Kiana Hassanpour, MD, MPH, and Bahareh Kheiri, MS

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My surgeon refuses to do LRI any longer because he says he has not been able to get predictable results. I had wanted him to do it. He did say that he could refer me to someone that still does it. I didn't take him up on it. The second Lasik specialist I saw diagnosed my irregular astigmatism as keratoconus and I am unsuitable for Lasik, and likely LRI as well.

This sounds a lot like Conductive Keratoplasty which uses heat from RF to change the shape of the cornea. LIRIC uses laser to do something similar I believe. The problem with CK is that it does not last and you have to keep going back to get it redone. Burning the eye just does not seem like a nice thing to do over and over...

Do you think instead of the toric contact, I could do the same simulation with eyeglasses that have +1.0 sphere and -1.75 cylinder?

We have a local shop that makes inexpensive glasses the same day, so I can test this theory tomorrow!

Thx.

Have never thought of doing that, but it should be possible. The advantage of contacts is that you can try different powers so easily. I got Costco Optical to give me a number of different powers and types for "free". I bought bunches of the ones I liked, so I guess they were not really free!

did Costco require a prescription from an optometrist to buy different power lenses?

Yes, they require a current prescription to get started. I have found that if you explain what you are trying to do to simulate monovision for an upcoming cataract surgery they are quite cooperative and will give you a sample of 5 contacts of two or three different powers to see what works for you. Their only stipulation is that they have a requirement to test your binocular vision with the contacts I presume to test if you are safe to drive. If you have good vision in the other eye, that is a slam dunk.

rwbill, thanks for your thoughts. Knowing what I know now, I should've insisted on having a toric IOL for my -1.50 astigmatism. My surgeon has good surgical skills I think, but very questionable judgement, which is amazing for a guy with 20+ years of practice. He NEVER even mentioned to me things like dominant vs. non-dominant eye, monovision, targeting -.50 instead of plano, chances of missing the target, different IOL choices, etc. He keeps insisting I get LASIK to fix residual errors (he even wants to pay for it to his credit), ignoring what I tell him about my severe dry eye problem, and the LASIK guy's advice to me not to do LASIK.

Thanks for your offer of referral, you can PM me. I wish I had found this forum BEFORE having had the surgery, I would've made different choices.

I decided to do nothing about my right (operated) eye. The risk of eye damage from LASIC or explantation are not worth it for me, not to mention the risk of ending up no better than it is now, or worse. I can live with 20/25 corrected distance. I think it can't be corrected better than this because of my thin optic nerve, crowded optic disk (whatever this means), and some retina (?) defect that makes me miss flashes in the upper-left quadrangle on the peripheral vision test, all of which reduce the amount of information going into my visual cortex. And the Eyhance lens probably contributes to all this -- I read that it achieves a slight improvement in the intermediate range by a slight reduction in distance, thus 20/25. I can live with this.

I'm going to act on the advice I got from you all in this discussion today, I'm going to get glasses or contacts which would simulate mini-monovision of -0.75D, -1.00D and -1.50D for the left eye.

Thanks everyone,

Allen

Moderator comment: I have removed the email address as we do not publish these in the forums. If users wish to exchange contact details please use the Private Message service.

rwbill, my reply to you this morning went into the moderation delay, hopefully it's pass the review. Thanks for your suggestions.

Allen