Monofocal vs Multifocal - cataract surgery - ACK

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Hello all.  I just found this board and it seems to be a wealth of information.

I am 45 years old and have never worn corrective lenses.

I was recently diagnosed with a rather large cataract in my left eye.  When seeing with two eyes, I see fairly well.  But the one eye is very cloudy and hazy.  My eyes get fatigued quite easily.  I work at a computer screen for my job.

I had a consultation today and the doctor recommended a multifocal lens.  I also have a slight astigmatism so he would do laser cataract surgery and correct that.  He explained the risks with the multifocal - mainly the halos and poor night vision.  I also understand it is $2500+ more.

I think the reason he recommended the multifocal is that I really would prefer not to wear glasses.  I never have - and would prefer not to start now.  He did say that I may need some sort of reading glasses in 5-10 years.

But I'm confused.  Sounds like the monofocal lens would be better - but then I would need glasses.

One more thing.  Doc was surprised that I was doing 'as well as I'm doing with my vision.'  I guess my right eye is compensating - so I don't have too many issues at night and this is tolerable.

Any thoughts or ideas?  Obviously I want to do what is best for the long haul.  

Thank you in advance!

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11 Replies

  • Posted

    I just had surgery a week ago. The doctor implanted the wrong lens and its a night mare. Anyway ,Ive been doing a lot of research. Apparently multi focal lenses are about 3,000 dollars extra. Since its higher technology it seems more people have after efects or problems later. Monofocal are less troublesome. In my case on the other hand this doctor put standard distance lens in my right eye 10 yrs ago. Except for close vision its pretty good. The mistake he made was putting a high powered reading lens in my left eye. I wanted the same as right eye but oh well. It is my dominate eye and other than fine print everything is a distorted blurr. Also it wants to over power my resessive eye. I have to cover it to do anything, especially drive. Ive read that most people with distance monofocals have good vision from far to even looking at computer screen. I think its the best decision. Just dont let them do what my doctor did. You may still need readers. If later you want to read you can put a closer range lens in other eye. Just dont make it too strong cause you lose depth perseption and make sure its not your dominate eye. Oh and these are just my suggestions based on personal experience and research. It never hurts to surf for info. Good luck
  • Posted

    Hi, keep searching the forum to get some input re: Mono verses Multi.

    I paid for Multifocal, neither eye worked after 6 months,I demanded my money back & got it. I can see distance only. The capsule in my right eye was punctured, having vision problems. Fuzzy, cloud goes across my vision making everything blurry. Have a dark curtain that comes down from the top that I can see. Very annoying. He wanted to do surgery again. I said "No" I'm seeing another specialist next month to see what he thinks. As long as it doesn't get worse, I can live with it.

    But, I think the outcome is only as good as the surgeon. Just arm yourself with knowledge then make the decision based on what you learned. If I had done that, I would have gotten the Monofocal, because I ended up with glasses anyway. Also what you can live with if outcome isn't what you expected. You have to be prepared for it. If you know your surgeon & trust him, that would be a help. Remember, bad things don't always happen.

    Good luck in your search and your decision.

    Good luck to you & keep searching.

  • Posted

    Michelle,  Run monovision by your doc and get his opinion . This procedure is done with monofocal lenses only one eye is set to close vision while the other is set to mid, and distance. Unlike multi-focal, you get crisper visionbecause the light isn't broken down to the three different focal planes you find in a multi-focal. This is why people have a hard time seeing well in dim light situations. Monovision takes a bit of getting used to in the begining because it's a whole new operating system for the brain and eyes, but in time it's quite amazing  Check with your doctor and see if you are a candidate for monovision,  the best of both worlds. I had mine done about 6 weeks.

