I have no idea which lens to choose!! Please help!
Posted , 16 users are following.
Hello, I am a 48 year old female who very recently found out that I have cataracts in both eyes! My left eye has quite a significant one and the right eye has just a bit (but the surgeon says I'll probably want it done as well as it will eventually need it regardless). So, I have been reading all of the literature and online reviews of these different options. My last Rx was -4.00 OD/-4.25 OS with a progressive Rx for reading of +1.75 corrected to 20/20 in both. The eye surgeon says its now more like corrected 20/50 in the left and 20/30 in the right. I have been wearing glasses/contacts for many years. I really cannot drive at night anymore, so I don't think not having the surgery is an option (and well, it appears that it will get worse and I will go blind if not - so definitely NOT an option). Here are my options/brands:
Acrysoft monofocal Acrysoft Vivity Acrysoft PanOptix
I am working full-time and drive, use devices and read all the time. What concerns me is making the wrong choice! My surgeon warned that I won't be able to read my mobile phone or up close without glasses, EVER, if I choose the monofocal. With regard to the Panoptix, I've read that people have had all sorts of issues - including halos, brain not processing new sight correctly, not seeing correctly for MONTHS,. I don't have that kind of time to wait 😦 I REALLY need to see in my job. So, I am a bit lost and would welcome any advice. I will pay whatever...just need to make the right decision. My surgeon is great as he is not trying to persuade me..but now I am a bit overwhelmed with all of the information. Thank you in advance.
0 likes, 60 replies
RonAKA Jennifer_Guess
Edited
You have identified the three basic options for IOL choice, and the issues with them. Your surgeon is correct that a monofocal set for full distance correction is very unlikely to let you read without reading glasses. I have one eye done that way. I can just start to read my iPhone if I hold it out as far as I can, but that is obviously not a workable situation. I can see my dash instruments in my car though.
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However, there is one more option using the basic monofocal lens which is called mini-monovision. Ideally in this case you identify which eye is your dominant eye, and correct it for full distance with a monofocal lens. The non dominant eye is then under corrected to leave you with a small amount of myopia, of about -1.25 D. This is enough to do most reading. Not everybody adapts to this arrangement where one eye reads and the other sees in the distance. It is best to simulate it first using contacts to see if you like it. From what you describe you may still have enough vision left to give it a test. If we assume the right OD eye is dominant then you would wear your normal -4.0 D contact in that eye. But, in your left eye instead of using your normal -4.25 D contact you would instead use a trial -3.0 D contact. Optometrists and places like Costco will usually give out free trial contacts in a package of 5 or so. This arrangement would let you give mini-monovision a test drive to see if you like it. You could also experiment with a little more or a little less monovision by using a -2.75 D contact and a -3.25 contact. Ideally you would want to try all three of these to see what you like. If you like monovision then you can do the same thing with monofocal IOLs. But, in the case of IOLs you really only get one shot at getting the right amount, as IOL exchange is not a trivial surgery. And the thing to remember about monovision is that you can still get progressive glasses to correct to perfect distance vision in both eyes for the situation when you want the very best vision. These will be significantly thinner and lighter than the -4.0 lenses you have now.
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There are the other choices you have identified and should be considered. The Vivity choice is going to leave you marginal for reading unless you do a bit of monovision with them too. The knock on Vivity is that it has lower constrast sensitivity and may not be the best for night driving. Some also report the halos and flare that are a virtual certainty with the PanOptix.
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Oh to identify your dominant eye, just point at an object across the room. Then close your left eye. If you are still pointing at it, then your right eye is dominant.
Jennifer_Guess RonAKA
Posted
@RonAKA thank you so much! I am new to all of this and am feeling very overwhelmed!! So unexpected! Not quite sure what my previous people were up to with regard to my eye exams! I have them EVERY year at the same time and now find out I have a quite pronounced cataract on my left eye (which seems to be the dominant one based on what you suggested - neat trick and thanks btw). So the plan is to do the left eye first and goodness me, I am just so confused by reading all of the information. I do like the idea of trying the mini-mono...seems like it would be a nice option if available. I'll ask him about that at my next consultation in December. Thank you again 😃
RonAKA Jennifer_Guess
Edited
If your left eye is dominant, that is probably ideal. Normally the dominant eye is done first for distance. Since that is the one that has the worst cataract, you will want to do it first too for that reason. Then you can wear a contact in the second (right) eye to simulate mini-monovison for a longer period of time. And you still have a choice on the second eye to use another monofocal or possibly the Vivity. I have only one eye done with a monofocal (AcrySof IQ Aspheric), and have considered using the Vivity in the second eye, but will more probably just under correct by -1.25 D to get mini-monovision with another monofocal. If you are interested in mini-monovision I would suggest you try to simulate it as soon as possible. Normally you would work with your optometrist to do this, and then relay the desired amount of mini-monovison you want to the surgeon who will do the implant.
