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

sorry made a typo.  I meant to say that I can NOT see very well near with my glasses

I have no trouble reading my smartphone with the Symfony, even though one of my eyes is hyperopic (+0.5D). Usually caller-id is larger than the fonts used for email&web browsing which is what I'm referring to when I mention using a smartphone.  There is no guarantee unfortunately what result any one patient will have since studies just report averages, but most patients are glasses free with the Symfony, especially with micro-monovision. A slightly larger level, mini-monovision, of a diopter or so would likely be an even safer bet just to be sure if someone didn't mind risking slightly less distance (but not much). On the manufacturer's website for the symfony they have a chart showing typical visual acuity with different degrees of monovision (since this site moderates links I won't post a link, I trust people can google to find the Tecnis Symfony site).

So you didn't have any monovision at all and you can still write and read your texts and emails on your smart phone?

Always seemed a little strange to me to have each eye not set to the same focal length and I heard it could cause them to have a restrictive condition on your drivers license and then there is the issue of depth perception.

Yup, I don't have any useful monovision. In a sense I have unintentional reverse monovision, one eye is +0.5D which reduces near while serving no useful purpose so I'm getting most of my near from the plano eye. It hasn't been enough of a concern to bother with, but I might consider a tweak to -0.5D for the hyperopic eye. Though alternatively I might not mess with it now, and   perhaps in a decade or whenever they have a truly accomodating lens with a large range then I'll do a lens exchange. 

I hold my smartphone at what seems like a natural distance when I use it, and have no trouble with the default fonts. With some newspaper web pages with 2 columns the print is a bit small so I double-tap to zoom to a column, but I suspect most people would do that.  I don't know if using a phone with a smaller screen would have been an issue.  The phone I had when I had my surgery had   a 4.7" screen (HTC One M7) and now I hav one with a 5.1" screen (Samsung Galaxy S7).

Micro-monovision isn't enough to have much of an impact on depth perception/stereopsis since most eyes have decent vision over the most of the range. Its likely not enough to have any sort of restriction on a drivers license, there are a fair number of people whose natural eyes are that far apart. With the Symfony set at  -0.5D in one eye, plano in the other, studies show the average binocular distance vision is still between 20/20 and 20/16, and even the near eye would be between 20/25 and 20/20 by itself. Of course all studies merely show averages, some people are worse and some better.

OK, and in that case, which would you set the dominant eye at?  So, then =if near is important to you , just taking the two symfony lenses would not give me near unless I had at least some degree of micro monovision in one of my eyes? If not I would not be able to text on my 5.5" mobile phone without readers?  Same question for reading menus in restaurants.  thx.

Again, I don't have micro monovision (if anything I have the reverse, one eye is set at distance and the other is farsighted, +0.5D so it has less near, so I'm seeing near really just through the 1 eye set at distance),  and I have decent near, 20/25 and can read my smaller smartphone without trouble with the default fonts. However everyone's results are different, studies merely report averages so individuals may be worse or better depending on the rest of their visual system, and how well they hit the target refraction, etc. A bit of micro monovision would increase the odds of having usable near. 

There is a useful page which lists what size print you can read with what visual acuity to get an idea of what e.g. 20/25 or other visual acuity means in practical terms. Since they send links to a moderator, Google "print comparison of font sizes"  (keep the quotes) to find the page.

Then check the Tecnis Symfony manufacturer's page on the "clinical" tab and they'll have info about the results of micro-monovision, the typical near and distance vision you get with different amounts of it. 

SD,

I do remember that you didn't consider micro monovision since intermediate was your highest priority during the intial surgery and that you were rushed into it. Even though you did end up a little more farsighted, if you weren't do you think you would be more satisfied with how much near vision might have had compared to now? Although I know you mostly are even now. I assume then it may have never came to your mind if you ended up more nearsighted or just on plano for both eyes.

Is the reason you ended up farsighted because of the refraction error when they put in the lens or does it have to do with someone being more myopic vs farsighted prior to the surgery?

