near vision poor after getting Symfony...seeking others' experience

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Hi,

I'm 44 years old and just had the first of two eyes implanted with the new (I'm in the U.S.) Symfony Toric lens, which I've researched extensively and was very eager and excited to get.

Now four days since having the surgery, I'm mostly satisfied: colors are much brighter and more vibrant (and more pinkish, bluish, interestingly), my distance vision is now restored and fine, and I can see pretty well at intermediate distances, i.e. objects are clearly defined all the way in to about 23 inches away, perhaps even 21 inches away in bright light (yes, I notice some degradation in low light, more than I'd expected).

The real issue for me is my near vision, which is much worse than I was expecting. I do know that the Symfony isn't all-around perfect, that e.g. I might expect only 20/32 or so (mean uncorrected near achieved in the U.S. clinical trials). And I know that's just an average, but even the distributions left me hopeful, with 81% of trials patients achieving 20/40 or better (that's monofocally; 96% were better than 20/40 bifocally). Meanwhile, I'm struggling to make out these words as I type, pretty much anything inside of 23 inches is blurry, and in good light I can only make out the 20/80 line (if I really exert myself, I can barely make out, mostly by guessing, some of the 20/60 letters, but mostly they're entirely unrecognizable). I feel as if I could have gotten results like this simply by going with monofocals, and I'm beginning to fear this is as good as it'll get, which is depressing.

Some background facts: Pre-op, I was mildly myopic (-1.75) in this eye and mildly astigmatic (about 0.94 cylinder). Also, at 44 I'd already gotten used to presbyopia, and typically would wear +1.25 readers for near. The specific lens implanted was the ZXT150 +16.5 (1.5 D cylinder). I doubt lens alignment is off, as my distance and intermediate vision feels non-astigmatic. My other eye (right) is scheduled for another Symfony lens 10 days from now.

So, I wonder:

1) Have others had similar experiences, i.e. poorer than expected near vision?

2) Does anyone have any idea what might have caused this?

3) Can anything be done to correct it?

4) If anything can be done, should I expect my ophthalmologist to do it (without having to pay more than the significant amount I've already paid)?

Thanks for any info and advice!

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  • Posted

    I had same lense and am 46 years old. Had issues but not lenses related. Immediate reaction is has been 4 days so you are still healing and vision will change. If far and intermediate is good then it does not sound like you have and surgery related issues. Perhaps your second eye can be set a bit closer more for intermediate and close vs far. That is what I did. Right eye more distance less reading. Left eye more reading less distance. Both give me 20 20 unless I am reading a drug bottle ingredients.
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    • Posted

      Thanks very much, Glen. Assuming this turns out to be nothing out of the ordinary, and as a worst case, that's my plan, i.e. to request a small amount of monovision, 0.5 or 0.25 D, whichever the doctor recommends. My fear with this approach, though, is that it won't be sufficient to counter, or properly complement, the poor near vision in my current eye. As softwaredev suggests below, there's a possibility, I fear, that I've been left slightly hyperopic, or (and this I hadn't considered) that the lens alignment is off a bit despite my feeling as if my astigmatism is corrected.

      Was your vision similarly poor in your first eye? It would be nice to hear that I might still get to binocular 20/20 via a slight degree of monovision.

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    • Posted

      No I had CME. Corrected with meds. If you have good far and intermediate vision than it is likely a sizing issue. I would simply see if the can purposely under size other symphony. You will still have distarance but closer to 20 25 or 20 30 but near vision should be better. Again you still need to heal to figure out optimal vision so I would not rush second eye choice until your first eye stabilized.
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    • Posted

      I was in a similar situation. My left eye was not good for reading but my vision did slowly improve after a few weeks and I could manage to read mobile text. The lens in my right eye was supposed to improve my near vision. Now 4 months after the second operation I cannot see any text without blurring with my left eye, so it has become worse in my view. My right eye is better but not perfect and I need to wear glasses all the time. The risk of these lenses make them unacceptable. They should be banned from use.