  • Posted

    I was in your position not too long ago. I am 35 and have perfectly good Left eye....I see 20/15, but my Right eye for some reason had developed pretty big cataract. No one was able to tell me why I had it in one eye and such young age. I went to 3 different surgeons, 2 of whom are world renowned. Everyone said its either due to trauma (dont remember any), steroid use (Not a user here), diabetes (dont have that either). So I pretty much gave up on figuring out what caused it and move forward and decide what to do next and which lens to get.

    Choice was between Monofocal, Multifocal and Toric. No one recommended Toric as my antistigmatism is bad but still not so bad that it couldnt be treated with laser incisions.

    My dad got monofocal in both his eyes and coundnt be happier but he wears glasses for was ok for me but I didnt want to do that.

    I decided on multifocal and am VERY satisified. Its been 3 months since my surgery and glare, halos, shadow image have all gotten better but they are not gone. I am sure in few more months I will get use to them and wont notice them anymore or they will go...either way I am fine.

    My surgeon said that multifocal lens in young person is tricky because we are so much more aware and its harder to make us happy...which I totally agree because even though my Right eye is good after the surgery (20/20), I keep comparing it to my Left non-cataract eye and it falls short. Its not as sharp and not as great in darker environment as it is in more bright environment.

    Multifocal definitely work better when you have it in both eyes as they adapt better and you dont compare multifocal to natural lens, but that was not an option for me since I only needed one eye done.

    You cant go wrong with either, though I have not heard many good things about monovision as someone else suggested and none of these amazing surgeons even gave me that as a choice.

    I didnt have much problem either to begin with as my Left eye became dominant and I was seeing everything perfect (20/20). Its only when I would shut my Left eye, I was pretty blind...thats when I realized I needed to get it done.

    All I will say is that make sure you pick a surgeon who knows what they are doing and take perfect measurements. It all comes down to surgeons skills and how accurate measurements are.

    Only advice I will give you, which is hard and i dont follow it myself, is that after the surgery...give it time atleast 3-4-6 months and dont try to compare it to your natural lens. It will always fail.

    Hope this helps. Let me know if you have any particular questions.

  • Posted

    re: "may need some sort of reading glasses in 5-10 years"

    People start needing reading glasses  in their mid to late 40s since they become presbyopic, the  eye gradually loses the ability to accommodate, to change focus to near, over time.  If you hadn't had a cataract, you'd need reading correction within the next few years (many do by your age already). A monofocal IOL can't change focus at all for near, so if you had a monofocal set for distance in the left eye, and retained your natural lens in the other eye, then you would definitely still need reading glasses within a few years. 

    A multifocal IOL will provide better near vision in that eye, so there is some possibility you could do without reading glasses even when your other eye loses its near vision. Since that would only give you good near vision in one eye, its  possible that you'd be more comfortable wearing glasses when doing extended reading to give both eyes good near vision, but at least it would let you do many tasks without readers. Its also possible that your other eye will develop a cataract as well within a few years and need surgery and you could also get a premium IOL for that eye to able to do without readers. 

    The vast majority of people with multifocal IOL are happy with the results, and a large majority never need reading glasses.  Most people who are happy with the results of surgery never post, it is usually only the tiny minority with problems that post and so its easy to get a distorted view of the risks. A minuscule fraction of people are bothered enough by halos or other issues to get a lens exchange to a monofocal lens, so it is important to be aware of that possibility since someone winds up being the "statistic" with bad luck to need an exchange. However people who are comparatively young for cataract surgery may be living with the results for a few decades, so the issue is whether the possibility of doing without glasses all that time is worth a tiny risk of the need for a lens exchange.  

    Of course some folks wind up in between, not entirely happy but not unhappy enough to get a lens exchange.  The newest low add multifocals have a lower risk of problematic halos than older ones. The study for the Tecnis +2.75D lens showed that fewer people had trouble with night driving with that lens than they did with a monofocal (since although the monofocal had lower risk of halos, the multifocal let them see the dashboard, navigation, and other things easier).

