My experience of the Symfony Toric lens

re: "Dr. wrote +2.00 to the right"

That does have to do with the progressive lenses, it is the reading addition. The distance part of a progressive lens goes by the rest of the prescription, but the near part is focused +2D closer in. 

The prescription does show you are farsighted in the first eye and nearsighted in the 2nd eye. The first number is the spherical correction, the lens power in one eye. A negative number indicates being nearsighted, and positive is farsighted. Astigmatism means the eye isn't exactly shaped like a sphere, so the lens power is different in different directions.

The  2nd number, the cylinder, tells you how much the power differs from the first power in the other direction. So your first eye needs a power of +2.25D in one direction, but in another direction it needs a power of (+2.25D + -0.75D)= +1.50, which is also far sighted. The average power of the lens then is (+2.25D+1.50D)/2 = +1.875D, which is called its "spherical equivalent".  That also works out to be spherical_equivalent = (sphere_power+ cylinder_power/2). 

In your 2nd eye the main power is -0.5, but the astigmatism shows in the other direction it is (-0.5D+-0.5D) = -1D, for an average power of -0.75D.

In both cases your prescriptions are fairly small (unlike the original poster) and the odds are high that they can accurately determine the right lens power for you to give good results  from the start.

 Residual astigmatism of -0.5D after surgery doesn't tend to have too much impact on the results with the Symfony. One of my eyes after surgery had -0.5D of astigmatism in the initial exams (2 years later they measured  -0.25D of astigmatism and -0.25D of sphere, which might be just measurement error causing the difference sicne they are almost the same). It was close to 20/15 at first, and now its at least 20/15. 

Since the level of astigmatism you have is fairly low, often they correct low levels like that   via the use of incisions during surgery that cause your eye to reshape itself as it heals.  Doctors do vary in what level of astigmatism they correct via toric lens vs. incision. It seems likely, but not definite, that they would use an incision for the -0.5D eye   since the smallest amount of astigmatism the Symfony toric corrects is 0.69D at the corneal plane. Spherical lenses are simpler since they don't need to be rotated in a specific direction, so they are easier to insert and there is no need to worry afterwards about checking to see if they have rotated after surgery and needing to reposition them. In theory they could use a toric lens for the -0.75D astigmatism eye, but thats in the range where most surgeons would usually still use incisions to attempt to correct the astigmatism.  It is much easier to get good results with someone with a prescription like yours than it is for the original poster who had a great deal of astigmatism.

At your age it seems odd a doctor would suggest lasik for the eye that hasn't been operated on, rather than correcting it with an IOL, since eventually you will need cataract surgery and an IOL like the Symfony would also give you more near vision.

Even though the odds are they'd get the IOL power right in your case, there is always a chance, even if small, that the IOL power might be off. In that case a small laser correction might be useful after surgery (though they aren't perfectly accurate, they are likely good enough). Thats an additional reason why it would seem odd to do lasik on your eye with the natural lens, then one day need cataract surgery and get an IOL, and then perhaps need more laser enhancement afterwards. Although small corrections aren't a big deal with modern technology, it still seems best to limit the number of times you get laser correction to limit the risks.

Sorry, just saw this (after having written you a private message)!  Thank you so much - great advice.  

I don't think the Dr. necessarily was sayng that after the IOL in the right eye, if, I wanted correction in the left eye, that he definitely would recommend Lasik, but he did say, that we should leave the left alone initially, and then over time if I wasn't completely happy, and wanted more clarity, I could do something to the left eye, and he did mention Lasik or an IOL.  But, the IOL for the left eye makes more sense to me too, as I would imagine I would get a cataract eventually in the left, plus, doesn't the IOL offer the advantage of the EDOF over Lasik at my age?

The IOL does offer advantages over laser at your age, that was why I was expressing puzzlement of the idea of laser surgery instead. Eventually everyone gets cataracts, though the age does vary quite a bit (mine became a problem at age 49, though the other eye was fine so I waited until 52 for surgery). So they usually figure a presbyopia correcting IOL (Symfony or multifocal or accommodating) is a better option than laser.

