Monofocal IOL set for Plano question

I have never worn glasses and have no real idea of my prescription.

OK. I can kind of see why. If I have to guess I think your right eye is about plano and is only suffering from presbyopia which is limiting your closer distance to 20" or so. A plano monofocal IOL is likely to be very similar. Your myopic left is likely giving you pretty good close vision and sounds very similar to what I get with my -1.40 D near eye. You potentially have natural mini-monovision right now, and would not need contacts to simulate it. If so, and you are OK with it, mini-monovison could be a very good solution for you with monofocal IOLs only. You would get what you have right now without glasses. The only difference may be that vision will get a whole lot brighter without cataracts in the way.

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It may be worthwhile to get an optometrist eye exam to see exactly where you stand and see if a contact trial is even necessary. Normally when a cataract surgeon does they initial evaluation they will do an eye vision test. Perhaps just ask them for a copy of it.

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In any case, if my estimations about your vision are correct you would be the perfect mini-monovision candidate using a monofocal lens like the Clareon. The beauty of monfocals is that they provide higher contrast sensitivity which peaks at the distance they are set at. So you will have two peaks in contrast sensitivity; one at distance and the other close.

Somewhere I read that some doctors don't use clareon as it has not stood the test of time yet and could be risky? I will soon have to choose a monofocal lense but unsure what my HMO uses and I can't get a preimum lense because of AMD according to my doctor. Will find out tomorrow what lense she recommends for me in monofocals.

The Clareon material replaces Alcon's AcrySof material that many patients found problematic because, over time, it produced an unacceptable amount of glistening. Alcon claims that the Clareon material does not suffer from this problem. A number of surgeons, my own included, are taking a wait-and-see attitude because Alcon previously claimed to have fixed the problem with AcrySof, its claims didn't prove out.

I do also have the option of choosing a panoptix, a lot of people talk about the halos, which I can’t imagine would be worse than when I’m dealing with having cataracts, I understand it also has a contrast reduction. I wonder what the halos are like for vision with panoptix at concerts with lights on a stage.

I guess you were the one I had read who said that. Probably wise advice!

My surgeon let me in on a little known secret in the cataract surgery industry when I asked about the issue of glistenings in Alcon IOLs. He had recommended Alcon AcrySof IQ lenses for me and they have collected the reputation of developing glistenings over time. His response was that he had seen glistenings in the AcrySof lenses when doing an exam with a slit lamp but they were never to the point of impairing vision or requiring a lens explant. He also went on to say in somewhat guarded language that some private clinics get all of their very expensive exam equipment like the IOLMaster and Pentacam "donated" by a lens manufacturer. In return there is an "expectation" that they will specialize in using that manufacturer's lenses only. And, further there were certain clinics that liked to spread the "glistenings" story. The conclusions were left to me. He did not say more, but offered to use the J&J Tecnis 1 lens instead of the AcrySof IQ if I wanted it. I was having this first eye done at a public hospital and where I am both the AcrySof IQ and Tecnis 1 monofocals were fully covered by our Alberta Healthcare System.

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So I took the time that I was in the queue for surgery to do some of my own research. I found that the AcrySof lens did in fact have glistening issues in the earlier production days and over time they have significantly improved their production quality control, and it was no longer a real issue, but the stories do continue, especially from certain clinics that use J&J lenses.

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He called me again right before surgery and asked which lens I wanted. At that time I told him I would prefer the AcrySof IQ and that is what I got and have had for a little over 2 years. I like the use of a blue light filter in the AcrySof as it duplicates the colour spectrum of a young natural eye. The J&J lenses do not use the blue light filter and the result have a much higher transmission of the blue light end of the spectrum to the eye with a blueish unnatural colour balance. It is not huge but may be of interest to someone that does digital darkroom photography work. The AcrySof also has a reputation for resisting PCO development and has a lower YAG rate than the J&J lens. It also does not fully correct the asphericity like the Tecnis 1 does and there are some claimed benefits to that. It also has a reputation for being a "stickier" lens that stays in position better than the J&J material which is slightly different. This factor is more important with toric lenses as the benefit of a toric can be significantly reduced if it rotates out of position even a small amount. In any case these are the factors that caused me to select the AcrySof lens over the Tecnis 1.

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When it came to my second eye the Alcon Clareon had become available. So I did some research on that and liked what I saw. It had the similar advantages to the Clareon and even claimed slightly lower risk of PCO. And, I found a study which found that the AcrySof material had improved to the point where glistening were highly unlikely and that it was even lower with the Clareon. You can find it by googling this.

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David J Apple Laboratory Glistening through the years Timur Yildirim Feb 05, 2021

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So I decided on the Clareon. It was not covered fully unlike the AcrySof and Tecnis 1, as it was a new lens. I paid $300 extra for it. And, in the evolving healthcare system in Alberta this also got me into a private clinic with a 3 week wait instead of the many months in the public system. To me the $300 seemed like a bargain!