    There is also the Crystalens, which is an accommodating lens (though some dispute that is how it works) which in theory can change focus a little bit and may provide better near than a monofocal, with a risk of halos  closer to a monofocal. Unfortunately a higher percentage of people need readers with it than with a multifocal (I haven't seen a good figure offhand, but I've seen some docs guessing that perhaps half need readers), and small percentage don't see the lens accommodate at all (I've seen guesses at perhaps 10-15%) so it winds up being no better than a  monofocal. There is some slight added risk of other complications compared to other lenses due to its ability to move in the eye (e.g. z-syndrome, which might be low risk in the newest generation of Crystalens). It may provide better intermediate than a high add bifocal IOL.


    It also possible to try to avoid reading glasses by using monovision with monofocal IOLs, having one eye set to focus at distance well, and having an IOL in your other eye set to leave you nearsighted, focusing better closer in to be able to do some reading.  Your brain will choose  the best image to use for each distance. Since the brain is relying on only one eye, some people reading for a long time (or driving) will prefer to wear glasses to correct both eyes for near or far rather than relying just on 1.  Others function well at all distances with monovision without ever bothering with glasses.   Usually they use your non-dominant eye for the near eye, but studies suggest it doesn't matter that much, so you could consider having your first eye set for near vision to reduce  the need for reading glassses in a few years, and then when your other eye needs surgery it can have an IOL set for distance.

    One drawback with monovision is that it reduces stereopsis a bit, you sense of 3D vision and near depth perception, since your brain is relying more on just one eye. Most people adapt to that fine and don't notice it.

    In my case I'd always worn contacts before I had a cataract appear at age 49, but I'd started to need reading glasses several years before that and so I had instead used  contact lenses set for monovision. I liked that,  and didn't really notice the loss of stereopsis. However I then got multifocal contacts, and noticed the near world seemed more subtly 3D than it had with monovision and I preferred that. If I'd never experienced both options, I suspect I'd have been happy with monovision since I wouldn't have known the difference. I did notice that low light vision was reduced with multifocal contacts, but I was happy with them so my first thought when I had a cataract was to get a multifocal.

    I discovered though that at the time the bifocal IOLs available in the US had a high reading add, they  tended to be best for far and close near, and not as good for intermediate distance (like for computers and social distance).  Outside the US they have trifocals that provide better vision for all 3 ranges. I figured I'd be living with the results for perhaps a few decades so I wanted the best option possible, and 1 eye remained 20/20, so I tried to wait for the US to approve a better lens before getting surgery (since I only had a bad cataract in 1 eye, the other remained 20/20 correctible).

    When the bad eye was causing too much trouble, I  decided to travel outside the US to get a better lens. In the meantime a new  type of lens had come out, the Symfony which also wasn't approved in the US (though it might be approved by the FDA within the next 6 months I've heard, though I don't know how accurate predictions of the FDA are). It  isn't a multifocal or a monofocal or an accommodating lens. It is a new category of lens, an extended depth of focus lens which has a low risk of halos comparable to a monofocal, but provides better intermediate&near vision than a monofocal and fairly comparable contrast sensitivity to a monofocal (I definitely see better in dim light with the Symfony than I did with multifocal contacts, though perhaps not as well as with monovision contacts before my cataract). One study suggests it has the best vision of all the premium lenses from 46 centimeters outwards (it may just not provide as really good close near vision as some bifocals or trifocals). So I went to Europe 1.5 years ago  and got the Symfony in both eyes (almost 20/15 at distance, and 20/25 at near). The Symfony is available now closer by in Canada&Mexico, though it wasn't at the time.

     The US now has low add bifocals that do a better job of intermediate vision while still providing some near, which is likely what they are recommending for you. They also have a lower risk of halos than high add multifocals, and more people tend to be happy with the results. 

