Multifocal vs Monofocal Near vs Far Laser vs Conventional

thanks for your help Keith.  I live in Miami Florida.  I am also a terrible eye surgery patient.  I cannot even tolerate someone putting dropsin my eye I am so squeamish about anything touching my eye.  My doctor told me she could not even get a pressure reading because she was unable to touch my eye with the pressure reading machine.   She told me that she wanted to totally anethesize my eye so that, I will be awake, but my eye will be "blinded" for about 3 hours. OMG!!  That kind of freaks me out a little bit as I am waiting (hoping) for that anesthesia to wear off so I can see again.  I wonder if general anesthesia would be better than injecting anesthesia that temporarily blinds me.  

Hi Again

Well at least I have met another soul like myself. When the Dr first mentioned the general I was very surprised but in truth it was by far the best option for me. Not being ever in a hospital since I was 13 I was really worried and uncomfortable with the thought. However the staff were just great and as mentioned it wasn't such an ordeal at all. The afterwards stuff was fine. Since I've learned from various sources that the offset vision and dizziness that I mentioned are normal I feel good about that. I would say that if you have that option go for it. I did and would certianly do it again if I needed to.

Good luck

actually I wasn't given the option of general.  what is offset vision?  how long did the dizziness last? thanks

Well as mentioned, it was the specialist who suggested that he do general because of my younger age (being 58) and the need to remain very still during the procedure. I don't know if my use of the term offset vision is actually what I'm experiencing. It just seems when I go outdoors I get the sensation that you might expect as if you had just had a bang on the head. Not quite double vision but not that far from it. Kind of makes you feel a little dizzy as well. It's really quite hard to describe this. However I have read that it's a normal reaction and as my op was only just 9 days ago, it's really still early days. I have read that it will go with time. I'm not unduly worried now having read what I did. Hope this helps

wow, thanks for yoru comment.  So many choices.  So confusing.  So I asked my doctor today about tri focals and he and his staff looked at me like I had 2 heads.  Apparently they don't do tri focals here yet.  And I live in Miami Florida.  You would think they would have the latest of everything. I explained that, according to what I researched, tri focals are a distinct improvement over bi focal multi focal IOL's in that they correct for near, distance AND intermediate.  Anyway I met this doctor for the first time today.  My 3rd opinion I guess u could say.  So, as I understand it, multi focals are not perfect in that, as you mentioned the halos and starbursts around bright lights.  But that doesn't worry me so much.  What I am more concerned about is the loss of contrast and the problem with low light conditions.  From what I have researched, multi focal lenses, by their very nature, split the light coming into the eye into different segments so, whatever focal length you are looking at, you don't get 100% of the light that people with normal eyes see.  You get anywhere from 75% to 85%.  I think enough to be noticeable.  So I was concerned that everything would seem slightly dimmer to me, if I had multi focal, than it would to everyone else.   Of course under bright light conditions, it wouldn't matter because plenty of light to go around, but in dim light conditions??? Have you noticed a loss of contract and/or focus in dim light conditions, whether at night outside or inside in a dimly lit room?   The trade off is of course being able to see tiny letters very close up.  That is very cool.  

So now they are telling me I should try accomodating lenses.  Theoretically they are supposed to move with the muscles of your eyes to allow you to see distance and intermediate by changing the focus of your eyes naturally,  I am told in practice it may not work as well as on paper but this doctor said, still better than just monofocal which you know you are going to get distance only.  

I thought that, with glasses, I wanted the best vision possible and that if I got multifocus, I would never have that since you cannot correct for contrast, even with glasses.  Anyway the big question is are you happy with your choice?  I know you expected perfection and didn't get it, but considering the alternatives, monovision (one eye near and one eye far), mono focal (one focal length of your choice only and the other two you will need glasses) or accomodating (distance and maybe intermediate - or maybe not- and glasses for close up BUT you get 100% of the light all the time so excellent contrast in all lighting conditions and only a very small chance of seeing halos or starbursts), are you happy with the ones you have or do you sometimes wonder if it would have been better with one of the other althernatives?  In other words, if you could start all over and do it all again, what would you have chosen?

Last question. Did you get laser or conventional knife and did you need to correct for any astigmatism.  

thanks.

re: "And I live in Miami Florida.  You would think they would have the latest of everything."

Unfortuantely the problem is that the FDA is overly cautious about approving new technology and keeps us a number of years behind what is available in the rest of the world in some areas such as IOLs (even ones that are made by American companies which are often the innovators, but sometimes don't even try for US approval).