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As for monofocal lenses I would say all of the following are acceptable; Tecnis 1, AcrySof IQ, Clareon, and a less popular one called B+L enVista. They all have their pros and cons, but really they all are acceptable. I did not have the choice of the enVista but if I had, I would seriously consider it. Between the Tecnis 1 and Clareon, I obviously prefer the Clareon, and others may choose differently.

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But, keep in mind when selecting a surgeon you may very well be selecting a brand of IOL when you select the surgeon, for the reasons I made above. They may be "locked into" one supplier or another. So, ask up front what lenses they offer.

Interesting and detailed discussion of these lenses. With AMD, AcrysofIQ or Clareon would seem a possible good choice because of the blue light filter. Other things you mentioned sound convincing that it is a good choice. Will speak with doctor tomorrow and know what she is going to choose and whether I might have a choice on monofocal selection?

At EyeConnect International, a forum limited to ophthalmic professionals that for a time I was able to peruse via websearches (but, alas, no longer), ophthalmic surgeons talking to themselves often mentioned glistening as a problem with the AcrySof material--and Alcon's many unkept promises to have fixed it--that dissuaded them from recommending AcrySof IOLs and made them cautious about Alcon's new Clareon IOL. This also was my surgeon's experience. Specifically, he told me that he'd be comfortable recommending a Clareon IOL if I were over 80, but that at 73 he was concerned that, if Alcon hasn't solved the glistening problem, it would show up during my lifetime.

In 2021 (published) open access article in PLOS One, authors Timur Yildirim and others published Qualitative evaluation of microvacuole formation in five intraocular lens models made of different hydrophobic materials. The IOLs studied included the Alcon AcrySof SN60WF and the Tecnis ZCB00. Among the five IOLs, "mean glistening numbers were ranked the highest in the SN60WF" and lowest in the ZCB00. (IOLs from Rayner and Hoya also were found to "show high resistance to microvacuole formation.") Attaching some numbers, the average microvacuoles per square mm for the SN60WF was 66.0, with a standard deviation of 44.5, and for the ZCB00 was 0.9 with a standard deviation of 0.6.

The authors also note a controversy over the relevance of glistenings to optical performance of IOLs. The authors did write, however: "Lenses with

an elevated number of glistenings were found to have the potential to induce symptoms that could result in difficulties for patients while driving."

Regarding the rotational stability of Acrysof vs. Tecnis toric IOLs, it appears true that Acrysof is more rotationally stable. But a June 12, 2018, story in Review of Ophthalmology found "no significant difference between the Acry--Differences in Stability Between Tecnis and AcrySof--adds that "Despite these differences, refractive outcomes were statistically equivalent between groups." A more recent study by Daniel Schartmuller and others published in the December 2020 issue of the American Journal of Ophthalmology is to the same effect ("no significant difference" in overall rotation between the Acrysof and Tecnis groups): Comparison of Long-Term Rotational Stability of Three Commonly Implanted Intraocular Lenses. The whole issue of toric IOLs seems to be somewhat fraught, however. Also, the authors write that they could have shown a statistically significant advantage for the Acrysof IOL had they excluded results with more than 10 degrees of rotation, which I suppose underscores the importance of understanding the parameters behind any statistical claim.

A brief addendum. Two studies of JnJ's newer Toric II IOL apparently show rotational stability on a par with Alcon's AcrySof. See Reproducibility of the Magnitude of Lens Rotation Following Implantation of a Toric Intraocular Lens with Modified Haptics (2022) and Reproducibility of the Magnitude of Lens Rotation Following Implantation of a Toric Intraocular Lens with Modified Haptics (2023, reporting on a study that I haven't been able to locate).

Sorry, but that is a perfect example of the misinformation that J&J surgeons are spreading. Alcon did fix the problem with glistenings in the AcrySof material and quite a few years ago. And in accelerated ageing tests the Clareon is even better.

I have a friend who got PanOptix. She is very disappointed in them. She has not had them replaced as some do, but she thinks she wasted her money paying the $4500 it cost to get them over the fully covered monofocals. She ended up needing +1.75 reading glasses for any kind of close work. I would not recommend the PanOptix to anyone.

The jury seems to be out on whether blue light filtering could delay progress of AMD. But, since there are other good reasons to use blue light filtering it seems to be a good idea. It is said to improve contrast sensitivity in dim light conditions, kind of like the yellow shooting glasses I guess...

No comment. Believe what you want to believe.

So if I'm reading this correctly, a Clareon Vivity may be better contrast than the previous version thanks to a blue light filter?