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There is nothing special required to achieve mini-monovision. It just uses the standard monofocal lenses. The only thing different about it is the power of the lens used. There should be no extra charge for mini-monovision over two monofocal lenses set for distance.
Jennifer_Guess RonAKA
Posted
Hi @RonAKA - thanks again. Could you help me to understand what the benefit would be of having one eye mono (as you note above for my left eye) and then maybe a Vivity in the right as you are considering? So sorry - I am still not up on these options yet.
RonAKA Jennifer_Guess
Edited
The knock on the Vivity lens is that it has reduced contrast sensitivity. Alcon the manufacturer says that if you put the Vivity in both eyes, the reduction in contrast sensitivity is not "clinically significant". Some users here have reported that they see fine at night with two Vivity lenses, and others do not.
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The advantage in using a standard AcrySof IQ monofocal in the distance eye is that contrast sensitivity is much improved at night. A Vivity in the second eye only may be more tolerable for night driving. The advantage of a Vivity over a standard lens for the closer eye in mini-monovision is that your distance vision in that eye will be a bit better. Close vision is going to be similar.
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What discouraged me about the Vivity for the second eye is that some still report some halos and flare at night. If you have a monofocal in one eye and a Vivity in the other will your brain ignore the eye that has the halo and flare? One would not know for sure until you tried it. Since the monofocal has the best contrast sensitivity I have rationalized that two monofocals in a mini-monovison configuration is the safer choice.
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Keep in mind that if you go for a standard distance monofocal in the first eye, you can defer (and procrastinate!) over this decision until it comes time to do the second eye. I would wait a minimum of 6 weeks after the first eye to see what the stable outcome is of the first eye before deciding on the second eye. For that six weeks or longer you can do a longer term trial of under correcting your right eye, with say a -2.75 D contact to see if you like it.
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This all assumes of course that you want to be eyeglass free 95+% of the time. If you do not value that, then there is the most often used choice of distance monofocals in both eyes. Then you use readers for close. Or you use progressives all the time. The advantage of progressives is that you are not constantly putting them on or taking them off. And they can correct any residual error in your eyes. The IOL's come in steps of 0.5 D unlike glasses and contacts which come in steps of 0.25 D. So there will always be some error, unless you get really lucky. There will also likely be some astigmatism to be corrected which the progressives will do as well.
RonAKA
Posted
Surgeons tend to favour one of the two major manufacturers of IOL's in North America. It sounds like your surgeon favours Alcon (AcrySof, Vivity, PanOptix). The other of the two big guys is J&J (Tecnis, Eyhance, Symphony, and Synergy). I consider them as the Coke and Pepsi of the IOL suppliers. There are others, but will be much harder to find.
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Recently Alcon has come out with a new material called Clareon. It is basically the same as the AcrySof for design but uses a so called upgraded material. My wife just got the first of her eyes done and we are hoping to get her lenses in the new Clareon material, but found out that at least in Canada it is only available in the basic monofocal range, and she needs a toric. So she will be getting an AcrySof Toric. My eye was done with the AcrySof IQ (non toric), but I hope to get my second eye done with the Clareon material. Since you are relatively young for cataract surgery you may want to ask your surgeon about the availability of the Clareon where you are. I don't think it is a real big deal, but if you have the choice I would go with the Clareon material. It costs $300 more in Canada where I am, but in the scheme of things that is not much.
Jennifer_Guess RonAKA
Posted
@RonAKA - thank you so much for the explanation. I understand now. So much to think about 😃 I am having the first one done in early January and the 2nd one in mid-March (spring break). Hopefully that will be enough time to make a decision. I like the idea of waiting! I'd love to break free of glasses actually - so a lot to consider for sure. Thank you again 😃 Very kind of you.