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  • Posted

    You hadn't mentioned the crucial factor which is what the refraction on that eye is, which you may not know yet. I'd guess there is some chance  that you wound up slightly hyperopic, farsighted in that eye which takes way some of your near vision with any lens and could explain the results. I have Symfony IOLs in both eyes and  although one of my eyes hit the target at 0D and is what gives me  20/25 near vision, he other is +0.5D and has quite a bit less near by itself.   Also the lens is tolerant of some amount of astigmatism so it isn't clear that you could tell if it "feels non-astigmatic", and if a toric lens is rotated that impacts how nearsighted or farsighted you might be.  

    In addition the time it takes to neuroadapt can vary greatly between people. One doctor who did studies comparing the AT Lisa trifocal and the Symfony indicated in email that the Symfony seemed to require  longer for neuroadaptation than the trifocal, though he didn't respond to a request to quantify the difference. In my case my near vision came and went for perhaps a day or two before settling in, and was 20/25 by testing at 1 week postop, but that might be very atypical given the doctor's comment about it taking longer for neuroadaptation than the AT Lisa tri.

    The odds are very high you'd have far worse near vision if you'd had a monofocal with the same refraction the Symfony is at (e.g. also hyperopic, if that is the issue). Unfortunately the results do vary between people partly due to the quality of the rest of the visual system, and it could be you have some other issue that would have given you subpar results with whatever IOL you got.

    In terms of degradation in low light, I have better low light vision than I did with multifocal contacts and don't consider it a problem. Someone I know, about the same age, with the Crystalens has far more noticeable degradation in low light (though he may be an atypical data point, individual variation). We met after a lecture in a well lit auditorium, and he showed me that holding a file folder over the near vision chart to cast a shadow was enough to reduce his near vision by some lines, but it didn't make a difference to mine. It may well be that even with a monofocal lens you might have noticed a degradation in low light vision, I've read a number of times that people after cataract surgery tend to find more light is needed, when referring to people who have likely gotten the default monofocal lens.

     

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    • Posted

      Thanks, softwaredev. As for refraction, we targeted 0 D, although to be honest this was hardly discussed pre-op; and I don't know actual/current refraction, as my day-after post-op visit was very casual, informal, with no mention of what my numbers were. Instead, a nurse had me briefly read a distance chart and briefly read a hand-held near chart--no autorefractor, no "which is better, 1 or 2" with lenses, etc. Then the ophthalmologist checked me with a slit lamp and said everything looked fine, end of story. (We did then discuss my poor near vision and targeting micro monovision, assuming things didn't change.)

      All of which leads me to a new question: How is this typically measured post-op--autorefractor, full manual refraction, or something else?

      I plan to visit my (unaffiliated) optometrist in the next few days, and am scheduled to see the opthalmologist's optometrist in 6 days, just before surgery on eye two. So any information I can get beforehand will help in discussions with them.

      Last, I'm curious about your comment about astigmatism. Are you saying that due to the tolerance to residual refractive errors with Symfony, that my alignment may be off, contributing to my near vision issues, even though my distance vision to me is now "non-astigmatic" (by which I mean, I can see sharp edges and lines far away, that when uncorrected in the past would often appear sort of ghosted, with a slight offset double image blurring them)? It seems odd to me that vision at one distance (far, as well as intermediate) would feel corrected for astigmatism, while another distance (near) would still feel uncorrected and so poorly focused. In my very limited understanding, all distances would either be corrected for astigmatism or not, which then to me suggests that seeing things fine in the distance would mean the lens was lined up on the correct meridian. With all that, I don't mean to sound strongly opinionated or like I know what I'm talking about--I'm just spelling out my train of thought in hopes of getting a better understanding.

      Thanks again for all your help.

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    • Posted

      Targetting 0D is different from achieving it, as I know from my results. Usually the lens power formulas are fairly accurate for those with low prescriptions (unlike my former high myopia) but they can still be off. Also the lens can change position during the first few weeks, moving further in or out, making the issue better or worse. Usually its stable after a month so they wait until then before prescribing correction if someone needs it, but in some cases it can take a few more weeks beyond that to stabilize. 