Ron, what makes these opthalmologists "J&J surgeons"? And why should we think that the authors of the articles I referenced are acting dishonestly?

FWIW, my own surgeon, as part of his "welcome" mailing last summer, included brochures for both the Alcon PanOptix and the Tecnis 1. I see no evidence that he's a paid shil for JnJ. Rather, I believe him when he describes his experience and that of his previous patients with the material.

As for Alcon having fixed the glistenings problem with the AcrySof material, I don't know. On the one hand, my surgeon isn't convinced. Nor are a number of surgeons whose intramural posts I read at Eyeconnect International. On the other hand, you tell me it was fixed quite a few years ago. At this point--with Clareon replacing AcrySof and Toric II replacing the earlier Tecnis formulation--I'm not sure it matters. But if it does, do you have any published studies?

No I don't really think so. Essentially all the Alcon lenses commonly used like the AcrySof, Vivity, and PanOptix have had blue light filtering since they were introduced. In theory Alcon have non blue light filtering versions in the monofocal line, but I understand they are seldom used. Your selection of lenses is going to be limited to what the clinic stocks. The Clareon material does have a higher light transmittance factor, but I have not seen any data that would show it translates to higher contrast sensitivity.

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I have one AcrySof IQ lens and one Clareon, and other than the Clareon is set for a closer distance there is no noticeable difference in image quality between them.

I repeat. No comment. Believe what you want to believe.

thanks again for your responses. The clinic needs a decision 2 weeks prior to procedure (March 1st) because they order lenses rather than stock them. I'm still torn, having too many options means decision paralysis unfortunately. The difficult thing about contrast sensitivity is that I cannot find any good visual examples online like I can for halos/starbursts. So i'm trying to imagine what it might actually look like. Also, having never worn glasses I'm not that worried about needing them but finding them disorienting when going from close to far by taking them on/off constantly. I'm not opposed to glasses, I just have no real world experience with them. I've tried them once years ago for my mild correction and wore them intermittently for a week and gave up. Its like the depth and perception of the world changed like a fishbowl when i put them on. That is why I'm torn between the vivity and mono...i want crisp colors and sharp lines but fearful of adapting to glasses. Do you wear glasses all the time with mono set for distance? Does distance become blurry when I wear glasses to see my dashboard? Am i constantly going to be lifting and lowering them when driving?

That is true about blue light and AMD. I have been using blue light glasses for about a year mainly on the computer and really like using them but wouldn't know if they help or not?

With your eyes where they currently are, you have an excellent opportunity to go with mini-monovision. The risk of optical side effects would be much higher with the PanOptix and even the Vivity. You have very good prospects of being as glasses free as you are now. Your odds of seeing the dashboard clearly with your distance eye are are very good. And you will see it for sure with your close eye once you get that done. And when you get one eye done for distance you will have the opportunity to further try mini-monovision simply by going without glasses. From what you say, your other eye is giving you good close vision. You can refine what you see with the close eye when you get the second eye. If a Clareon monofocal lens is available for your first eye plano needs I would recommend it. The normal practice is to target -0.25 D in the distance eye.

I think my eyes are similar also. I am going to try to get mni-monofocals. I never now wear glasses and can see ok both distance and close but not perfect.. I wonder if I would also be able to test it without contacts? Would intermediate for one eye and distance for another eye be a good idea?

Do you know what your eyeglass prescription is now? Or, do you not have it as you have not worn glasses? And eyeglass prescription is the best way to measure where you stand now. If you naturally have a close eye and good distance eye, then mini-monovision may very well be a good solution.

The last Eye Exam I had Feb 2022 is

R -1.25 Sphere, Cyl -1.50 . 80 Axis

L -1.00 Sphere, Cyl. -2.00 ,93 Axis

Prescription

R +1.25 Sphere, -1.50 Cyl. .80 Axis

L +1.50 Sphere, -2.00 Cyl. .93 Axis

I just sent it all over to you but it is waiting to be moderated??

R is + l.25 sph. -1.50 cyl and L is +1.50 sphere, -2.00 Cyl that is the prescription that I have

I think they are all sleeping in the UK right now. It will probably show up in the morning.

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You do have some astigmatism indicated for eyeglasses (the cyl number). You may or may not need a toric in an IOL. You won't know until they measure the shape of your eye to determine how much of the astigmatism is in your cornea compared to what is in the lens. The lens is removed in cataract surgery so that part will be gone. What matters is what is left in the cornea. They will know that part after the eyes are measured.

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When there is astigmatism involved the cylinder part is sometimes converted to an equivalent sphere by adding 50% of the cylinder to the sphere number. It is a rough estimate of what the combined effect of the sphere and cylinder is. In your case this would be:

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Right: +0.50 D or mildly far sighted or hyperopic

Left: +0.50 D the same as the Right

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Being far sighted especially when you are younger gives pretty good vision without glasses as the accommodation in your eye can correct it to a point. Near vision tends get worse as one gets older when the lens loses the accommodation ability.

