Just had cataract surgery - Jumpy vision

The vision people get with a monofocal lens set for distance depends on the eye's natural depth of focus. A tiny minority, a few percent, of lucky people can do some reading, but it isn't good to expect that sort of lucky outcome. A more typical result I hear is 6 feet inwards being blurry. That is part of why the results for something like the Crystalens vary as well, since some people have more natural depth of focus and would have seen well even with a monofocal. 

Some people do, it just isn't that common. On the Medhelp site there is a page or two of people discussing that option. I think the issue is that with monofocals set for distance (or monovision) you can presumably wear progressive glasses to try to cover intermediate&near. If you get monofocals set for intermediate, you might need a pair of glasses/contacts for distance, and perhaps for near.  If someone goes for monofocals, to me though the idea of monofocals for intermediate sounds interesting though since with a bit of monovision  (different levels of intermediate) you could perhaps cover most social distance, computer distance, and most household tasks without needing glasses. If you only get a slight bit of monovision (micro-monovision or mini-monovision) there is less risk of depth preception being reduced.

I was highly myopic, before cataracts changed the prescription it was something like -6D and -9.5D, so I needed to wear correction all the time, mostly contacts, so I liked the idea of potentially not needing to wear correction  again (or if I did, only sometimes for reading).  I suspect part of the issue of what people go for depends on what they are familiar with. The average cataract patient in their mid 70s lost their near vision long ago and is used to that and probably doesn't mind the idea of monofocal lenses. In my case my cataract became a problem at age 49 while I still had some accommodation left and didn't like the idea of losing all of it.  Also what you go for likley depends on what correction you've used before.  I had used multifocal contact lenses and liked them, and preferred that to monovision contacts due to better depth perception.

The point of the crystalens is that in most people it does seemingly accommodate at least a little bit (though there is debate over whether it is actually moving) to give some better near. I've seen different guesses as to how many need reading glasses, one noted surgeon I recall seeing mentioned perhaps half.  As I mentioned on the other page here you started (perhaps you missed that, reread the page) there are some fraction of people for who it doesn't accommodate (I've seen varied comments, I seem to recall some guessed perhaps 10-15%, but I'm not positive) and its no different than a monofocal. The newest model crystalens reportedly has less of a risk of z syndrome, but I hadn't seen figures.

In my case since I was willing to travel outside the US to get a better option, I decided the Crystalens wasn't worth the risk when the trifocals (which are better than the US based bifocals, less contrast sensitivity reduction and lower risk of side effects) and then the Symfony which I wound up with seemed a better bet for my needs. As I noted on the other page, there are now corneal inlays to give people better near vision, and they have been tested with monofocal IOLs so I suspect they'd also work with the Crystalens, as an option to try later if you don't have enough near vision. (though it is an added surgery and expense of course).

btw, the Symfony is now available in Canada so you needn't travel to  Europe or Asia or Australia or New Zealand (which were the options I explored before going to Europe), and the AT Lisa trifocal is available in Mexico (I don't know about Canada) and there are at least a couple of clinics just over the border from San Diego, walking distance from the US, that seem to cater to US patients so they might be US quality treatment but using non-FDA approved more modern  technology.

The distance of 6 feet was only a vague general guideline that I commonly hear repeated, not an exact figure. If you want to understand the likely performance of IOLs, you'll need to look at study results, sometimes located on the manufactuers web pages or via searches,  which usually given the average visual acuity of the lenses at various distances (though again those are averages, some folks get better, some worse). Those distances are sometimes given in diopters rather than inches or centimeters, e.g. the visual acuity may be 20/40 for -2Diopters. You can convert those to   distance_in_centimeters  = (100 / -diopters), e.g. if they give the visual acuity for -1D that is for 100 centimeters ( 1 meter), for -2D that is for 50 centimeters, etc.  For instance if you look up the Tecnis Symfony lens, the manufacturer page on the clinical tab has a defocus curve that shows the visual acuit of that lens (which isn't FDA approved yet) but it also includes the Tecnis monofocal as well which is a high quality monofocal you can use as an example.