      Refraction needs to be measureed with full manual refraction after the Symfony IOL (or multifocals), as the Symfony site says in the fine print in the instructions for doctors. Their optics confuse autorefractors which may or may not be accurate. 

      You were indicating that you didn't think the lens was rotated because you didn't think you were astigmatic. Its possible that the lens is rotated so you do have some minor astigmatism which isn't enough to cause problems with decent distance vision. That lens rotation however also influences the spherical refraction, leaving you more or less myopic or farsighted (though I hadn't thought through if that is likely the issue in your case, which way rotation would likely have shifted it). It could be lens rotation (rather than lens power) that left you hyperopic, and that on top of the astigmatism might reduce near vision.

      I might consider a laser tweak to move my +0.5D eye to -0.5D or so for micro-monovision. So if you are hyperopic in that eye (and it isn't due to lens rotation), one option is  a laser tweak (to 0D or slight myopia for micro-monovision). You might wish to decide on that if possible before deciding whether to target your other eye for 0D or micro-monovision. It may be that the lens power for the other eye would be more accurate if the results of the first eye provide a clue, it depends on how similar the eye measurements are, often people's eyes are similiar, but not always. 

       

       

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    • Posted

      SD,

      Does the extent of being left/set to 0D vary depending on if one is myopic or hyperopic pre-surgery assuming no other conditions exist aside from astigmatism? Would it affect the choice of whether one should have one eye set for more near if one was previously far or near sighted? I guess I am trying to ask if there is a difference if a previously myopic person would end up with varying 0D results (to be left more myopic after surgery) than a hyperopic indviidual who would be left more farsighted post surgery even at 0D and whether the myopic individual would still need to set for minimicrovision for more near.

      I am assuming since you lose all accomodation without your natural lens that it won't matter, but since 0D often varies from person to person I was wondering if there are pre-existing factors (perhaps astigmatism?) that causes one to be left more myopic or hyperopic and whether this affects minimicrovision.

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    • Posted

      Softwaredev, thanks, that makes sense. Perhaps the lens is slightly misaligned, leading to some spherical error, while I remain unable to notice anything that feels like astigmatism at distance.

      I just did a quick distance check with some charts I use, and it seems I'm about 20/40 to 20/30-1 for distance, which surpised me. I think the huge improvement from my poor cataract-impaired vision, and the increased vibrancy in colors and brightness, led me to think my distance vision was better than it actually is. So this, to me, lends some credence to the misalignment theory--or, the spherical correction being off...

      I'm hoping my optometrist can add some clarity here, and I'll report back what I learn from him. But I'm now even more concerned than previously, as it seems my vision at all distances is worse than should be expected. Near remains the most bothersome. If all distances are less than average to poor, what might be the cause?

      And, slightly related, do you happen to know if manual realignment is the only resolution to an alignment issue, or are their laser-based alternatives that could be applied instead to address it?

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    • Posted

      They are more likely to hit the target with someone with a low prescription, and I'm not sure if it varies much depending on whether the person is hyperopic or myopic.  They are more likely to be off for those with higher prescriptions, and although I think its more common for them to be off with high myopes than hyperopes, I'm not positive. They have come out wiht some better formulas this year so the best thing to do is to be sure the surgeons are up to speed on the latest research and talk through the risks of being off target.

      If they don't hit the target, that impacts micro-monovision if they aren't near enough to provide much difference, or too near and it reduces distance or stereopsis. Being off target a little bit doesn't matter too much. 

       

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    • Posted

      If all distances are off, that suggests that astigmatism is the cause as usually that applies to all distances (even if the Symfony is more tolerant than most lenses). Also it could be that you are still healing from the surgery. 

      In terms of the lens being rotated, as far as I know they would manually rotate the lens. 

