Just finished my consultation and wondering if I made the right decision
Posted , 8 users are following.
I was diagnosed with cataracts in both eyes recently and decided to have cataract surgery early rather than putting it off until they get worse.
My optometrist referred me to an experienced and respected ophthalmologist who has agreed to do the implants. At my consultation I was told I qualify for all types of IOLs, and she clearly favors Alcon products, specifically the Panoptics and Vivity IOLs.
I do a fair amount of night driving, so I declined the Panoptics because of glare, halos, and starbursts which I'm experiencing now and find very bothersome, even dangerous.
The Vivity is interesting and attractive except for the manufacturer's warning that it reduces contrast significantly over a monofocal IOL, a 40% reduction in MTF (modulation transfer function). This is concerning. How will that affect night driving?
To address my concerns, my ophthalmologist suggested implanting the Vivity in my non-dominant eye first. I have only a small amount of astigmatism in that eye. I'll have two weeks to decide if the contrast reduction is acceptable. She also suggested targeting -0.5D myopia in that eye (mini monovision) fora bit better near vision. That sounded like a good thing although I told her that I'm not opposed to wearing glasses for reading.
If the Vivity IOL works well in the non-dominant eye she will implant another Vivity (this time a toric) in my dominant eye at plano. If I'm experiencing poor contrast in the non-dominant eye she will implant an Alcon monofocal IOL instead. I agreed to this plan, and have scheduled pre-op screening in 10 days and first surgery in 3 weeks, and the second 2 weeks later.
Does this sound like a good strategy? Are there any drawbacks to this approach I should be aware of? Has anyone taken this course of action, and if so, how did it work out for you?
0 likes, 18 replies
RonAKA clara26552
Edited
All considered I think you have a pretty good plan. It is a bit unconventional as it is normal to do the dominant distance eye first. However, I can see what you are doing. I would suggest a few points to consider though.
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I was considering doing what you are doing but kind of in the reverse order. My thoughts for the non dominant closer vision eye was to target -0.75 D myopia rather than -0.5 D to give better reading ability. However keep in mind that these lenses come in 0.5 steps of power, and they don't always turn out exactly where they are targeting. I think it is better to think of a target range. For example -0.5 to -0.75 myopic. That range would be better than targeting -0.25 (which is where they target for a plano eye) to -0.5 D
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I am not so sure you will gain much in reading ability with a second Vivity set to plano, even if contrast sensitivity is not an issue. If it were me, I think I would go with an AcrySof IQ monofocal toric in the second eye. It will give you better contrast sensitivity at night and the best driving vision. Keep in mind that some Vivity users report some halos and flaring although Alcon tries to downplay that. The target for this eye should be -0.25 D. You do not want to go into the + far sighted range, as that will impact close vision, and not give you any better distance vision.
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What I would strongly object to is scheduling the second surgery 2 weeks after the first. It takes 6 weeks for the eye to fully recover from cataract surgery and have the vision stabilize. You really want to know what you have for vision before you make the second eye decision. I cannot think of any reason to rush the second surgery.
clara26552 RonAKA
Posted
Thanks, Ron. Good points as always. I'll bring your suggestions up with my doctor at the pre-op screening. My doctor seemed to be fully aware of the targeting issues, and understands my wanting to obtain extra near vision with the Vivity implanted in my non-dominant eye. She reminded me that the greater the offset, the greater the adaptation risk. She also mentioned the risk of losing some stereoscopic vision (depth perception), also important for driving.
My doctor may have taken my willingness to use glasses for reading as reason not to be more aggressive with mini monovision. If she can hit -0.5 D under correction on the Vivity, I should get >2.0D of extended range of vision. Am I right thinking I could see two lines better than a monofocal at plano in my near eye, i.e., 20/30 at 40 cm (16 inches) uncorrected? That would be more than acceptable for me.
If I don't have the second eye implant done two weeks after the first, I'll have to put it off until next year given my current travel plans, and wear a contact lens in my distance eye. I really don't like wearing contacts.