It is hard to picture of course what a particular visual acuity means. If you google "visual acuity print size" the first hit should be a page giving an idea of what near visual acuity you need to read various size print. Visual acuity can be given sometimes in 20/20 type format, other times in things like logMar or decimal, if you search you'll see on wikipedia and elsewhere charts to convert between the different measurements. 

I'm thinking about getting symfony which is now available in the US for $5,000 per eye.    Are you still happy and is this about what your paid in Europe?   I have been wearing mono vision contacts but need better distance and don't want reading glasses.   I want 20 year old eyes so thinking symfony is my best bet.   I'm wondering if I should wait as technology just keeps getting better and better but symfony seems to be new as only one, out of two Doctor's I met with even mentioned symfony as an option so was glad I decided to get two opinions.    Is symfony laser only? Been reading laser may not be better than conventional.   As I'm sure you can tell from this email I'm at the early stage of investigation.

In the Czech Republic the cost is more like $1200-$1800/eye with a premium lens (I got it for  a bit less than that since I got a discount others won't get since i was the first person to get the Symfony there, but since its implanted just like other Tecnis lenses that are the exact same size&shape it wasn't a concern to me to be the first there).

 Laser cataract surery would have been just a few $hundred more but I didn't bother going for it since my reading on the topic indicated that it hadn't proven its benefits for uncomplicated cases, with merely a different set of rare complications. The surgeon offered the laser, but agreed it wouldn't really provide any benefit for my case.   I'm used to the reality that in the tech world sometimes new technology is immediately better than prior options, but other times it can take a while to be polished before its better than prior technology (even if many people jump on the bandwagon early). I decided the Symfony was worth the bet, and the travel, but that the laser wasn't worth going for.

?Unfortunately there is no lens yet which will give you the sort of visual range you had when you were 20. Your distance vision might be comparable to what you had at that age  with the Symfony (or with a good monofocal with a low abbe material like the Tecnis). The natural lens does degrade with age (dysfunctional lens syndrome) even without a cataract so an IOL can improve things in certain ways. My distance (and intermediate) vision seem better than  I can remember them being before I had my cataract and I wore contacts or glasses. My distance vision is almost 20/15 (actually the last times they just confirmed it was at least 20/20, it could be it is 20/15 or better now). 

In my case I'd describe it as being like early presbyopia where you just start noticing you can't always see near. e.g. I can read the small print on an eye drop bottle, but I do need to find the right distance to hold it (unlike larger print where I don't need to). I have 20/25 vision at my best near, and have no trouble using my smartphone with the usual fonts, but for instance to thread a needle I needed readers. 

The Symfony was just approved in the US this summer, and it wasn't until the last month or so that they got distribution setup for US doctors to start using it, so US surgeons are often going to be less familiar with it. Its been approved in Europe and elsewhere for a couple of years. 

Unfortunately there is no lens that provides perfect vision at all visual ranges yet, so its a matter of deciding what your visual needs are and finding the option that best matches your needs. It partly depends on how much risk you wish to take, since .e.g. most people don't have problems with halo&glare issues with any lenses, but the odds of a problem are higher with multifocals than the Symfony.  Outside the US there are trifocals that attempt to provide good vision at distance, intermediate and near. I was originally going to go for one of those until the Symfony came out. The tradeoff is that studies tend to show slightly better intermediate vision with the Symfony (one study indicated the Symfony had the best visual acuity results out of all premium lenses from 46 centimeters and outwards), with the trifocal providing better near vision. In my case intermediate vision was more important to me than really near vision, since I figured worst case I could use readers for that at home/office (or they make foldable readers to carry in a pocket). The Symfony also has a lower risk of halos and glare issues than multifocals. Although the risk of night vision issues like halos is lower in trifocals and the new low add bifocals than it used to be, I preferred a lower risk of night vision issues to having a bit better near. The Symfony also has reportedly better contrast sensitivity (e.g. low light vision) than multifocals, even though again the trifocals and low add bifocals aren't too bad.  

In my case I was happy with multifocal contacts before my problem cataract arose. I didn't mind having reduced vision in low light, but I definitely have better low light vision with the Symfony than I had with the multifocal contacts. (though granted the optics of a multifocal IOL may be better than a multifocal soft contact lens and have less light loss). I notice the difference in a restaurant I have a weekly meeting at which is somewhat dimply lit.