       

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    • Posted

      UPDATE: Well, I got to my optometrist, and got some bad news on two fronts: I have a good amount of residual astigmatism (it's now .75 down from .94 pre-surgery), and also I'm overcorrected and now have 0.5 D hyperopia. Via manifest refraction I'm 20/30 - 1 for distance, due to both, but mostly the astigmatism, the optometrist believes.

      I now have an appointment with the surgeon in two days. I'd like to get my already implanted eye resolved before continuing with the other eye, but I'm not sure what my options will be. It seems to me a laser correction or re-alignment of the IOL might work, but I'm not sure.

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    • Posted

      If the IOL is rotated, then rotating presumably would impact the issue. If the power is still off, then it can be corrected by a lens exchange or laser correction. Unfortunately it can take a number of weeks for the refraction to stabilize after surgery so it would be a while before most surgeons would consider a laser correction since they wish to be sure to get it right, though I don't know how long is typical offhand. Usually they wait a month before prescribing glasses, though in some cases vision isn't stabilized yet and they wait a couple of months, so presumably they'd wait even longer before doing surgical correction. 

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  • Posted

    Same thing I went thru. Then they changed the lense to astigmatism shape a football shape. Still didn't help I could not see anything far even up 2 feet a four inch print out of the eye. Then a laser was done, it did not help. 

    Went nt to another specialist. No one can explain what happened any why my vision is worse since cataract surgery. 

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    • Posted

      Yes.. Not much left to fix the eye. Astigmatism is apparentl to blame .

      very frustrating seeing double is part of my life now. No one wants to take responsibility. I have the other one to have cataract surgery will take wild horses to drag me in again on the good eye with cataracts.msounds rediculous! 

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    • Posted

      I'm not sure if I quite understand your situation. Are you saying you got the toric version of the Symfony to correct your astigmatism, but it didn't correct it and left you with worse vision? If it is a toric version then it might have been rotated. If your near vs distance is better prior surgery and worse surgery it might be because of how you set your focus to. But if you have one corrected eye and the other one uncorrected (only had cataract surgery in one eye) then your vision perhaps will be much worse until you have both done.

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    • Posted

      Yes there were two lenses the first lense not for my eye shape and then the second for symphony for astigmatism then laser. All failed and the vision in that eye is worse that it was before the cataract surgery. I cannot see a for inch letter from 10 feet. I had great vision before surgery now I cannot read street signs unless I am on top of them. Also am now stuck with double vision. Have glasses to read since surgery after time a few hours all the print is blurry even if I stretch out the page on my IPad. I Was livid at first but after 3 years just adapted to it no one can fix it since laser. 

       

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    • Posted

      If this was 3 years ago, I'm unsure how you could have the Symfony since it was only approved 2 years ago. Unless you are saying one eye was 3 years ago and the other was done more recently with the Symfony. 

      It sounds like the issue isn't related to the lens or they'd be proposing a lens exchange. Perhaps the astigmatism is irregular, or some other eye issue arose due to cataract surgery (or around the same time, out of milllions of cataract surgeries some people will have the bad luck to have some other issue just happen to appear at time of surgery).

       

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    • Posted

      The first lense was three years ago the result vision was as explained above.

      The second replacement lense was symfony done 2 years ago. Same eye this time for astigmatism . They admitted finally the wrong lense was put in the first time, after over a year of complaining. 

      It should have been for astigmatism shape eye. Which means the eye shape is not perfectly round but slightly oval. 

      That second replacement symfony lense done less than two years ago, was no better & my vision was blurry worse than before cataract surgery. 

      The third try to fix my vision was laser . It was to clear my vision it did not. 

      There is no other eye issue found it has been a problem finding why they cannot fix my vision. Now blurry, double and lost farsight which was very good before surgery in the eye for cataract surgery naw can't see a street sign. 

      I have had had another opinion every possible test no other eye problems were ever identified at that time or reciently as Jan 2016, and no one wants to take responsibility. That is the unfornuate bottom line. 

       

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