Songirl RonAKA
Posted
i have high myopia and some astigmatism. Do you think minimono will work for me?
RonAKA Songirl
Posted
If your cataracts are not too bad, it is best to do a test drive of monovision using contact lenses first. That way you can determine if you like it or not, and also how much monovision you would like. The basic process is to under correct your non dominant eye in the range of -1.0, -1.25, and -1.5 D, to see what you like. The other eye is corrected for full distance vision or plano.
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Your past posts indicate that you have myopia in excess of 10 D. With this much myopia it is hard to get an accurate measurement of the eye to get an accurate correction. You would be well advised to spend some time to find a surgeon that specializes in doing high myopic eyes.
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Astigmatism can be corrected with toric lenses, and that should not be a problem. The standard monofocal lenses used for monovision are available in toric versions.
Songirl RonAKA
Posted
Thank you. The earliest I can get an appt with my optometrist is in February. This is something I had tried many years ago when thinking about Lasik. I just want to explore all my routes before commiting. I went to another ophthalmologist that is supposed to be on the top surgeon list according to US news. I was not impressed after reading his report it said will likely need glasses for distance and highly likely to use glasses for reading. Not something I want to see when I’m thinking about multifocal. I do not drive at night if at all possible but I am somewhat concerned about the glare and halos. I am just confused. I don’t know which route to go and not feeling confident in either doctor I have seen. My cataracts are not that bad but I was hoping to enjoy my mid life with out glasses or at bare minimum even though there is no immediate need to rush to surgery.
RonAKA Songirl
Edited
Things may work different in the US, but my practice for many years has been to get my eyeglass prescription at an independent optometrist. I then take that prescription to get it filled at Costco for glasses and contacts. Other discount places like Walmart here do the same. All you need is a valid prescription. I have found the Costco optical department quite helpful in giving me various contacts in different powers to try so I can simulate mini-monovision. After trying about 6 different kinds of contacts I have settled on using their Kirkland Signature contacts which are made by CooperVision. At least for me, I have found them the most comfortable and the least expensive.
assia99778 Jennifer_Guess
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Hello Jennifer,
good that you have found this forum before your surgery. Unfortunately, I didn't. I received trifocal IOLs in both eyes one year ago which are very similar to PanOptix. And here is my advice:
Don't go with PanOptix! I am about your age with same requirements (work, driving). You will certainly get dyshotopsia with a trifocal IOL because of the diffractive optic of lens. The question is how strong they will be. In my case they are so strong that they severely impaire my night driving ability. The many rings and spiderwebs drive you crazy. Approaching cars or traffic lights are looking like monsters in a horror film. SUVs double in size if the driver touches the brakes. Maybe you will only get moderate dysphotopsia and then it's possible to adapt while getting used to it. But no one can tell you in advance.
Second issue: These IOL split light to make them work. In my case (Zeiss AT LISA) you will have 50% for far, 30% for near and only 20% for intermediate vision. That means that there is contrast loss and that you will likely need reading glasses to fulfill your job requirements. And: There are gaps, no seamless vision! I need +1,0 reading glasses for laptop work and +2,0 reading glasses for readings books, articles or doing handwriting. Varifocals don't work with trifocal IOL! Because they didn't hit the refractive target in my case, I need glasses to correct the residual astigmatism in both eyes. I always have to put the reading glasses in front of the far specs. I never imagined things like this before the surgery and I wasn't told at all that these things may happen. If you are lucky with your refractive outcome, you will probably not be lucky with the near/intermediate performance because of your needs. For cooking it's okay, but not for working.
Vivity has no diffractive optic. You will need reading glasses. But I got to know a young guy with these IOL who now suffers from contrast loss, which makes driving at night for him very difficult. There are pretty good threads here about PanOptix and Vivity experiences. It takes some time to get through but it's worth the effort. If you can use monovision with monofocal IOL, you will increase your spectacle independence afterwards. You should try this before the surgery.
The less issues and clear sight you have with the Acrysof monofocal. But don't do both eyes at the same time. Wait for your left eye to heal. Then you are sure about the outcome and that your second eye will get what suits you most later on.