There are other methods for treating presbyopia like corneal inlays like the Raindrop or Kamra which go on just one eye (and can be removed if the person doesn't like them), though usually I think they tend to lean towards those more for younger presbyopes. Even people who don't have a cataract still have a natural lens that is showing its age by then in terms of reduced visual quality that an IOL can improve.  They also can use a laser to do a multifocal pattern on the cornea, but again I'd think an IOL seems a better option.

At this stage I still find it hard to detect much difference between the vision in my left and right eye. I have had a sensation of itchiness in my right eye (I am still putting anti-inflammatory drops in the left), but it is not there all the time and rarely bothers me.

Distance and intermediate vision are still excellent and I can now (with some effort) read newsprint at about 16 inches.  The clarity of vision, the colours and the light with the new lenses, when compared with my vision before the cataracts were removed is still a pleasure - even the colour of my car is much lighter than I thought it was. Fortunately I prefer the ‘new’ colour. I wonder how much all this is the absence of the cataracts and how much the lens?

At night there are still starbursts around bright lights (something I was warned about by my surgeon) and unless this changes, or someone develops glasses to remove the effect, it is unlikely I will drive after dark.

I will be seeing the surgeon again next month for a post op check-up.

The odds are decent you'll adapt to the starbursts, but no guarantee. Apparently things like a wrinkle/crease in the capsular bag can cause starburts with any IOL. I think dry eye  after cataract surgery can also lead to starbursts for some, hopefully only temporarily, and that may be part of the itchiness (which lubricating/wetting drops may help)

As I noted on another page, it is amazing what the brain can neuroadapt to that we would never suspect since its hard to imagine. They've done studies with glasses that turn the world upside down, and people eventually adapt and see the world right side up. Search for: neuroadaptation upside down

An aging natural lens, even without a cataract, lets in less blue light than  a young natural lens. So most of the color shift is likely due to replacing the IOL with a lens that lets through more blue light (in fact it lets in some light in the UV spectrum that the natural lens blocked, so some can see slightly into the UV range, not that thats useful). However I don't know if the Symfony's chromatic aberration correction has an impact on this, having light of all colors from the same object  more in focus than the natural lens did. I know colors seemd more vibrant afterwards, but I figured that was mostly having a clearer lens. 

 

Would you please update me on your vision and hallow effects since March 15?  Thank you

About that "blue" light...when I had my first cataract surgery, in April '16, I immediately noticed the difference. My "new" eye (I had a Tecnis toric mono) was bright blue, and whites were blue with that eye--but yellow with the other. I went about 16 months like that, with a yellow old eye and a blue new one. (To amuse myself, I'd often cover one eye, then the other, just to see the difference and appreaciat my new eye )

Then a few days ago I had a Symfony IOL inserted...and when I came home, I immediately noticed that THAT eye was much bluer than the old eye, which by now must have aged enough to develop some yellow tint. Which seems strange...it's something I intend to ask about when I go on Friday for my 1 week check up. There must be something about new IOLs that reflect more light?

 

Your results are very atypical, and likely not what you'd expect in the long term. 

Most people have good vision in the first few days after surgery, but I have seen comments from surgeons that its possible (with any IOL) it could take a week or two for some for the eye to get good vision after  surgery. In my case I had great distance vision when the bandage came off 1 day postop, but for the next couple of days my near vision would go in and out, sometimes requiring strong readers for computer&phone, but then it settled down and it was  20/25 at best near at the 1 week postop (and since then, it was 20/30 at 40cm recently, but they didn't have a 20/25 line and I read some on 20/20, so it may be 20/25 at 40cm also rather than just at best near). Typical newspaper print only takes 20/60 - 20/50 vision or so. However some people take longer to adapt so it could just be taking time to adapt, 1 week isn't that much.