None of the trifocals have been approved yet by the FDA. Trifocals have been available for a few years in Europe (there are  3 main models out  now, the AT Lisa Tri, the Finevision and the recently approved Alcon Panoptix, and I think another minor brand or two like the RevIOL might still be in the trial stage, or recently approved).  The trifocals tend to provide lower risk of halos&glare than the older high add bifocals, but I'm not sure how they compare to the new low add bifocals that were approved this year by the FDA which also tend to have lower risk of night vision issues. (the lowest add Tecnis bifocal has a study suggesting there are fewer night driving issues with that lens than with a monofocal).

I was diagnosed with a problem cataract in one eye at the atypically young age of 49 and figured since I'd be living with the lens for hopefully another few decades that I wished to get the best choice possible, and was frustrated to discover the situation. Since one eye remained good, I postponed surgery for 2.5 years   in hopes something better would be approved, but finally gave up and travelled to Europe last December for my cataract surgery to get the latest lens. I was more concerned with intermediate distance than with near vision since as a software developer (/entrepreneur) I spend lots of time on a computer.

Although I almost went with a trifocal, I instead went with the new Symfony lens (also not yet approved by the FDA, but it is in trials here now so it might be in a year or two) which provides better intermediate vision than the trifocals (one study from a few months ago says it has the best visual acuity from 46 cms outwards of the IOLs they tested) but not quite as good very near vision, but with also a lower risk of halos&glare issues (comparable to a monofocal) and less lost of contrast sensitivity (again comparable to a monofocal).   

The right lens to go with depends on your visual needs, and whether you wish to risk things like halos&glare.  The vast majority of people have good results with multifocal lenses, and even the minority that see halos usually don't consider them a problem. It is a minuscule fraction that ever get a lens exchange due to issues with multifocals, but unfortunately of course on the net its often those with problems that post to the net so you can get a skewed perspective of how many people have problems. Unfortuantely of course anyone can wind up being the "statistic" that has a problem so it is something to factor in.

The newer low add bifocals as I mentioned tend to have lower risk of halo&glare issues than the older high add bifocals, especially the Tecnis lenses which seem to have some advantages over the Alcon lenses (which seem to merely be marketed better so many doctors use them). 

There are some doctors that mix&match different add multifocals for each eye to try to give them good computer distance vision in one eye and better near vision in the other for reading. 

The Crystalens is the only accommodating lens available in the US, and has a good chance of giving better intermediate vision than a high add bifocal, but I'm not sure how it compares to the recently released low add multifocals. The reason I didn't consider it is because in some fraction of patients the lens doesn't seem to accommodate at all and is merely the same as a monofocal  (the guesses vary, I think I'd seen one surgeon recently talk about 10% or 15% perhaps). Older versions of the lens also seemed to have more of a risk of complications like z-syndrome, which the newest lens may be less prone to but I hadn't seen good statistics on that. Even among those where it does accommodate, how much near you get varies, I think I'd seen figures suggesting that perhaps half of the people need reading glasses. (though that can be made up for by using some degree of monovision).  I decided the trifocals, and the Symfony, were a better bet for decend near in addition to decent intermediate. (I have 20/25 near vision at my best distance, and have no trouble reading my smartphone or even the fine print on eye drop bottles). 

If I had to do the surgery in the US today, I'd likely have gone for the low add Tecnis bifocal out of the limited choices available here.  However the other option with the Crystalens is that if it doesn't provide enough near vision, there are now corneal inlays that may be able to provide more near. They are intended for people with presbyopia to give them better near vision, but they have been tested for people with monofocal IOLs as well, though I haven't seen a study of them being used with the Crystalens to see how well they do. The Kamra inlay was approved by the FDA this year, though I think the Raindrop (approved elsewhere, but in trials here so it may be approved) may be a better bet since it seems to reduce contrast sensitivity less. I don't know if the inlays could be combined with a multifocal lens (or the Symfony), it just seems likely they'd be an option with the Crystalens since it is a single focus lens like a monofocal, and merely is able to perhaps accommodate a bit to change focus. 

I don't know if your vision is too degraded by cataracts to do a contact lens trial, otherwise you might try multifocal contacts and perhaps monovision with single focus contacts. The optical quality won't be as high as a multifocal IOL (e.g. I suspect they reduce contrast sensitivity, low light vision, more) and the optics aren't quite the same, so even if you don't like them you might still like a multifocal IOL, but if you do like them that might give you a clue. I liked the multifocal contacts I  had (which I fortunately was wearing even before my cataract) so I wasn't concerned about risking a multifocal, or the Symfony. I have noticeably better low light vision with the Symfony than I did with multifocal contacts.

re: "Did you get laser or conventional knife and did you need to correct for any astigmatism. "

Unfortunately the issue of whether laser cataract surgery offers any real advantage is still a research topic. Studies so far  show for the most part the results are comparable visually, and the risk of complications is comparable but merely with different complications. Some surgeons like to get a feel for the fragility of the capsule when they cut into it to give them some clue how cautioius to be so they prefer manual surgery, but as I said the overall statisttics show them as being comparable.  They are always improving the technology though so its possible at some point it will have a proven advantage.