If you use more monovision with the Symfony, it merely risks reducing the  binocular distance vision a bit. If you google "tecnis symfony" and look at the manufacturer's page, on the clinical tab they have information about study results regarding micro monovision and the average distance,intermediate and near vision produced. Going for -0.75D gave an average binocular distance vision of just barely under 20/20. If you used monofocals, you'd  either need to use a larger amount of monovision (risking reducing binocular distance vision, and stereopsis) or have even less near and intermediate. 

I hadn't heard of any  concerns with high myopes having lower quality results with the Symfony. Many US surgeons aren't aware of its details since it was just announced here, and unfortunately some seem to confuse it with a multifocal merely because it is a premium lens that uses diffractive optics, but it is different. Many surgeons are experts in medicine, but not necessarily advanced optical technology.  I've seen a number of reports of surgeons considering the Symfony for people they wouldn't give a multifocal to.

I wasn't anywhere near as highly myopic  as your (more like -6 and -9.5, though the -9.5 might have been partly due to the cataract shifting it even before it cut down on visual acuity since eventually it made that eye -19 before surgery).  

I don't think there is a greater risk of overshooting with the Symfony than with another lens, but unfortunately lens power calculations for various reasons tend to be more prone to error with high myopes (as I was, though not as myopic as you) than with those with more normal eye measurements.  I should have risked erring on the side of being a bit myopic, that is slightly easier to correct with laser if you wind up too myopic.  They determine the power based on statistical analysis of past eye measurements and results and I suspect there may be merely less data for high myopes since they are a small subset of the population, though there are other indications there may be issues with the measurement of highly myopic eyes. (if you can wade through technical jargon, google "High to Extreme Axial Myopia - IOL Power Calculations" for Dr. Hill's writeup). There has been work on better formulas the last couple of years though. 

 Computers are often considered to be in the intermediate vision realm, depending on how far you are from the screen though (I use desktop monitors > 24" out), which is where I do most of my reading (even for ebooks) so I was more concerned with intermediate than with really near. One abstract of a study indicate that out of the various premium lenses available last year, that the Symfony had the best visual acuity from 46 cms and further out (when targeted at distance). It provides some nearer vision than that of course, but other lenses do better for that.  Other premium lenses provide more near (when targeted at distance at least), at the expense of slightly lower quality intermediate and/or distance. In my case my visual acuity is   fine to e.g. read a smartphone with normal fonts or to read the Wall Street Journal or New York Times set flat on a table at a coffee shop, without any monovision (in fact one eye is slightly hyperopic so I'm seeing it with my other eye thats targeted at distance).

Unfortunately there is no perfect lens in existence yet.  Since you've engaged in medical tourism before, outside the US (Europe, Canada, Mexico, etc)  there are a few trifocals which  try to target all of near,intermediate and distance and would provide better near than the Symfony.. but they might not have quite as sharp intermediate or distance. It may be a worthwhile tradeoff depending on how important near vision is to you. I debated whether to go for a trifocal or the Symfony up until the day of my preop when they had to order the lens. In my case I decided I prered the lower risk of night vision issues, better contrast sensitivity,  and the better bet for good intermediate and distance vision. The differences are minor, but I figured it was the best bet for my needs (but people's needs differ, I admit wondering how well a trifocal would have worked, even though I think I made the right bet for myself, those who need more near might bet that way). It seemed the best bet for having high quality vision doing most non-reading tasks and a decent bet for not needing correction for reading. I figured if I did need reading correction I could have readers at home/office (and at Barnes&Noble I've seen readers that'll fold up and fit in a pocket, though fortunately I didn't wind up with a need for that), or the magnifier app on my phone. 

If you are concerned with hitting the refractive target due to your extreme myopia, one option to explore might be the Light Adjustable lens where they can alter the lens after its implanted to fine tune its power. I don't know if its available for high myopes or not, or whether you'd wish to go through the hassles with having to be around a few days to have the lens power adjusted. I don't know how much of an early adopter you are, but they are also experimenting with giving the LAL more near vision via an extended depth of focus or multifocal pattern, though I don't know how many patients they've used that with and what the results are like. A couple of years ago when I checked they didn't yet have data, and I hadn't searched for it since.  I suspect it wouldn't have as high a quality near or intermediate vision as a pre-made multifocal or extended depth of focus lens.