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What is interesting is that there is another contributor here that got monofocal non toric lenses which did not correct the astigmatism, only the sphere. It left fairly significant astigmatism. She got good near and far vision. That might work for you depending on what the residual astigmatism will be. It is rather unconventional, but has worked in her case.

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The more conventional approach would be to correct one eye to plano, and the other to mild myopia of -1.5 D and use torics to reduce the astigmatism if it is predicted to be -0.75 D or higher.

The doctor said after measurements that can't offer me a premium or tonic...only monofocals. I am meeting with her tomorrow and want your input prior on the mini monofocals. Thanks!

Did she give a reason why she cannot offer a toric lens? With your AMD issues I understand why she would not offer an extended depth of focus lens like an Eyhance or Vivity, or a multifocal lens like the PanOptix or Synergy. With AMD you do not want any lens that could compromise contrast sensitivity. That makes sense. However, a toric lens is not in any of those categories. To my knowledge it does not compromise contrast sensitivity. It is just a monofocal lens that corrects for astigmatism. It does cost more though if that is a consideration. Where I am a basic monofocal is no cost. The toric in a basic monofocal is $1,100 extra per lens.

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From memory I think the questions you should ask are:

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1. What is the reason for recommending an intermediate distance correction in both eyes?
2. What will my astigmatism be in each eye if I get a non toric monofocal?
3. Why would a toric lens not be suitable?
4. What would be wrong with getting mini-monovision using monofocal lenses?

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   That might get you closer to where she is coming from. It is probably a good idea to take your questions and make notes of the answers.

No and no thay don't. This has been a scam almost forever. ( Are Blue Light-Blocking Glasses Worth It? By Celia Vimont )

Wrong. The jury has been in a long time. It's a bad idea. ( Blue-blocking IOLs decrease photoreception without providing significant photoprotection. ( Martin A Mainster 1, Patricia L Turner )

Blue light filters on eyeglasses are not really worth it when you have natural lenses in your eyes. Even youthful people have built in natural blue light filtering. As a person ages the degree of blue light filtering increases providing even more protection as we age. Then when we get cataracts which causes another drastic increase in blue light filtering to the point were many with cataracts can see that their vision has yellowed. The problem comes in when we get the natural lens containing the cataract removed and replaced. If the natural lens is replaced with a plastic lens with zero blue light filtering then all of a sudden the retina is exposed to more blue light than the eye has ever seen in the whole lifetime. This is when it can make some sense to restore the natural lens level of blue light filtering, by using an IOL with blue light filtering.

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Some people make the wrong assumption that blue light filtering is being added to the eye. Actually all that is being done is the restoration of the young eye natural blue light filtering. This is not the same as wearing blue light filtering glasses over natural lenses. See this image for more information.

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Your a Alcon fanboy, I get it. ( Acrysof - come for the cat eye, stay for the glistenings! ) Did they get any better ? Possible, but think they would have had to work pretty hard to make them any worse. There was truly only one way to go. I have never seen an explanation for the ability of the glistenings to bend light around them and not scatter it. Nobody else has either, because that would render them invisible. When I look at pictures of those lenses, it scares me. Dr Saffron says he's still replacing the late model glistening masters. I believe him. You believe Alcon and their people.

So, upon discussing a little bit further with my ophthalmologist assistant, although he prefers to use Alcon premiums, when he’s implanting a mono focus, he prefers Eyhance. so I guess I need to start researching what that lens provides now ugh

You should keep in mind that some clinics unfortunately like to push the lenses that give them the most profit. It seems to me that your doctor has already given you misleading information that seems to be intended to push you into a premium lens. A monofocal will never start to drop off in vision at 3 meters or 10 feet. That is an outlandish claim. It starts to drop off in the 2 to 3 foot range.

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Keep in mind that the Eyhance is NOT a monofocal lens. The lens varies the power in a radial direction. This results in a small extension of the nearer focus distance and a small reduction in the quality of distance vision. If you get two Eyhance lenses implanted with a target for distance you will come up short for near vision, and near vision will not be nearly as good as what you have now without glasses.

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To get near vision with an Eyhance you have to use some monovision similar to what your eyes have now just by chance. But, you can get just as good vision and possibly better by using a true monofocal instead of an Eyhance.

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So my thoughts on Eyhance are that it produces a very questionable benefit at a premium price. What is he charging for the Eyhance compared to a true monofocal?

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Keep in mind that all the Alcon lenses provide blue light filtering which would give you a more accurate colour balance for photography, while the J&J lenses have no blue light filtering, resulting in a colour balance to the blue side.