My surgeon could have performed laser cataract surgery, but he didn't see any advantage to doing so in my case.  His impression was that the laser was better than an inexperienced surgeon, but he had done 40,000+ manual surgeries so that wasn't an issue so I decided to trust his experience. (studies do show that practice makes a difference, on average more experienced surgeons have better results, but of course there is some variation in skill as well).  I'll note that even experienced surgeons have a learning curve with a laser, so if you go that route it is best to be sure they have done at least 100-150 or so with the laser. 

There  are some individual cases where some factor leads there to be a demonstrated advantage with laser cataract surgery, like a very ripe/mature cataract (which is rare unless you have a very rapidly developing cataract, since most people get surgery well before their cataract is that mature). If you research the topic you'll see mostly optimism about the future of laser cataract surgery, but disagreement among surgeons because the evidence doesn't yet show a benefit.

In terms of astigmatism, it depends on how much you have whether its best corrected with an incision or with a toric lens, and surgeons do disagree over where the dividing line is to switch to a lens. Since the astigmatism is due to the shape of the cornea, to me it makes sense to correct it on the cornea if possibel with an incision. However the incisions can be less predictable so there is a tradeoff.  Then again some surgeons like using laser incisions even for a fairly high degrees of astigmatism since they are having luck with that (though no studies on the issue that I have seen indicate which way is best). In my case I only had a minor bit of astigmatism so I didn't bother with a toric lens. 

In terms of your concern earlier on this page about anesthesia, they very rarely go with general anesthesia for a surgery like this. They just gave me a mild sedative and a local anesthetic. I felt no pain at all, just a minor annoyance when they rinsed the eye occasionally which wasn't painful. It was far less of an ordeal than even a minor dental filling in my experience. They are used to whatever normal movements someone might accidentally make so that isn't an issue. I admit that in my case since I traveled beforehand I was also out of it from being jet lagged and sleep deprived so perhaps I was able to zone out easier and relax. 

 

You "beat yourself up" orioginally because you had "strange" vision in arftificial light?  Do you have a better description of what you mean by "strange"?  If you didn't need cateracts removed, why didn't you just do LASIK? But I guess u had reasons for making your choice.  

I am glad you are happy with your vision now. I would love to get multifocus but I heard that you see significant halos and starbursts. I don't think that would bother me all that much.  What concerns me is that I read that distance is fairly good but not great, intermediate is not very good at all and near is excellent.  More important I understand that multifocals split the light coming into your eye so you only getr 75% of the ligtht that everyone else sees.  I would love to know if you notice this.  It seems to me that everything would always seem a little dim compared to what everyone else is seeing.  That's why the night vision is not so great, from what I hear on multi focals.  Still good enough not to wear glasses which is great.

I don't really mind wearing glasses and want the best vision possible at all distances, even if that is with glasses.  I wont get that with multifocals because you cannot correct for contrast.  

So I am considering accomodating lenses.  One doctor wants to totally paralyze my eye because she is afraid i might move during surgery since I am so squeamish about anything touching my eye.  She say I won't be able see for a few hours.  That's not what everyone else gets and that really freaks me out.  Considering using a different doctor for that reason alone.  

As for laser vs scalpel. actually I was told that the scapel makes a smoother incision, but the laser is more precise.  Maybe you heal faster.  Did you?  Or no difference at all? Was there any pain during surgery, after surgery?  Did you see anything during surgery?  

The amount of choices is dizzying.   I would put the whole thing off but they tell me that the longer you wait, the harder and more brittle it might become which could cause problems during surgery.  One doctor told me to wait and 3 others told me to do it now. every doctore has a different opinion.   unbelivable.  thanks for you help.  I really appreciate it. 

re: "She say I won't be able see for a few hours.  That's not what everyone else gets and that really freaks me out. "

That shouldn't be a problem since you can see with your other eye. As far as I know, standard practice these days is to put an eye patch over the eye after the operation and remove it the next day, which is what they did with my surgery. You will be sedated from the surgery so you shouldn't be driving yourself after the surgery so seeing through only one eye shouldn't be a big deal for the rest of the day. I have heard of some people who didn't need to keep an eye patch on overnight, but I don't think that is typical. 