 

The European surgeon who did my ICLs recommends a trifocal lens (Fine vision/PhysIOL), but I'm concerned about greater risk of glare/halo/contrast sensitivity and poor vision in low light, plus discontinuous vision.  My local surgeon thinks the LAL is very exciting, but to me it sounds like a better option for perfecting single vision than for spectacle independence (which is really the goal, or to get as close to it as reasonably possible).  I think the PowerVision FluidVision IOL sounds tremendously exciting, but I haven't heard much about it in the past few years.  Dr. Hill's suggestion that shallow anterior chamber leads to less predicable power calculations is interesting, I'll be sure to ask my local surgeon about this.  The Symfony clinical info page, with the average acuity results, looks terrific, but there's no mention of how myopic the patients were to start out.

So it looks like there are some pre-exisiting factors that one can use to predict their visual outcomes. But that seems hard to predict because it's hard to say a myope would end up more myopic post surgery or someone farsighted would end up more farsighted when shooting for plano and even when shooting for micro monovision there may be some errors correct? Are these usually discussed during the pre-op or the intiial evaluations? Surgeons don't seem concerned about the exact measurements and although I've been to a couple evals I have never talked about the exact measurements. There's a brief discussion of setting one's focus near intermediate or distance etc but have not ran into anything too detailed which is an importance for someone undergoing surgery.

I hope you have better luck with surgery than most. 

Pits all so complicated and many web sites make claims that are not necessarily  what we end up with. 

It sounds to me like you have been especially unlucky in your outcome.  Not that it's much comfort to you, but I think most people have better results.  Has your situation improved at all?  Did you find out exactly what the issues are?  Have you gotten opinions from other surgeons?

Yes absolutely went to many specialists and after three tries . Two lenses & laser. My sight was great farsight before surgery. After my caataract surgery my sight is worse. Even glasses don't help. I wear three different prescriptions for doing differt things, yet not a good outcome. It was recommended to rest the eye. I see double and must use my IPad in huge letters. By the end of the day I hardly read at all. Hoping new technology will come along soon.

 

Very sorry to read this.  Were the specialists able to explain what is causing your problems?

The LAL's initial focus is perfecting single vision. However as I mentined they are working on patterns to provide multifocal or extended depth of focus correction. The issue is that I hadn't checked to see if they have study results, and the result likely don't match dedicated multifocals or EDOF lenses for near, though it is possible they are good enough, to consider it you'd need to be an early adopter since its still in development.

As far as I'm aware, how myopic patients were before getting the Symfony ( or multifocal) shouldn't matter.. as long as they do make a lens in the power you need, which I am assuming they would, that you aren't myopic enough to be beyond the power range of typical lenses. 

The last I'd heard the PowerVision was applying for a CE mark in Europe, but I've no idea if they will receive it or how long it would take. Even once its approved there, I'd personally be cautious about being too early an adopter of a new accommodative lens. The issue is that static lenses can be tested well outside the eye on optical benches, with only some issues needing to be confirmed in humans like issues of glare&halos. An accommodating lens in contrast depends on the eye to be able to accommodate so most of its function can only be effectively tested in the eye, and it seems like there should be concerns over what impact movment might have on the eye over time, and its ability to continue to accommodate over time. Its something to keep an eye on (I'm hoping something they come up with will be worth a lens exchange eventually, though I don't recall offhand if that is one of the ones implanted in the bag or outside it, i don't know offhand which technologies for accommodation will work with those whose lens capsule may be altered by having had an IOL implanted and the natural lens removed, or if they need to be the first IOL)

Some FluidVision info indicates they've had terrific results in tests so far (5D or more), "despite considerable variability ... [in] zonular capsule, most have the ability to transfer those vector forces to the still-working ciliary body to this man-made, accommodative, shape-changing lens", and bench testing shows the lens should last "many decades."  The lens is implanted in the capsular bag, so as you say it might not be an option for someone with prior cataract surgery.