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These are not huge issues, but if it were me I would choose the Clareon or Tecnis 1 over the Eyhance when using them in a mini-monovision configuration.

She was definite in saying she could not really offer me a toric lens but had looked at it as possible.

If the astigmatism resides in my lens mainly it would removed so maybe that is the reason? I will find out late today when I speak with her. Those are good questions you listed and I have many more. I have had to scale them down but there are so many. Will let you know what she says.

Mini Monofocals sound like the ticket for me as I can't bare losing either closer in or distance.....Gee I need both and don't like wearing glasses except occasionally.

Don't forget that RonAKA has had excellent success with his own ones which is definitely something to note!

That is interesting info. about blue light. Now I am afraid of having it too bright when I get the new lens without a blue light filter. I will be covering that with the doctor today.

I did a little more research on using a toric lens when there is AMD involved. What I found is that there is no contradiction to using a toric with AMD. In fact if astigmatism correction is warranted, a toric is recommended even with AMD. However, if predicted residual cylinder (astigmatism) is less than -0.75 D then a toric is not justified. So it is possible if they have taken the detailed measurement for cataract surgery that you don't have enough astigmatism to warrant a toric. You don't want a toric implanted if astigmatism is not over the limit. It would make astigmatism worse.

I just asked what the cost would be for Eyhance, and I’m waiting for a response now. Keep in mind my Opthamolgy clinic is through a teaching/research University Hospital. So I'm not sure they are upselling me the way a private practice might.

That sounds like highly possible but will find out. The good news is the monofocals incur no extra cost!

Yes, here in Alberta where monofocals are free, the extra cost of a toric is $1,100 per eye.

I just got a surprising note from doctor that they will contact me for a contact lense fitting for the monofocal. I had written her about the mini monofocal idea and looks like she is receptive. Is it possible for me to try it with my own eyes/glasses once I get one monofocal lens put in as you had recommended to one other person? I hate having to wear contacts as I never have done so.

I think the critical bit of information you are currently missing is your eyeglass prescription. If you knew what that is, you would also know why you are seeing the way you currently see, and what impact getting IOLs would have relative to what you see now. Based on what you say, you may have natural mini-monovision. That is very easy to replicate and probably improve on with monofocal IOLs.

Yes, you could do it now with contacts in both eyes. The only issue is that if they are going to take more detailed measurements then you have to discontinue wearing soft contacts 1 week before the measurements. They can impact the shape of the eye.

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Yes, if you get the first eye done for distance then you can simulate mini-monovision by only correcting the unoperated eye with a contact. Normally you target -1.5 D in that eye to get the reading vision.

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I have worn contacts on an off since about 1975, all soft. As I got older and the contacts seemed to get thinner and thinner, I found them very difficult to handle to the point I stopped wearing them. I could not get them off my finger and onto my eye. More recently I tried many different brands and materials. I found some that are not so flexible, and much easier to handle, but still very comfortable. They are the Coopervision My Day daily disposable lenses. Costco sells them as their Kirkland brand. The other two brands I found to be nearly as good are the J&J Acuvue Oasys and the Alcon Total1. They are made of a silicone hydrogel materials which is better than the straight hydrogel ones which I find way too flexible. The Alcon Precision1 might be another good one but I have not personally tried it.

Yes, Ron, I am that contributor. With 2D astigmatism that I was planning to correct with glasses (not a toric or LRIs), I asked for intermediate vision and now have 20/22 distance, excellent intermediate,and only need readers for sustained reading of a book or magazine.

I meant I have 20/20 distant vision not 20/22!

Thanks I will jot that down.

This is an excellent medical journal article about cataract surgery and AMD published in 2021. Goes into toric IOL and blue light.

Google:

"management of cataracts in patients with age macular degeneration"

I found this first image from 3 years ago, the last time I tried glasses, and the second image is from the notes of the most recent visit. Not sure if this is what you wanted to see.

I have been looking around for a good article like that. Thanks.

Wrong search terms. Google this instead for above article

"Management of cataract in patients with age- related macular degeneration pmc"

Yes, I remember now. Very good outcome, but not many have a vision condition like yours. So good, but hard to replicate.

What vision conditions led to such a good outcome with intermediate monofocals?

Yes, that is a good article. I would say the relevant takeaway points are:

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1. Contrast sensitivity is a concern and MF lenses should be avoided
2. EDOF lenses are less of a concern, but probably should be avoided too. The Vivity would be an issue.
3. Torics are not contradicted and should have some benefit in visual acuity
4. The jury is still out on the benefit of blue light filtering, with only one small study showing benefit. But, it seems to me the conservative approach is to return the eye to the natural blue light filtering degree.
5. No information I saw on using mini-monovision. But in that it provides vision close and far it seems to me to be a good solution to maintain high contrast sensitivity across the distance range without resorting to MF or EDOF lenses.