In terms of your poor near sight, the usual explanation is residual refractive error, e.g. being left hyperopic (farsighted), which has nothing to do with the IOL choice. Usually they have a 1 week postop and check things like that, I don't know if you'd had that or if they are waiting a long time for some reason. Unfortunately the formulas they use to determine the IOL power to use based on eye mesaurements aren't exact, they are statistical estimates based on the results of past patients. They are usually fairly accurate for those with low prescriptions, but there is more of a risk the power will be off for high myopes. The lens can move a bit the first couple of months after surgery, which can influence the refraction in either direction, it could get better or worse. After vision stabilizes they can do a laser enhancement to correct the refractive error permanently if you don't wish to wear glasses/contacts.

If you have residual astigmatism, that can also diminish visual quality at all distances but perhaps be more noticeable when trying to read, and a decent minority do have some residual astigmatism with a toric lens. You say you have the same lens, so I'm assuming you meant the Symfony toric to correct astigmatism rather than the standard Symfony. If you didn't have much astigmatism pre-op and this isn't a toric lens, it is still possible to have astigmatism postop since sometimes people have astigmatism on the cornea in one direction, and counterbalancing astigmatism in the natural lens in the other direction which reduces it and when the natural lens is taken out, astigmatism in creases.  Residual astigmatism can be sometimes be corrected via rotating a toric  lens, otherwise via incision or laser.

Most people with the lens don't have problems with halos or glare or starbursts. Usually studies on issues like halos&glare with IOLs are only done after 3 or 6 months postop after most people have had time to recover from surgery and any temporary issues subside. This site moderates links, but if you google this title you'll see discussion of the statistics on the issues:

"High rates of spectacle independence, patient satisfaction seen with Symfony IOL"

In terms of night vision, you can't tell what it will be like at 1 week postop since many people even with monofocals have visual artifacts at night the first few weeks (or months) that go away with further healing and with their brain adapting to tune them out. Things like residual swelling, astigmatism and refractive error migh contribute to initial problems, as might things like initial dry eye (which can happen after catarat surgery, due to nerves being cut and needing to heal, which leave your brain unaware your eyes are as dry as they are).  If the issue is adaptatoin, then using your vision at night  like the walk you took will help your brain adapt.

 

Unfortunately there is no guarantee you'll be able to see read without glasses since everyone's results differ, but most can. It also helps if one eye is set for slightly nearer than the other, micro-monovision, which isn't enough to have much impact on stereopsis (3D perception) or on distance vision. 

In terms of canceling the 2nd surgery, it isn't clear if you have cataracts or not since you say your "vision was not as declined" which might imply mild cataracts or merely decline from aging. If it is cataracts, then eventually of course the cataract in the other eye will get bad enough that it'll need surgery. It may make sense though to postpone it to see how the problems with this eye resolve, and decide if the issue is the lens choice or unrelated to that. They think neuroadaptation happens faster with the same IOL in both eyes, but obviously its best to be sure you want the same lens before the second surgery.

In terms of needing to carry reading glasses with you, they have foldable glasses that'll fit in your pocket. I don't need them so I don't know about durability, but I'd seen them browsing at Barnes&Noble, and out of curiosity checked to see they have a variety on Amazon.  If your near improves to where its   occasional use for fine print, there are phone apps that serve as magnifiers, using the flash for dim light, though again I haven't used them (I just put some  on my phone in case the need ever arose, but haven't needed them and keep forgetting to play with them to decide which is best).

 

Again I don't know if you have residual astigmatism, its just one possibility. Assuming you did have the Symfony toric (since you said the same lens), an article from last year noted that 29% have a level of astigmatism postop with any toric lens (not just the Symfony) that would require adjustment:

"Visser 31 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."Since they moderate links, you can find that by googling:

"IOL Surgery Astigmatism Elimination" "24 March 2016"

 

I very much appreciate your response!  I was not expecting perfect vision from the Symfony, howver I also was not prepared for significant loss in near vision from it either.  Ihave had three (3) post op check-ups with my optometrist [none by the surgeon].  In all visits she only checked my distance vision [determined to be 20/20], measured the pressure [initially @ 30+, then 16, and 19, and used drops looking for any signs of leakage or infection.  I was told my astigmatism now measures +0.25 [pre-op was +1.50].