I'm not sure there's any advantage to postponing the second eye surgery, though.
Once the first eye is done, it's done. I'll have to accept whatever contrast sensitivity and refractive outcome I end up with once healing is complete. It does mean, however that I should drop any intention of putting the Vivity lens in my distance eye as you suggest, because it won't improve my near vision very much. I will discuss with my ophthalmologist, and ask that the Alcon IQ monofocal toric IOL be implanted in my distance eye to preserve whatever contrast sensitivity I'm left with in the near eye. I'm not sure why my Dr. didn't mention this. It will save me $1000, as well.
Thanks again for the helpful advice.
RonAKA clara26552
Edited
Here is a graph I put together to help estimate what vision I would get with the various options, and myopic shifts. The theory is that vision is good out to a LogMAR of 0.2. The advantage of the Vivity in the close eye is that even with an offset of -0.75, it still gives a LogMAR of 0.1 at distance. This is significantly better than using a monofocal with a -1.25 myopic shift which gives a LogMAR of 0.2. And close vision is extended out to -2.75 at a LogMar of 0.2. The monofocal with a -1.25 shift is nearly as good. I currently simulate my close eye vision with a contact to leave me at -1.25 and I am quite happy with it. My distance eye has a monofocal that ended up at 0.0 D Sperical and -0.75 Cylinder. I can read the computer easy and my iPhone 8+ very well. Fine print on paper especially in lower light requires +1.25 readers.
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RonAKA clara26552
Edited
Here is another graph that shows the impact on the MTF and contrast sensitivity with the two options considered. My conclusion was that the combination of 1 distance mono plus a -0.75 Vivity would be better than two Vivity lenses. And, that two mono lenses with a -1.25 offset may be just as good or perhaps better than a Vivity plus a mono.
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RonAKA clara26552
Edited
I made a couple of posts about the defocus curves and MTF's of the various options. They are delayed due to moderation as I included some graphical images... Be patient and I think they will show up after moderation.
clara26552 RonAKA
Posted
Okay, I was confused about how this works. Got it now.
clara26552 RonAKA
Posted
That is very interesting. My intuition wouldn't have thought that the Vivity distance at -0.75D would be logMAR 0.1. That's 20/20 right? Vivity really does flatten the defocus curve. Dr. Catherine McCabe, an ophthalmologist who participated in the FDA trials for Alcon Vivity, targets -0.5D for the Vivity IOL in the near eye and plano in the distance eye. Based on your defocus comparison graph , targeting -0.5D in the close eye with Vivity and plano with Vivity in the distance eye would give a larger intermediate blend zone at the expense of a small loss of distance VA (and some contrast sensitivity as well). Is there a significant benefit to having a larger intermediate region with presumably better stereopsis at that range?
clara26552 RonAKA
Posted
Again, very interesting, Ron. That confirms my suspicions. Vivity in both eyes is likely to be a problem at night and in low light levels. That's why I'm seriously considering having the AcrySoft monofocal implanted in my distance eye. I should be able to verify this for myself with a contact lens before my second surgery. If I find even a hint of problem with night vision driving, or a noticeable loss of contrast in the near eye with the Vivity, I will ask for the monofocal at plano. Not being able to drive at night is something I very much want to avoid.
clara26552 RonAKA
Edited
I found a research paper that backs up your view, Ron, that I'd get better near vision if I target my near eye (with the Vivity IOL) for -0.75D instead of -0.5D, and only give up less than a half line of distance VA in that eye. The paper is entitled:
The Effect of Spectacle-Induced Low Myopia in the Non-Dominant Eye on the Binocular Defocus Curve with a Non-Diffractive Extended Vision Intraocular Lens
Authors: Gundersen and Potvin
The research studied 40 patients who had a Vivity IOL implanted in both eyes at plano 12 months prior. The authors used glasses to simulated mini monovision by under correcting the near eye of each subject to yield -0.50D myopia, in one case, and -1.00D in a second case.