I haven't heard of a surgeon paralyzing an eye during the surgery  because the patient is squeamish, but it makes sense. If they do it, it  shouldn't be a big deal since as I said most people don't use that eye the rest of the day anyway.

As I mentioned above, this year the FDA approved  new low add bifocals from Tecnis and Restor which give better intermediate vision than the high add bifocals of the past, with the tradefoff being near vision isn't quite as good as with a high add bifocal.  Some doctors chose to mix and match different adds in each eye to try to give you a mix of intermediate and near vision, depending on your needs. 

I had multifocal contact lenses and although they split the light also (likely less efficiently as an IOL) and reduce low light vision, I never found that to be a problem.  Each person's reaction will vary however, which is why doctors really should have people try multifocal contacts, and monovision contacts, before they get a problematic cataract which makes such testing more difficult.

re: "If you didn't need cateracts removed, why didn't you just do LASIK? "

Since I'm responding to something else in your post, I'll note that standard some  people who are presbyopic these days (moreso outside the US) choose to get clear lens replacement surgery (i.e. the same surgery as for a cataract, without the cataract) in hopes of getting better near&intermediate vision with a premium IOL. 

Standard LASIK only corrects the distance focal point, it doesn't correct for presbyopia. There are some methods to use LASIK to create a multifocal pattern on the cornea, but many people think replacing the lens is a better option. It is easier to exchange a lens if it doesn't work well than it is to deal with a multifocal pattern lasered onto your cornea if you decide you don't like it. There are   also corneal inlays as I mentioned above that some consider a better option to correct for presbyopia, rather than replacing the natural lens. The advantages of replacing the natural lens is that you'll never need to get cataract surgery, and  that even in people without cataracts, the natural lens of someone in past their 40s has still usually deteriorated with age and isn't as transparent as a young natural lens, or an IOL. 

You know I would LOVE to get multi focal, but I have heard so many bad things.  The main things being that it splits the light (does that mean that to a person with multi focal lenses, you are seeing the environment that a person with normal vision slightly dimmer?  Probably wouldn't notice it because you cannot put yourself into that "other" person to see what they are seeing to compare but that thought woudl bother me.  Also bad contrast and night vision.  What I want is the best vision possible at all distances WITH glasses, and I am told that, with multi focals, you will never see as good WITH glasses, as you would with the monofocals WITH glasses since you cannot correct for lack of contrast.  If I get multi focals and see OK at all distances I would rather wear glasses and see perfect at all distances.  Have you heard anything about the accomodating IOL's which are supposed to give you both distance and intermediate?  I have been near sighted all my life and cannot imagine not being able to see anything close like my cell phone.  I would get mono focal for near or intermediate except that no one does that as I understand and everyone gets distance.,  I wonder why. 

What I meant by not being able to see is that the thought of having my eye open and not being able to see is a little scary. It's like I hope the anestheia wears off.  Well it always does when u see the dentist.  

I did not/could not have laser surgery as it is apparently noit appropriate when you are over 50 (I am in my 60s). I had a few years ago gone for a consultation but was told that they would only be able to 'take my eyes back about 5 years' and that my eyes would continue to age as most people's eyes normally do.

Regarding receiving less light, my eyes are very light-sensitive and I have to wear sunglasses more frequently than most people - even when driving on a winter's day. So I am not aware at all of less light getting in, or being split up by the lens.

I have just looked out of my window and can see the tiles on a fairly distant neighbouring roof, the leaves on the trees, and individual bricks of the house across the road. Not too bad, I think.

It is now about 18 months since my eyes were done. In the months afterwards I made notes on how things felt/looked with my new lenses, which were on the whole not at all what I had hoped for - blurry, inconsistent vision, poor low-light vision, starbursts and haloes - I summarised it by saying that my vision felt as though I had someone else's glasses on and things just didn't look 'right.'

It's been interesting going back over this diary as  I now realise how much better things are now. I guess I have got used to it, or things really have improved albeit very slowly, but I am now OK with it all. The only thing that disturbs me are the haloes and starbursts at night, and when driving I choose the route that would have the least traffic. 

You are at a very difficult point in your life, having to choose between so many types of len, and so many doctors' recommendations - all very alarming and distressing. 

With regard to the actual procedure - the worst part was the time leading up to the event, but when it happened it was entirely painless and easy. And no, you don't see a knofe coming towards you - you are barely aware of anything coming towards you - only the surgeons head! Of course your eye will be anaesthetised - you wouldn't want to feel anything, would you? But it will be covered over till the next day with padding and an eye shield, by which time it will have recovered. There was really hardly anything to it when it was actually happening, and many many people say the same thing.

I do wish you well with your decision, and look forward to hearing about it.