    • Posted

      I have been wearing glasses since I was five - and many decades later am contemplating cataract surgery. As I understand it, a new lens offers a permanent solution to the cataract problem and a Symfony lens should also help with my extreme myopia and to some extent with astigmatism. If, after the surgery, my sight continues to deteriorate, am I right in assuming that the new lenses will take care of the myopia, but I will probably need glasses for changes to my astigmatism?
    • Posted

      Ideally the Symfony can correct myopia entirely, though unfortunately the choice of lens power isn't done using an exact formula. It is based on statistics regarding eye measurements based on how past patients have done, and although the results are fairly accurate for most patients, there is more of  risk the power will be off for those who are highly myopic. There has been progress with improving their calculations, they get better all the time, but there is some risk it could be off a bit. If it is, some people opt for a laser tweak to perfect it, since small laser corrections are more accurate and less prone to side effects than the larger corrections most people get who go for lasik due to having a high prescription. 

      There are toric lenses that deal with astigmatism, or for minor levels they sometimes perform an incision during surgery (often an LRI, limbal relaxin incision) which is calculated to cause the eye to reshape itself to reduce astigmatism. 

      You seem aware that astigmatism does tend to change with age, though the changes usually tend to be minor and low levels of astigmatism tend to not be too noticeable so it may take a long time, if ever, before you feel a need for it to be corrected.  

      The sort of incision surgeons do during cataract surgery to correct astigmatism can also be done later on its own to correct any astigmatism that arises later. Some surgeons will do the incision at the slit lamp in their office since its just a surface level of incision so it doesn't require the same overhead as cataract surgery where they actually need to work inside the eye. Alternatively some surgeons will do the incision via laser.

      Surgeons can take the likely future change into account when they plan cataract surgery  if they are asked, its more of an issue for atypically young patients who have more expected time later for astigmatism to arise. The astigmatic shift usually goes in a predictable direction so they may leave you with a slight bit of astigmatism in the opposite direction which isn't visually significant. Then when you age, the change in the opposite direction will take longer to be noticed, since at first it'll just reduce the minimal astigmatism you were left with.


    • Posted

      Many thanks for your reply. I shall be seeing the surgeon next week and will discuss the consequences should there be problems. My myopia is -12.50 (right) and -11.00 (left) - severe, but it could be worse.  My astigmatism has not altered that much over the last few years and is currently -6 (right) and -4 (left). If I can get to a stage where all I need is reading glasses, I shall be very pleased. If I go ahead with surgery and if it is useful to others I would be happy to record the results on this site.
    • Posted

      Its likely you are in the range where there is more of a risk the lens power could be off, though it can be fixed later with a laser tweak if needed. That level of astigmatism is rather high, but a quick check on their website shows they do have toric versions of the Symfony that go that high. A toric lens has to be oriented correctly, if it rotates after surgery (before it has healed firmly into place)  that can impact both the astigmatism and the spherical correction, though they can rotate it back into place. The higher the cylinder correction the greater impact even a small rotation will have. I didn't have much astigmatism so I didn't need a toric lens and  hadn't researched how accurate the orientation tends to be and how rare rotation issues are.

  • Posted

    I am 49 never wore glasses had a cataract on both eyes, I work on the computer for 10 - 14 hrs a day. I couldn't stand glasses so I opted for multi focal I wasn't told I would need glasses in 5 to 10 years this lens is permanent should not need glasses later. But go into it knowing everything I have 20/20 vision however I have halos and I do have a beveled glass edege effect in the pereffery of my vision, however for me not to need glasses it works for me, and I am only 1 mo post op on my left eye and 2 mo for my right. They say they has to adapt and at times I see it and at times I don't so I am hopeful that will go away. I am happy I don't need glasses so do your due diligence and make your own informed decision. Best of luck.

  • Posted

    Hi all,

    Thx for discussion Michelle. I need to decide within a few days on multifocal or monofocal. I am 47 and have a congenital condition (Posterior Polar Cataract) which effect both eyes. I am most concearned with the night driving as my wife has been drving me around at night for gthe past several years as my sight worsened. Anyone with multifocal having trouble with night driving?


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