A different lens design is the Synchrony (available in Europe since 2006). "It has a movable plus-power anterior optic that is connected by spring haptics to a static compensatory minus- power posterior optic. The haptics allow movement of the front optic in response to changes in capsular tension and ciliary body tone."  "During attempted distance vision, the two optics are close together. Near vision is achieved by attempted accommodation with subsequent decrease in capsular bag and zonular tension. This in turn moves the front optic forward and changes the focal point to intermediate or near vision"

Then there's the Dynacurve: a "sulcus-based accommodating IOL ... similar to FluidVision in that it uses a gel or fluid to change the shape of the lens. But the Dynacurve (NuLens) is implanted in front of the collapsed capsular bag instead of inside it, and the capsular bag is used as a component of a dynamic diaphragm, which transfers forces as the ciliary muscles contract and relax."

"The Dynacurve, which is fixed to the ciliary sulcus, consists of a small chamber filled with a silicone gel, a piston-like element, and a flexible membrane. When activated by the capsular diaphragm, the piston pressurizes the chamber and gel, which then modify the shape of the membrane."

"In theory, the Dynacurve could provide up to 10 D of accommodation. In a pilot study of 10 patients with AMD and cataract, surgeons implanted the Dynacurve IOL in the eye with worse visual acuity. At the 12-month follow-up, the researchers found that both corrected and uncorrected near visual acuity in the treated eyes had improved, without compromising distance visual acuity."

http://www.meddeviceonline.com/doc/novartis-alcon-partners-with-eye-device-startup-powervision-0001

http://www.eyeworld.org/article-presbyopia-correcting-iols-on-the-horizon

http://www.aao.org/eyenet/article/eyes-on-europe-new-options-in-multifocal-iols

http://www.medscape.com/viewarticle/813332_8

rgCalfironia,

The PowerVision lens looks like an interesting one if it does actually end up accomodating. Similar concerns seem to exist like compared to a Crystalens but so far according to the studies it looks like it has a good outcome. Question is will it ever be approved in the U.S and if so when. Also it doesn't correct astigmatism and there was no mention of a toric version? Unless I missed it, correct me if I'm wrong.

One thing I read from other threads is people mistaken a Symfony for a multifocal. To be sure, it isn't an accomodating lens right? As in it won't improve the proces of presbyopia where you switch focus etc as you get older like a multifocal would?

Also I remember you mentioning you were considering the Symfony minimicrovision, did you proceed with your surgery? Would appreciate if you could keep us updated once you do or if you decide to go a different route.

Jason.

Hi Jason,

The PowerVision would be likely to tackle astigmatism after they've demonstrated success and gotten approval in one region (e.g., CE mark for EU).  I think that's how other premium lenses have developed.

The Symfony isn't a multifocal, it's an extended depth of field, so it solves the presbyopia problem with a different approach.  So far, the approaches to presbyopia taken by various lenses are multifocal, accommodating, and extended depth of field.  (See, e.g., this link for more detail on the various approaches: http://www.eyeworld.org/article-presbyopia-correcting-iols-on-the-horizon)

At this point, I'm pretty sure I'll opt for the Symfony with mini-monovision.  The "Clinical" tab on the Symfony site shows some pretty terrific looking results for various degrees of mini-monovision.  I was thinking that targeting a residual refraction of -0.75 in the eye with the bothersome cataract (my non-dominant eye) would be ideal, and the local surgeon I've consulted with at first agreed with that, but now suggests targeting 0.5 due to the fact that it's difficult to precisely achieve the targeted refractive error, especially in high myopes.  His thinking is that if he shoots for -0.75 and ends up with -1.25 that would be more difficult for me, whereas if he tried for -0.5 and ends up with plano, that would be OK, since most people with the Symfony at plano can read pretty well. 

Hi Jason,

The PowerVision would be likely to tackle astigmatism after they've demonstrated success and gotten approval in one region (e.g., CE mark for EU).  I think that's how other premium lenses have developed.