I found some stuff and I posted the images, but it’s awaiting moderation on what I believe is my prescription

@Lynda111 has a large amount of post surgery astigmatism that provides an EDOF effect. It is not going to deliver the most crisp of vision but it obviously still lets her see well. Astigmatism effectively varies the power of the around the 360 degree angular position of the lens. It is essentially a multifocal effect. You are getting a range of effective lens powers instead of a single power.

If you can just type it out, that would help. It is normally just a series of numbers like this for each eye:

X.X D sphere, X.X D cylinder, and an angle of the cylinder (between 0 and 180 degrees)

Oh, that is interesting. I was wondering about her excellent results having chosen intermediate monofocals.

Manifest Refraction

Sphere Cylinder Axis

Right -1.50 +0.75 031

Left -1.75 +1.75 160

Manifest Refraction #2

Sphere Cylinder Axis Dist VA

Right -0.75 +0.50 164 20/25+2

Left -0.75 +1.00 151 20/20

Ok, so who took those measurements? I am assuming it was done in an ophthalmologist office? And do you know why there are two sets of numbers? Are they from different eye exam dates? They seem quite different.

like I said, I truly have no idea. It was during an ophthalmologist appointment when I was first complaining about cloudy vision in my right eye it’s just something that I found in the notes. I had no intention of getting glasses, so I never really asked for a prescription.

The set of numbers from three years ago are as follows

OD -.50 blank blank

OS -.50 +.75 160

OD/OS +1.75

I want to say thank you for all the effort you’ve made to try and help me through this decision, but at this point, I think if these numbers don’t add any clarification, I will just go with my gut and make a decision on Monday as they’ve asked.

Sometimes the numbers that are older and prior to cataract potential are the most accurate. I will assume your three year old numbers are the good ones. They are in ophthalmologist convention with positive cylinders. This is how they convert to standard optometrist format:

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OD Right: sph -0.50 D, 0.0

OS Left: sph +0.25 D, cyl -0.75 @ 70 deg

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This indicates mild far sighted vision with some astigmatism in the left eye, and mild myopia in the right eye. The right eye should give better near vision.

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You manifest vision set becomes:

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OD Right: Sph -1.0 D, cyl -0.75 D @ 121 deg

OS Left: Sph 0.0 D, cyl -1.75 D @ 70 deg

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This indicates more myopia and some astigmatism in the right. Should provide the better close vision. The left is plano with some high astigmatism than the three years ago number. May be the influence of cataracts. It should provide the better distance vision.

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Manifest 2

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OD Right: Sph -0.25 D, cyl -0.5 D @ 74 deg

OS Left: Sph +0.25 D, cyl -1.0 @ 61 deg

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This looks odd compared to the other two, but the right is more myopic and the left closer to plano.

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This does not jive with your initial post that your left is myopic. These numbers indicate the right is more myopic, and your left is closer to plano.

After all of this, my suggestion would be to go for a monofocal in the right eye set for distance (target -0.25) and leave your left eye for now. Once your right eye heals (6 weeks or more) you may want to try contacts in your left eye to see how much myopia is required to see well without glasses. A contact lens fitting tech should be able to help you with this kind of trial. If you see well closer up now with your left eye without glasses then there is no rush, and you will have time to do the contact lens testing.

Just spoke with my doctor. We will be doing mini monofocals, Clareon, one eye intermediate and one eye distance. Testing with contacts. How long do you need to test it for as surgery date is March 2. I will have less than 1 D astigmatism left in my cornea after. No torics because not enough astigmatism. She didn't know which was the dominant eye. Which eye do you pick for the reading eye? Is one preferred over the other? What problems do some people have with mini monofocals if not tested first? I mentioned about at least a month between surgeries which would be ok. I have advanced cataracts which was disappointing since the year before the Optometrist said I was not yet ready for surgery so she may have been wrong?

Yes, I see the Clareon torics only go down to 1.0 D of astigmatism in the minimum toric power. The AcrySof IQ goes one step lower and the minimum power is suitable for 0.75 D to 1.0 D. My wife has that power in one eye.

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The dominant eye is fairly easy to determine. With both eyes open point to a small object across the room with your index finger. Close the left eye. If you are still pointing at the object then you are right eye dominant. If you are no longer point at the object then you are left eye dominant. Your dominant eye is essentially the one you aim with when both eyes are open.

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Mini-monovision (not monofocal) requires the brain to be able to switch from one eye to the other without you thinking about it. You should be able to look around the room and with different distances you should see the image in good focus. Some people have trouble doing that. That is the reason for testing with contacts if you can manage it.