With the -1.00D offset, 85% of the subjects achieve 2.5D of functional vision range, as compared with 68% with -0.50D offset. Only 38% did as well with no monovision (both eyes at plano).
Unfortunately, the paper doesn't mention the effect on contrast sensitivity with both eyes implanted with the Vivity IOL. As I said, that's why I'm having the near eye surgery first. If contrast is noticeably impaired with the Vivity, I will have a monofocal (Alcon) lens implanted in the distance eye instead of another Vivity lens. If contrast sensitivity is maintained, I think a second Vivity lens would provide a larger blend region.
I plan to ask my ophthalmalogist to target between -1.0D and -0.50D undercorrection in my near eye. My uncorrected near eye is -5.0D sph and 0.62 cyl. I understand it is difficult it is hit target for a small amount of myopia.
My pre-op screening is just two days from now. I understand that topography of my corneas will be measured, and a final decision on lens choice for my near eye will be made so that it can be ordered and ready for implantation a week later.
RonAKA clara26552
Posted
I think the advantage of using -0.75 in the near eye is better reading ability. Not sure it would make that much difference to the intermediate. The price is a slight reduction in distance vision with that eye.
dreamer2020 clara26552
Edited
I'm also thinking about getting Vivity to my non-dominant but much more impacted Left eye after comparing it to Tecnis Eyehance and other EDOFs. Some doctor told me that Vivity gives about 1-1.5D more for Intermediate distance over Eyehance which might be crucial for full-time computer users like myself. If I'm not happy with contract sensitivity and chromatic aberration of this lenses, I'll go with Eyehance or standard monofocal in my second eye.
clara26552 dreamer2020
Edited
I, too, was considering the Tecnis Eyhance in a mini monovision configuration as a way to avoid dysphotopsias and to preserve contrast sensitivity. I think it can work well for those who can adapt to a lens power offset of 1.5D. Some call it 'blended vision' and it works like shown in this graphic.
My doctor wasn't very encouraging when I mentioned the Eyhance. She hadn't implanted it in any of her patients, and I was reluctant to press her on the matter. She didn't refuse to implant it, however, if I insisted on it. She convinced me that the Vivity, which is a true EDOF, would give me better near vision than Eyhance without the adaptation risk doing -1.5D offset mini monovision.
Maybe implanting the Eyhance in the distance eye has a benefit over a standard monofocal by stretching the blended vision zone. Any tradeoff in reduced contrast sensitivity appears to be negligible.
clara26552
Edited
One observation that I made during my cataract surgery consultation is how little information is given to the patient about possible options and outcomes. Until I asked about mini monovision, for example, nothing was said about this important option. The visual disturbances associated with the Panoptics IOL were mentioned but downplayed. The loss of contrast sensitivity with premium IOLs was not brought up either. Only when I asked more in-depth questions of the ophthalmologist did the discussion go off script. They wasted no time talking about the pricing of the premium IOLs vs standard monofocals, however. My sense is that the uninformed individual is putting some very important decisions largely in the hands of the ophthalmologist. Is this the experience of others, and, if so, why do you think it's so?
RonAKA clara26552
Posted
I think there are at least a couple of reasons. They obviously make more money on the "premium" lenses. I think most people think they are "premium" quality, but really they are "premium" price. The optical quality of the monofocal aspheric is actually superior to these "premium" lenses, with the exception of the toric lens. It does offer superior optics to those that need them. There is a tradeoff that is not discussed which is that these premium lenses offer a superior depth of focus but with a reduction in optical quality.
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The other issue is "chair time". Surgeons like to minimize chair time talking to the patient up front, or after surgery dealing with complaints. If they raise the option of mini-monovision for example then they are on the hook to explain it, and then deal with any issues of dissatisfaction after the fact. They may feel it is best to only discuss it if the patient brings it up, and wants to try it. Then the onus shifts to the patient.