The Symfony isn't a multifocal, it's an extended depth of field, so it solves the presbyopia problem with a different approach.  So far, the approaches to presbyopia taken by various lenses are multifocal, accommodating, and extended depth of field.  (See, e.g., a nice background article with more detail on the various approaches at eyeworld dot org and then slash article-presbyopia-correcting-iols-on-the-horizon)

At this point, I'm pretty sure I'll opt for the Symfony with mini-monovision.  The "Clinical" tab on the Symfony site shows some pretty terrific looking results for various degrees of mini-monovision.  I was thinking that targeting a residual refraction of -0.75 in the eye with the bothersome cataract (my non-dominant eye) would be ideal, and the local surgeon I've consulted with at first agreed with that, but now suggests targeting 0.5 due to the fact that it's difficult to precisely achieve the targeted refractive error, especially in high myopes.  His thinking is that if he shoots for -0.75 and ends up with -1.25 that would be more difficult for me, whereas if he tried for -0.5 and ends up with plano, that would be OK, since most people with the Symfony at plano can read pretty well.

(I shouldn't have said that the lens "solves" the presbyopia problem, I should have said it "addresses" it, since at this point there is no ideal lens that truely solves the problem, there are lenses that addresses it to greater or lessor extents, or not at all.)

As far as I'm aware the Synchrony isn't being used  by anyone anymore because too large a minority of people had problems with it after it was approved. I had initially wondered about it when my cataract first appeared and had contacted them about a US trial they were planning, but fortunately they doubted they'd have a lens power available for a high myope in the trial so I didn't follow through with it (and I'd seen comments that it might be less effective in high myopes, since movement of the lens changes the power by a % of the lens power, and a high myope uses a lower power lens). 

The Synchrony serves as an example of why it makes sense to be cautious about new accommodating lenses. As I mentioned, a static lens can be mostly tested on an optical bench outside the eye before its ever implanted in anyone. An accommodating lenses main feature can only be fully accurately tested inside a human eye, and its movement might cause problems for the eye, wear out the lens, or perhaps reduce over time. 

The reports I see for some of the accommodating lenses talk about large ranges of accommodation, but the only time or two I recall seeing any actual early study results the visual acuity at various distances didn't seem to be a big improvement, but I don't remember numbers offhand. I'm sure they will get there eventually, its just unclear how long it'll take and how long its best to give them if you don't wish to be too early a guinea pig. I'm often an early adopter, I got the Symfony in early December 2014, not too many months after it was approved in Europe in June 2014 (I think I was the first patient implanted in the Czech Republic with it, where I traveled to get it). but in my case I considered the Symfony a lower risk because it could be tested on optical benches and is the same material and overall size and shape as the existing Tecnis monofocals and multifocals, merely with different optics. 

There are other trifocals out there that are approved but still being tested that might be more near term options to keep an eye on like the Tri-Ed Reviol (which I'd only seen brief mention of and not good comparison data) , and extended depth of focus lenses like the Mini-Well (which *might* have a slight edge over the Symfony, but I've only seen limited data and no head to head comparisons in live patients) that might possibly be an improvement but I'm still waiting to see more.

Very good point about being cautious with accommodating lenses.  Not only might there potentially be issues with the lens parts wearing out or becoming less effective, but the components of the eye that work the lens might have a harder time accomplishing this as they age.

Hi rgCalfironia,

Thanks for the response. In regards to the residual refraction are you saying that if a surgeon tries to put you right on plano distance that it'll be a bit off in most cases so it's usually better to target a little off more than that to give room for the error? Is there a general formula in doing so, like say a myope needs to be targeted more for near and will end up plano vs a myope being targeted more being left for distance and will end up on plano etc? Or is it mostly random?