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I would pin her down to a target diopter value instead of just "intermediate". That is a fuzzy definition at best. With monofocal lenses it is best to target -1.50 D to get good reading vision in the near eye. I ended up with at -1.4 D, and reading is pretty good without glasses. That would be another benefit of simulating with contacts. You could see what -1.5 D gives you for reading vision.

. I just wrote her with that inquiry. Thanks again for the valuable feedback! It has helped a lot!

I still can't tell which is my dominant eye. I see much better with my right but that is I believe the astigmatism? The doctor wants me to pick which eye would be the near eye 1.5 D? Do you have a recommendation? She is going to do the left (weaker eye) first. I don't know why? She did not know what my dominant eye is? I got to work fast as we still don't have the contact order and surgery is March 2. I wrote her about a week ago but she is now just dealing with the contact issue so there has been a big delay.

In general, although certainly not always, your dominant eye is the same as your dominant hand. Here are three ways to test:

Dominant Eye Tests

You can determine which of your eyes is dominant by conducting one or more of three tests: a hole-in-the-card test, a near convergence test or a miles test.

Hole-in-the-Card Test

This visual acuity test does not take long, and it distinguishes between the better-seeing of the two eyes. It is administered in four steps for each eye:

Take a black paper card and make a hole 3 cm wide at the center.

Hold the card in front of your eyes at arm’s length. Hold it with both hands.

Stand three meters (10 feet) away and cover one eye, then read one letter through the hole.

Repeat the procedure with the other eye.

Results: The eye that better sees the letter through the hole is the dominant one.

Near Convergence Test

This is the simplest of the three tests, with two steps:

Hold a stick 40 centimeters from your eyes.

Slowly bring the stick towards your nose bridge until your binocular fixation point breaks.

Results: The eye that maintains focus as you move the stick towards your nose is the dominant one.

Miles Test

The test is similar to the hole in card test, except you use your hands instead of paper. The process is:

Extend your hands such that they are in front of your eyes and your palms facing away from you

Crisscross your hands such that you make a triangular-shaped hole. It should be between your two index fingers and thumbs.

View an object 3 meters away through the hole with your eyes open.

Close one eye first and view the object again through the hole.

Repeat the procedure with the other eye.

Results: If the object doesn’t disappear as you change the view from one eye to another, then that is the dominant eye.

My dr did my weaker eye first because I had waited so long and my cataract was so dense that even with glasses I could hardly see,

Thanks for sending that along!

Just tried to get contacts but the Optometrist was unable to put it in. Very difficult if you have no prior experience. So had to give up on that. My doc said something to the effect that:

" Many surgeons will aim intermediate for AMD to create a telescoping effect when glasses are worn. This will help magnify images which may help if your vision declines later on. This is based on high level optics and experience and I do NOT expect our patients to try and learn the underlying science and medicine behind it. That is why as physicians, we help guide you"

Does that make any sense to you? I wonder if she would be able to vary intermediate so that each eye is slightly differen gettng better distance and near coverage.. I will be speaking with her on this topic soon.

On the contacts do you know what lens they tried to use? There are certain lenses which are very thin and flexible. The J&J Acuvue Moist (hydrogel) is one example. I essentially gave up on contacts because I simply could not handle them. They would always fold back onto my finger and not stick to the eye. When I decided to get serious about testing monovision I tried different lenses and there was a newer material (silicon hydrogel) that was much much easier to handle and even more comfortable. Coopervision MyDay was the one I liked best, but the J&J Acuvue Oasys and Alcon Total1 were very good too.

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No I don't follow the logic she is using to justify setting the lenses at intermediate. I would think there is advantage to setting them to distant and close so you get across the range high contrast sensitivity, which seems to be the biggest concern with AMD. I recall there was part of article @Lynda111 posted that talked about magnifying lenses used with advanced AMD, but I don't know anything about them. I did not see anything in the article that suggested there was a benefit to using an intermediate distance. It seems to me that eyeglasses can correct vision whether they are set for close, intermediate, or distance. It is really more about what you see without glasses.

The real problem is I couldn't stand putting anything in my eye and kept closing it. It was too difficult. I even shouted which I never do!!! It was very traumatic and don't want to attempt again!

I will mention what you said about high contrast sensitivity.

That is too bad. I did my first contacts about 1975 and recall that it wasn't the most pleasant experience but I got used to it. Ideally when you are comfortable and relaxed doing it with a good lens you just lightly touch the outside rim of the lens to the eye and it pulls itself onto the eye. But, of course you have to be relaxed and confident to do that. When it goes badly the damn lens just folds itself back onto your finger and will not go into the eye, no matter what you do. When I got older and found doing it was more and more difficult I blamed it on my age (73). Then I had a big breakthrough when I found the new material. Then it was easier than it ever had been.