My life is partly ruined because of that surgery and I suffer from it every day. Explantation, if not performed during the first few weeks/months after the surgery, is a high risk surgery and there are many surgeons who don't want to do it in our case because we are rather young with high visual demands. It's not an easy decision but I'm sure you will make a good one. All the best and please let us know!
Jennifer_Guess assia99778
Posted
assia99778 - oh my goodness. My heart goes out to you! Thank you so much for taking the time to share your experience and that of your friend. Now I understand why the surgeon was telling me to take my time and to think it over very carefully (in the session, I would say things, like 'it sounds like a no brainer, I want the one that will let me see everything...). What an AHA moment this is. And, as you say, at our age, this is a decision that is (hopefully) for a long life ahead. I am a Professor and I drive a lot a night between where I work and where I live (a few hours between them). I really need to be able to see students, the projector, the computer, articles I read, and driving at night! So, your words have suitably cautioned me....maybe the mini-mono will be an option. Any are better than going blind, but MY GOODNESS!!!!
Again, thank you so much for taking the time to reply to me 😃 Big hugs!
assia99778 Jennifer_Guess
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You're welcome, Jennifer! Thank you!
rwbil Jennifer_Guess
Edited
Here are my options/brands:
Acrysoft monofocal Acrysoft Vivity Acrysoft PanOptix
First, those IOLs are not your only options. The most important thing to do is make sure you are dealing with a top ophthalmologist. Factors I look for is does the Opthamolgoist do clinical trials, as manufactures want their results to be the best they can be so they select the best doctors. Does he write papers? Does he have experience implanting different IOLs.?
The second thing is even though the doctor’s advice is invaluable, you really need to do your own research on the different IOL and the tradeoffs.
There is no perfect lens selection for everyone. You need to take your time and think about what activities are most important to you. Only you can decide what tradeoffs you are willing to accept. Below is my list of IOL option in order of risk:
Non Premium Monofocals:
These are the most common IOLs implanted. They will have the best contrast and the least issues of any lens (unless you consider close vision an issue). They have been around and tested for a long time. A Monofocal lens should provide great distance. In general close vision is reading your cell phone or a book, maybe 33cm-40cm. Intermediate is about 2-3 feet or so. A perfect example might be the dashboard on your car.
One comment on distance vision. Some people I think are confused by that term. If you look at the defocus curve on a monofocal you should get pretty good vision down to about 2' -3' or so (again it depends on many factors). As you get in closer; vision quality drops off rapidly. This is important, everyone Visual Acuity will vary as there are so many factors, such as short & long eyes, astigmatism, macular degeneration, previous Lasik surgery, and on and on.
I also suggest just getting 1 eye done at a time and evaluating the results before getting the other eye done. Mix and Match is always a possibility to obtain the best vision possible.
Premium Monofocals:
LAL – If considering a monofocal I would recommend giving this IOL serious consideration. I have had Top Ophthalmologist highly recommend this lens. Having said that it has been around for a while now, but not as long as the standard monofocal so there is the test of time issue.
What makes this lens great is no matter what equipment Ophthalmologist use they don’t always hit the refractive mark and in a few cases can be way off by more than 1D. And let’s say you decide to do monovision. You want to hit those marks.
But it even gets cooler than that. From what I understand you can adjust the LAL more than once. So you decide on monovision, but not 100% sure how much monovison. So set 1 eye to plano and then try various settings with the 2nd eye to see which one works best for you. I would only consider micro-monovision like -0.75D, but if I had the option to adjust it you could try a different setting and see if you end up with a lack of stereopsis or other problems.
Crystalens Lens – You hardly hear about this lens anymore. This is the only FDA approved accommodating IOL. Many people did not get accommodation or much accommodation, so you were paying premium price for a monofocal lens that did not give the range of vision expected.
But from what I have read Crystalens at distance provides the same level of contrast as a standard monofocal and you are likely to get some accommodation. This lens could be a great mix and max with a
PanOptic Trifocal IOL.
IQ Vivity, RayOne EMV and Tecnis Enhance - The newest hottest IOLs on the block. A refractive IOL that provides some EDOF. I think IQ Vivity is around .5D and Eyhance a little less. So not a lot but combined with micro-monovision you should get decent intermediate and some close up vision.
Now here is the part that is trick. I have read that Vivity gets EDOF by manipulating SA. So that means contrast sensitivity will not be as good as a standard monofocal. Could the average person notice the difference, I don’t know. But I suggest you get an Ophthalmologist who is an expert with these lenses so you can discuss that exact issue. And of course there is the test of time issue.