Hi Jason,

The problem is that the formulas used to calculate lens power are an approximation, and depend on measurements (biometry), which can have some error.  As softwaredev has noted, higher degrees of refractive error (either high myopia or high hyperopia) might have more error in the measurements, and because there are fewer people with high refractive errors, the formulas might be less accurate anyway (because they are based on data from other people).  Either way, there seems to be a greater risk of not hitting the target in people with higher degrees of refractive error.  My surgeon is assuming that I might be off 0.5D from the target in either direction, so he recommends targeting -0.5D.  If he hits it, I'll be -0.5D in that eye, I'll have good vision at all ranges (slightly worse distance in that eye, but easily compensated for with the other eye) and good stereopsis.  If I end up -1D, that's about the maximum myopia he'd be comfortable leaving me with.  If I end up plano, my near vision won't be as good, but still should be reasonable for reading.  I don't think there's a rule of thumb about shooting for less correction in myopes.

That said, surgeons do try and minimize the risk of being off, by calculating the lens power using different formulas and comparing the results, and mine also performs a measurement and calculation during the surgery, after removing the natural lens and before inserting the replacement lens (which depends on the facility having in stock lenses that are close to the initially selected lens, something less likely with higher degrees of refractive error).

Hi rgCalifornia,

That makes sense. The main concern I had was that my surgeon and I didn't talk about what I'd be targeted for in terms of numbers, merely talk about setting the focus for distance and plano for Symfony. As I mentioned he didn't think it was a good idea to set it for micromonovision which seems to collide with many of the other opinions that people got from talking to their doctors. I have astigmatism as well and he said he wouldn't know exactly if he'd be using the toric or non toric version or if he'd take care of it during the surgery, I assume through an incision. But I was told that it was rare for the patient to not know about this info until the day of the surgery, so I've been on hold. 

By the way what number indicates how near or farsighted one is? I have papers from my optometrist which I can read my glass prescription but I don't know exactly how to read how myopic I am. Is it indicated under a specific category? Thanks.

Hi Jason,

It's unusual for a surgeon not to discuss this with the patient, and to dismiss micromonovision, and not know how he or she prefers to deal with your particular amount and axis of astigmatism.  You might consult with other surgeons to get a wider range of views.

In an eyeglass rx, the first number indicates the amount of correction needed (called sphere).  For myopia, it's a minus number.  I don't know if there are standard definitions for high vs low vs medium, but in general, I'd consider anything lower than say -5 to be low myopia, and anything in the double digits to be high.

The next two numbers in an eyeglass rx are for astigmatism, as diopters of cylinder power and the axis (as degrees from 0-180) that indicates where the split is between the part of your eye that needs the extra correction for astigmatism and the part that doesn't.  If you have a small amount of astigmatism, it might not need correction or some surgeons prefer to use an incision to correct it.  It also matters where the dividing plane is.

Hello,

So I took a look at the evaluation papers here and I got:

I'm looking at DVA:

OD: 20/70

OS:20/25

Autorefraction:

OD: -5.00-0.75x085

OS:-1.00-0.75x066

So if I am understanding you correctly my left eye is more myopic than my right and my left would be considered low myopia? And according to this it's showing 0.75 astigmatism in each eye at different dividing planes? Not sure how to understand the difference in the dividing plane if it is thus the third number there.

These results are from my optometrist, many opthamologists that I went for a cataract eval said I had .5 astigmatism in the left eye and 1.00 in the right. So not sure which is more accurate. I was told my eye glass prescriptions were off and my worse cataract (right eye) has progressed, while my left is still okay. Is there a way if I take these numbers and interpret it in a sense of whether it'll be okay for me to push my cataract surgery back vs. having it done soon taking into consideration that it might ripe too much and cause complications?

I was told if I get new eye glass prescriptions, I would be able to pass a drivers test, not sure how good or bad that is indicating my current vision is with cataracts. (I can still drive now in the mornings since my left eye is doing most of the work, not sure if that'll cause the left eye to eventually progress more like the worse right eye).

Hi Jason,

"OD" is your right eye (oculus dexter) and "OS" is your left eye (oculus sinister).  So your right eye is more myopic than your left, which could be due to the worse cataract.  Unless your cataract is growing rapidly, you probably can wait on surgery a lot longer if you want.  Waiting won't make your left eye get worse any faster.