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When you get to the actual cataract surgery, you probably want to consider what you use for sedative. Some people do it with nothing, but my surgeon recommends against that. He says something like people are not used to me putting sharp objects into their eye, and I need to have you relaxed. For my first eye I got an IV with sedative (not sure what), but I was barely conscious and pretty unaware of what was going on in any detail. With the second eye which was done in a clinic all I got was one tablet of Ativan. I was quite aware of what was going on, or at least I thought I was. I was OK with it, but since it was my second eye, and my wife had two eyes done with Ativan, I was confident it would be OK. Of the two methods I would suggest the IV route based on your contact lens experience.

Good point. They give a versed iv low dose. Hope that is enough? No antibiotics after as they give an antibiotic shot during surgery.

I believe most surgeons give an antibiotic injection during surgery. But, all of my research indicates drops are still needed after surgery. Surgeons vary in what and how long they use them, but I was not aware of any surgeon that does not use drops after surgery. No stitches are used to close the incision. You want it to heal quickly and without any infection.

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My routine was 4 drops per day for 7 days of Vigamox which is an antibiotic. At the same time Durazol, a corticosteroid, was prescribed at 3 drops per day for 21 days. I had no issues with infection or even much of a scratchy feeling after surgery.

From the discussion it appears only steroid drops but will double check on that.

Here is some more info. on AMD and intermediate lenses selection from my doctor:

"The intermediate aim in AMD is to create a weak galilean telescope effect when you are wearing reading glasses in addition. This creates some magnification, but I don't believe it is something that will benefit you at the moment as you do not have vision significantly affected by AMD. It was just another smaller reason to back up your thought that you wanted to keep your vision similar in focus to how you currently see." BTW, She said both my eyes now are intermediate? If I select intermediate she can vary the ranges so they are different.

If this makes sense to you, let me know?

Interesting, the tests. Thanks for posting them. I did the triangle one and the one RonAKA posted and I keep getting different results regarding which is my dominant eye. Probably because I initially was left eye dominant (but naturally right handed) until the retina tried to detach which left me both near-sighted (very) and farsighted in that eye. So my right eye became my dominant one (has been for decades). The first time I did both tests, my left eye showed as dominant, the second time, the right eye. I hope they don't start fighting over it, lol.

I can kind of see what she is getting at to get some boost in magnification. But in my thinking you could achieve something similar with just higher powered readers.

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I am puzzled as to where you are actually at now for vision. I went back to your posts 3 days ago. There was a post that got hung up in moderation, and then a second post. I calculated a spherical equivalent based on your second post. Which are the second set of numbers from the one that was held up in moderation. I had said you were mildly far sighted.

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The last Eye Exam I had Feb 2022 is

R -1.25 Sphere, Cyl -1.50 . 80 Axis - SE: -2.0 D

L -1.00 Sphere, Cyl. -2.00 ,93 Axis - SE: -2.0 D

Prescription

R +1.25 Sphere, -1.50 Cyl. .80 Axis - SE: +0.5 D

L +1.50 Sphere, -2.00 Cyl. .93 Axis - SE: +0.5 D

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You are saying you are intermediate now. That would suggest the first set of numbers are correct, with the SE of -2.0 D. If so your reading vision should be pretty good, but your distance vision not so great?

Currently my distance vision is adequate. I can read signs when driving as most are large. A small street sign could be more difficult. Near vision is good on the computer and cell phone but difficult under l0 inches. I did get an eye test yesterday and are now saying my vision is intermediate in both eyes? Thanks again! BTW, des the magnification indicate that I would need intermediate lenses? The second set of numbers I sent should mirror the first set that was moderated.

Regarding the statement that the Eyhance comes "at a premium price", one should be aware that what may be true in Canada is not necessarily true elsewhere. At least in the United States, because the Eyhance doesn't qualify as an EDOF IOL Medicare and most (all major?) health insurance plans won't pay/reimburse more than the cost of a 'pure' monofocal IOL. The result is that, here in the U.S., surgeons may not charge patients more for implanting an Eyhance than a Tecnis1, Clareon, etc. (Nor, if we choose premium-priced IOLs, do we get a credit against the cost of premium IOLs for what Medicare or our insurer would have covered for monofocals.)

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Indeed, when the Eyhance first was introduced to the U.S. market a number of ophthalmologists posting to each other at the EyeConnect International discussion forum voiced a possible reluctance to use the Eyhance because they could not pass on to their patients the couple of hundred dollars more that Johnson and Johnson wanted for the Eyhance as compared to a conventional monofocal IOL. The Eyhance's market penetration suggests either that ophthalmologists using this IOL decided to absorb the additional cost or that Johnson and Johnson decided to make the Eyhance more price competitive. In all events, whatever benefits the Eyhance may provide are made available at a non-premium price.