Sometimes I wonder if I should have bet on a trifocal to have a bit more near, but I think the crisp intermediate and distance were a good choice. I know also that as we age we need more light, so eventually when I'm in my 60s and 70s the difference in low light vision may be more of  a big deal.

The Crystalens tends to also provide decent distance and intermediate , but with a slightly higher risk of night vision issues than the Symfony, and I'd seen estimates that around half of those with the Crystalens need readers  despite the near visual acuity results on paper seeming to be comparable to the Symfony, if perhaps even a little better. Most with the Symfony don't need readers. The thing that worried me about the Crystalens was that I'd seen reports (no hard figures) that perhaps 15% of people didn't get any better results than they would have with a monofocal, that it didn't seem to accommodate. I preferred not to risk that.  There was also a higher risk of complications like z-syndrome (which is lower in the latest generation, but I never found good figures for it) and other issues. I know someone here with the Crystalens, and he seems to have more of an issue with low light vision. (e.g. we met after a talk in a well lighted auditorium and he had a near vision chart. Holding a file folder above the chart to cast a shadow was enough to reduce his vision by some lines, whereas it didn't make a difference to me).

If you wait longer, there is a chance something better wil be approved. I waited 2.5 years for surgery (since I retained good vision in one eye) in hopes of a better lens.  I haven't heard of any new lenses working on getting US approval, I don't think any of the trifocals is trying for approval here. Its possible that might change since the Panoptix trifocal is from Alcon which is a major IOL supplier in the US so perhaps they'll try for approval, but I hadn't seen anythig about them even starting the clinical trial process. 

  Outside the US there are other lenses that haven't been well tested yet, seeming to be still being tweaked before they are marketed widely,  that might provide a slight edge over the Symfony (e.g. the Mini Well) but I hadn't seen good comparison data to know for sure (merely optical bench comparisons testing the lens outside the eye, not comparisons with the lens in humans to test for things like halo issues, etc) and the difference might be slight. 

Where in Czech did you get yours done?

I'm interested in either accomodating IOL eg Symfony. maybe toric IOL or corneal relaxation incisions

What was the total surgical cost?

The Symfony is an extended depth of focus lens, not an accommodating IOL like the Crystalens. It depends on the level of astigmatism whether a toric IOL is appropriate or an incision. Surgeons tend to use incisions for lower amounts and toric IOls for higher,but where the line is drawn varies with the surgeon. One prominent surgeon wrote in a trade publication about preferring an incision via  laser for even a few diopters of astigmatism. 

The Symfony is now available in the US, and I suspect any country where you can get a premium IOL. If don't know which country you are in, if the issue is cost, I know some in the UK use the Czech Republic for medical tourism.  In my case at the time only one surgeon there had gotten access to the Symfony before I had to decide which country  to go for surgery, but its available widely now. Where  I went wasn't as convenient since it was a small city where the surgeon spoke english, but not all the staff since they weren't really setup for medical tourism, so I hesitate to talk about it to any who aren't truly in for the ordeal. Now the Symfony is available in places like Prague where there are more English speakers than a small city (where even the cab drivers didn't speak english) and places that are setup to deal with medical tourists, even providing english language websites. Last I checked   surgery there varies in the range of $1200 - $2000 or so depending on IOL choice and whether to use a laser and other factors (I got a special discount being the first to get the IOL there so it was a bit less).  I've been in touch with someone who recently got the Symfony toric in Prague from an experienced surgeon, the price list shows about 1325 euros. (I hadn't checked the website guidelines to see if they mind mentioning specific doctors/clinics, some sites frown on public posting of that info and remove such posts, I don't remember if this is one, so I won't mention that in this post. I also hadn't researched the best current options, this was just one).

PS, oh, and the price range I was giving was per eye. I'm in the US so I used dollars based on memory of the conversions I saw, though most sites quote in euros and the Czech currency.

I'm in SoCal, asking for my wife.  She has about 2.5 diopters of astigmatism. Cataract got ++ worse over a few months, bothering her now.

We have family living in Berlin, so Prague is not unthinkable.  The out of pocket for the premium IOLs alone in the US is about the same as going to Czech or nearby, so it's definitely on the table.