At this point, and after doing exhaustive research and readings on the results by others, I will likely postpone the 2nd surgery until I am comfortable that the eye with the new lens has fully recovered and my brains ability [nero-adaptation] to use it properly has adjusted.  I do have a cataract in the left eye & realize it will need to be replaced at some time in the near future [currently age 60].  But as you suggested, "It may make sense though to postpone it to see how the problems with this eye resolve, and decide if the issue is the lens choice or unrelated to that."

Some lessons I have learned in the 10 days since the 1st sugery that may be helpful to others are:

* Do your research PRIOR to the surgery so you can develop your own thorough list of questions for your surgeon, and make sure she/he answers them all fully!

* Have your surgeon explain things very slowly, using non-medical terms and accronyms.  Doing research has been slow as most sites tend to be written for doctors, not patients.  I find I need to look up numerous definitions to truly understand the procedure, the risks, the potential complications & the benefits to expect.

* Make sure everyone reviews ALL of the changes you are likely to experience post-op.  I was not prepared by my optometrist or surgeon on what to truly expect in terms of vision quality, adjustment period, brightness, color shift, dry eye/scratchiness, glare/halo's/starburst and this issue of neuroadaptation.

* As for vision quality - it apparently means different things to the doctor thatn it does to the patient.  Be clear on your expectations and make sure the surgeon explains back to you what you want from the implant!

I'll take your advice softwaredev and give my eye more time to adjust.  I've also begun to use preservative free drops every hour and began taking fish oil & flax seed oil to aid the dry eye issue. 

I am trying to maintain a good relationship with my optometrist, who is doing all my post-op check ups.  The first visit was pretty adversarial on my part due to the stress of the surgery & the vision isssues I was experiencing.  I did apologize but then had a long heart-to-heart talk about both her & the surgeon not properly preparing me;.  As a result my expectations from what I was told were far different from what I am experiencing.   I was told the Symfony lenses are the best on the market and would provide me with vision throughout the range - near to far.  I was told these lenses are so clear that they have virtually no halo/glare issues.  I was not told that I would potentially have near sight issues -  only that I may occassionally need magnifiers in very low light situations.  I was never told that the brightness level of the eye would increase ~15% or more by removing the cataract.  I was never told there would be a significant color shift to the blue/magenta spectrum [as a photogrpaher white balance is key]. I was never told that it could take weeks or even months for the eye & brain to fully adjust.  Knowing this now would have better prepared me.

Having been in for 3 post-op visits, I am concerned that I have never been given a near vision chart to look at and never been tested for the halo/glare low light issues I'm having.  Is this normal and due to only having the surgery 10 days ago?

Thank you again for your wonderful support.  I will do a search on that text string to educate myself even more!

I think my surgeon uses a tool developed by an Australian ophthalmologist to help with some of the lens calculations. He inputs the results into the manufacturers Symphony calculator to arrive at the final outcome. He believes this method gives more accurate results. I’m afraid I don’t have any details beyond this, but wondered if you had come across any research about the Symfony calculation process. Many thanks.

re: "only checked my distance vision [determined to be 20/20]"

Unfortunately that isn't very useful, what is more useful is for them to determine your actual spherical prescription (you mention the astigmatism). The Symfony studies suggest that from its best focal point inwards there is a range of 1.5 diopters where vision will be at least 20/20 (on average). That means its possible to be left +1.5D farsighted and still have 20/20 distance vision.. which would leave   even less near than a monofocal on target at 0D. Its likely you aren't that far off, the point is merely that it doesn't indicate anything useful about whether refractive error might be why your near is poor. Being even a little bit farsighted would tend to reduce your near vision compared to where it could be, and that can be corrected via laser tweak (if you don't wish to wear correction).  The risk of being left hyperopic isn't any different with other lenses, you lose near if you are.