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But, I think they like it when the patient comes to the chair not knowing anything. Then they can run the show, and minimize the chair time. But, if they lead the patient down the MF path they then do have to be prepared to deal with the issues if things do not turn out well.
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The surgeon I went to told me an interesting story about the MF options like the PanOptix (besides the one that he would not put them in his own eyes). It was that some private clinics get all of their specialized equipment provided by the lens suppliers -- like J&J or Alcon. Then they "push" that particular product. I think we got on the topic when I brought up the issue of "glistenings" with the Alcon lenses, and asked if a Tecnis monofocal was an option. It in our public health system and he would use them if I wanted one, but he likes the AcrySof lenses. He works out of a public health hospital, not a private clinic, and the hospital provides the equipment so that is not a factor. The basic insinuation was that clinics with J&J Tecnis supplied equipment like to make a big issue about glistenings, but he has never seen them to be an optical issue. He called me right before the operation to confirm which brand (Tecnis or AcrySof) I wanted.
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So there are more things going on behind the scenes than we may think. A friend went for cataract surgery well before I did. She showed me the options she was provided with (a private clinic). They did offer aspheric monofocals at next to zero cost, but also two MF options including the PanOptix. At that time I had zero knowledge about cataract lenses and could not provide her any help at all. She did select the PanOptix (both eyes), and now regrets it. Basically she thinks she wasted her money ($4500 or so). She uses +1.75 readers to read books in good light. If I know what I know now, I would have advised her to go mini-monovision monofocal. But, she has always had issues with her vision, and she may very well not liked that either. We all are different in what we can accept. Today I was forced to thread a needle with my simulated -1.25 myopia mini-monovision and I managed it three times in good light. And I am a male with almost no sewing experience.
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Not sure why the posts are still waiting for moderation, but hopefully they will show up soon... I will be away for a while so may not be available to answer any questions you have about the defocus curves. I suspect you will figure it out, as you seem to have done a lot of research and are very well informed.
lucy24197 clara26552
Edited
My experience talking with 2 ophthalmologists is that they don't want to tell you ANYTHING that doesn't provide them with legal duck and cover ability. They won't discuss options/outcomes in any kind of detail, and you'll be lucky if they even answer any questions rather than running out of the room and referring you to someone else. They won't share test results or show you images from the tests. I'm still trying to get them to tell me what model of lens they use. What's really frustrating is they want you to sign consent forms before surgery saying all your questions have been answered (a requirement from our state.) I'm going for mini-monovision, something the surgeons wouldn't have mentioned on their own. They haven't provided any helpful input with regard to selection of targets, and have proposed different methodologies for the surgery & care (laser surgery, toric lens, "dropless" vs. manual surgery, no astigmatism correction needed, and steroids used during surgery followed by 6 weeks of drops.)They don't want to tell you that outcomes are highly variable depending on the surgeon's ability and even more on how your eye heals. The paperwork they require you to sign before surgery (at least that I've seen) has all sorts of clauses about how you understand that you may require glasses all the time. The person who schedules the surgery and has you sign the paperwork repeatedly tells you may not be able to see without glasses.
There definitely seemed to be a profit motivation for the first surgeon I met--a used-car-salesman vibe. With the second surgeon, I got the feeling that he didn't give a rat's behind about me personally or the effect of the surgery on my ability to see without glasses, but he cares about eyes and their health. The person attached to the eyes--their interests and lifestyle that can affect which range of vision is most important to them--doesn't matter to him.
The first doctor was pushing both eyes set for distance; the second kept saying "near or far, YOU have to decide." That was the extent of their discussion. Had I gone in without doing my own research I'd be miserable with the outcome. I still may end up miserable, but I'm trying to at least be informed and optimize the results. The doctors think they are gods and that their patients are idiots. Unfortunately, many patients think the doctors are gods, too, and take what is recommended as gospel.