In my case I'd initially planned to travel to get a better IOL that wasn't approved here (the US approved the Symfony a bit over 2 years after Europe did), cost wasn't wasn't the initial motivation to travel.  Then I discovered that treatment cost varied quite a bit, and  since I had no other reason to travel at the time, I could pick a lower cost country if it seemed a good choice. I had a high deductible and the cost of getting both eyes done, plus travel, was less than the deductible.(on top of which the 2nd eye's cataract wasn't causing trouble yet, it was 20/20 correctible, so it wouldn't have been covered since it was technically refractive lens exchange).

I should have mentioned that one concern with toric lenses of any kind is that there is some chance they may need to be rotated after surgery or that the astigmatism might need to be touched up with a laser enhancement.   In my case I was fortunate enough to have almost no astigmatism  so I didn't need a toric lens, and that complicates getting it abroad. They moderate links here, but one recent article on correcting astigmatism after cataract surgery mentions a meta study suggesting as many as 29% may have enough  residual astigmatism to warrant that:

"Visser31 considered 22 publications to 2012 that published toric IOL outcomes. The pooled estimate of the 22 studies was quite disappointing with only 43 per cent of eyes =6/9 uncorrected and 71 per cent =0.50 D of astigmatism.

...This rotation can be done on return to the operating theatre. Sometimes it is possible for the surgeon to rotate the IOL in the office using a 30G needle inserted through the limbus. Results are good and instantaneous."

Unfortunately they wait some weeks to allow things to stabilize before doing a final correction. However it is possible to have a local ophthalmologist do the final touchup of rotating the lens or laser treatment.  I don't know if the laser treatment cost would be enough to worth going back for.  

There is one surgeon who has been studying using laser incisions to correct astigmatism rather than a toric lens, and reported comparable results:

"Our initial laser arcuate results are generally comparable with the published data on the correction of astigmatism using toric IOLs and better than published data on manual AKs. ...

70% eyes had manifest cylinder of = 0.50D, 83% eyes at = 0.75D and 94% at = 1.0D."

I should mention that I heard back from one provider in India where I think it was around $1k/eye or less. I didn't check further into options there, I'd just checked one out of curiosity, due to the longer travel distance and requirement for a visa (which might be easy to get, I didn't bother checking), but people differ in what countries they might find of interest to visit. 

Since you mention Berlin, I think German prices were lower than US prices,  but I don't know how much insurance would cover if any of that (I didn't even bother finding out since my treatment was so cheap and below deductible).  Overall the Czech Republic is a common medical tourism destination for the UK, though there is also a clinic in Croatia that was part of the Symfony trials and is perhaps next cheapest country (though I don't know anything about the travel details there). Other European countries I think were cheaper than Germany,  like Belgium, Austria, and France, but definitely more than Croatia or the Czech Republic.

I would recommend doing your own research on clinics to see what one you are most comfortable with, and just take any clinics mentioned as one possibility (especially since I hadn't checked them out in detail myself, though at first glance they seem highly experienced and prominent). The fellow who got treatment in Prague recently that I've been in touch with wasn't sure which lens to go with and went to 3 clinics there before selecting one, but he is in the UK so he can travel there far easier than those of us in the US. He wound up with the Symfony toric, and will be needing to go back for a touchup for residual astigmatism, and says the surgeon seems dedicated to doing what it takes to give good results.

I should note that which lens is best does depend on the person, even though I suspect the Symfony is the best bet for many as it was for me, and there are more options abroad like trifocal IOLs (none of which are approved here, but there are 3 common ones abroad plus at least a couple of others less common). It was a close call whether to bet on the Symfony or a trifocal, which is gives more near but perhaps not quite as good intermediate, but which may have a slight bit more risk of halo&glare.

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.). There are medical tourism sites like Praga Medica, and the fellow who did the study on correcting astigmatism via laser is actually a Dr. Pavel Stodulka from the Gemini Clinic who for instance was selected to do cataract surgery in 2012 for the Czech president Vaclav Klaus. I don't know though if they do laser incisions in their Prague clinics or just in Ziln. 

In Croatia the Svjetlost clinic was involved in the Symfony trials and has some very experienced surgeons, but seemed a bit less medical tourism friendly, but there was a medical tourism site that seemed friendly that would handle dealing with them (getting a commission from them I guess).