I saw a video where a doctor said he was charging the same for the RayOne EDOF IOL as a monofocal. So maybe your insurance would cover it. Something to check on if you are interested in this IOL.
I tried mono-vision with contacts and I know it is not the same, but I hated it. I need good distance vision. That is why I say if doing mono-vison go with micro-monovision (<-0.75D). If you do that with Vivity you will be getting -1.25D of mono-vision, preferable in the non-dominate eye.
Enyhance is a little less clear to me as from what I read there is no CS lost, but you don't gain much EDOF. I am not even sure it is much better than some monofocals. But IMHO you have to be giving up something to get even that little bit of EDOF. So this one needs further research.
Vision acuity is more complex than it sounds. There are just so many environment factors and so many ranges to go with those conditions. Will you be able to see well indoor at a concert or basketball game vs seeing up close in dim light vs moderate light vs bright light.
Diffractive IOLs
These IOL, which include Trifocal and EDOF IOLs, give you improved intermediate and close vision but they all come with tradeoffs (dysphotopsias & Contrast Sensitivity loss). This category is a paper in itself, so I will not go into details unless you are interested in a defractive IOL. I personally have a defractive lens.
In the US the main defractive lens currently would be Panoptics, Synergy and Symfony IOL. I actual have the Tecnis MF low add, which is a bit of older tech now.
If all goes well I will be getting the Synergy IOL implanted this month.
Jennifer_Guess rwbil
Posted
@rwbil - thank you so much for the informative reply. I will need to look up some of the acronyms you have provided as I am very new to all of this. No worries, though, I like to study!
These are great points with regard to the ophthalmologist. This one seems good - but I really have no other indication of that other than Google reviews and his personable nature. There is one in a nearby town that does do research and works at various universities as a Professor and looks interesting. I may go to him for a 2nd opinion as I probably need to do anyway.
Also great points with regard to all of the lens options. It's a lot to consider for sure! I thank you for taking the time to respond and to provide them. Of course I want it all without side effects/distractions, LOL! I guess, at the end of the day, I am not quite sure about not being able to drive at night and being annoyed with halos, etc. - and sometimes during daylight or maybe even under the lights at work! It seems the safest bet is to do the mono and trial the mini-mono with a contact when the first eye gets done as suggested by RonAKA previously. I am starting to come around to that - it seems the risks with the others is too great!!
rwbil Jennifer_Guess
Edited
First, you can look at the FDA site and find doctors that have done clinical trials on specific IOLs and see if there is anyone in your area. Don't worry about getting a 2nd opionion. I saw many doctors before deciding. What state do you live in?
If you have ruled out the diffractive IOLs, I suggest you give serious consideration to some of the NEW premium IOLs that provide a little bit of EDOF. Combining this with micro-monovision can be a good solution.
Remember though there are always tradeoffs and you will probable not get "Great" Close vision with this approach or there would not be a need for diffractive IOLs.
Doing a trial with contacts is a great idea to see if you can tolerate monovision and how much you can tolerate as once again everyone is different.
Jennifer_Guess rwbil
Posted
Hi again @rwbil - can you please advise what search terms I need to use to find the FDA site? I am in SC.
rwbil Jennifer_Guess
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Search for
FDA Clinical Trials.
Then go to find a study.
Ideal, though harder to find, is a doctor that participated in a study in the IOL you are interested in.
For example, you sound like a good candidate for the Eyhance IOL. So put that into other terms and hit search.
And then you can see all the various places that participated in various studies regarding that IOL.
If you live in a small city you might need to travel a bit to find a top doctor.
There are other things you can also check out such as Castel Connolly Top Doctors and to do other research to see their academic background.
In my opinion this is the way to find a top doctor and not via the neighbor's recommendation or a Google search.
And BTW IMHO Top Doctor is not and end all. There were ones I went to that were so impersonal I would not let them operate on my eyes in a million years. So there is a balancing act. I finally found one that was top and I had a rapport with.
Once you start to narrow down your options I and others can give you more advice.
You get a wide range of people here, from Ron who is going with the safest option, monofocal, though he is doing higher risk monovision and myself who is going with a high risk diffractive IOL.