In terms of checking near vision, there are near vision charts on the net you can print out. Mine was tested starting day 1 postop and every time since, along with getting a refraction. Oddly since mine has been decent I hadn't hunted for the best one (partly since I don't have a working printer, don't tend to need one). That won't indicate what the problem is of course.  

The color shift of course is likely more accurate colors since you are getting more blue light than you were since it was blocked by your cataract and aging lens compared to the level of blue light a young natural lens lets in.  You may be able to see  a little into the UV spectrum (not that its useful) since the natural lens blocks some of the UV spectrum that our eyes still seem sensitive to.

I noticed the change in brightness for quite a while, but it was only the first week or two that it was bothersome.  In some ways its a useful reminder to wear sunglasses, which are still needed to protect the retina. 

In terms of searching on the text string, I think I gave a couple to look at between  the 2 posts. (you mentioned "text string" singular, just didn't know if you'd missed noticing one since I think both might be of use).

 

The Australian ophthalmologist is probably Dr. Graham Barrett. The formulas they use to attempt to determine lens power aren't unique to any particular IOL model, other than that there may be a constant or two that differs with each lens. Unfortunately   the lens power formulas aren't exact formulas like with a physical law, but are  based on statistical analysis of how the eye measurements of prior patients compared to their results, what IOL power would have worked.   There are a number of people who have come up with different formulas  based on different data sets and based on different types of statistical analysis of the data.

Often they use an instrument like the IOLMaster which takes measurements and then plugs them into a few different formulas,  and outputs the results, and surgeons see how the results  of the different formulas compare. Ideally the formulas agree, otherwise there tends to be some sense of which formulas work best for certain sorts of eyes (e.g. high myopes vs. high hyperopes, etc). It is an ongoing area of study since the problem isn't yet solved.

 I know in the last year or two there has been some progress on things like creating computer software   that know which formula tends to work best for different situations rather than relying on the physician to be up to date on figuring that out, and work on using neural network or other artificial intelligence or  optimization approaches to try to learn from the data to figure out what eye measurements should lead to what power recommendation.

It has been 5 weeks since the surgery on my right eye, and I am finally experiencing some improvement in the near reading distance of that eye.  I met with the surgeon last week, two days prior to the scheduled surgery for the second eye.  After a lengthy meeting we both agreed to delay the 2nd surgery for 2 months to allow me more time to heal and adjust to the Symfony lens that was put in the right eye.  My night vision (starburts, halos and spiderwebs) is still causing me issues, but with the left eye not yet done I am able to operate the car without any issues. My concern is that if this does not correct to some degree, with the second lens I may not be able to drive at night safely.

I was given some eyedrops to use, 20 minutes prior to any planned night time driving, to put in the right eye to prevent the pupil from dilating due to the lower light levels (Aphagan by Allergan - brimondine tarrate 0.1%).  The expectation is that by reducing dilation at night I may not experience as much of the light artifacts that are causing me problems. Tonight will be my first use of those drops to see if they help.

Overall, it just seems to be taking longer than originally expected for me to adapt to the new lens.  In the past week I have found I am able to read most of the text on my smartphone (with arms slightly extended) and the newspaper - something I could not do just a week ago.  Middle to long distance vision remains exceptional.

Would you please update me on your vision and hallow effects since your post 2 months ago.  Thank you.

Excellent post on pre surgery homework.  I was never even told there is laser assisted cataract surgery nor told about ORA.  Found out about that after my surgery at this site. 

My eyes were over corrected from -5.0 r and -4.25 L with a singlet +13 single vision standard abbott lens.  Post op I was over corrected as now I need a +.5 in both eye glasses for distance and a +2.5 for reading.  Overcorrection sucks as it reduced mid range vision as well. 

I am considering a redo with ORA performed.