The third number is the axis of astigmatism.  Think of your eyes as a circle (360 degrees).  The axis of astigmatism is the angle of a line through the circle that divides the circle into two halves, one that needs the extra power indicated in the astigmatism cylinder, and one that doesn't.  If the axis is 90 degrees, that is a line starting at the bottom (the 6:00 position on a clock).

It's common for a refraction from an autorefractor to be a bit different from a manual (or "manifest" refraction, where you are looking at an eye chart through a device with different lenses, and someone adjusts the values and asks you "better this way or that?"  The values from one manifest refraction can also differ from another one, because it's based on your subjective evaluation of which way is better.  It's common for myopes to prefer more correction, so a manifest refraction for someone nearsighted often shows a higher amount of correction than an autorefraction.  But an autorefraction is not always accurate either.

Hi rgCalifornia,

If I'm understanding you correctly does that mean people with monofocals don't have any presbyopic correction so they aren't able to change focuses and if they do, they end up with blurry vision when switching from far to near? and vice versa?

Hi Jason,

That's correct: monofocal lenses focus only at one distance, so no presbyopia correction at all.  There isn't any switching between distances because the lenses don't switch.  You can attempt to see at other distances, but for most people it won't work.   Almost everyone needs glasses or contacts to see at other distances.  There are some people who can see better than most at other distances, and some don't even need reading glasses, but that's rare.  Most commonly, monofocal lenses are set for distance, and people need glasses or contacts to see intermediate and near.  Monofocal lenses can be used in full monovision, with one eye set for distance and the other for near, which can provide acceptable vision at both (intermediate will be blurry though), but the difference between the eyes to do that makes it hard for many people to adapt to that, and causes problems with depth perception.  Reading for long periods may be too tiring, and so reading glasses might still be needed,  They can also be used with less monovision, with one eye set for distance and the other for intermediate.  That way there's less difference between the eyes, which makes it easier for many people to adapt, and causes fewer problems with depth perception, but reading glasses would be needed to see close.  Not everyone can handle monovision, though, so it's risky unless the patient has tried it using contacts lenses.

Essentially, monofocal lenses restore vision to what it would be for a patient who has lost all ability to accommodate, such as someone aged around 60 or older. 

Hi there,

Thank you that makes much sense! What are your thoughts on people living with only having one eye with cataract surgery and living with one natural lens? I know surgeons say its best to have both eyes done and they always mention that the patient will be "unhappy" if only one is done. Is this true or is it possible to live with only one eye being corrected and adapting? 

So for instance say I get a Symfony set for distance in my worse right eye, then I'll be living with one eye corrected for distant and I guess the less myopic (natural left eye), so in terms I'd basically be living off monovision? And the only difference the Symfony or having a monofocal set for distance in the worse eye would be that the monofocal would provide less extended range of vision than a Symfony so it'd make the extent of monovision worse so I'd lose a lot of depth perception etc compared to having one Symfony? Is this correct? Or would the adaptation process of a monofocal + natural and Symfony + natural be the same since you'd be neuroadapting to use your natural eyes more compared to the eye that fails to accomodate at all distances?

Maybe I'm overthinking this, but it was just a thought. I am aware eventually the other eye will have to be operated on but I feel like theres no best lens like your natural lens your born with, so it seems like a waste in getting the good eye done as well.

Hi Jason,

I don't recall if you mentioned what your current refraction and age are, but in general, there's no problem getting cataract surgery in one eye first and waiting until the other is bad enough, unless that would result in a difference in your eyes great enough to cause discomfort (and that could be fixed with a contact lens in the phakic eye).  If your worse eye is your dominant eye (which for most people is the right eye), than having that corrected for distance with the Symfony would make sense.  If you have some myopia in the other eye, that can help you with near vision.  Provided the difference isn't too large, then you would likely be able to adapt (as you say, your eyes were naturally different most of your life and you handled that OK).  I think it's very reasonable to want to stay phakic as long as possible.  All surgeries carry risk, and depending on your age, you might have some accommodative ability in your good eye.

In my own case, one of my concerns is not hitting the refractive target with the first eye; softwaredev ended up hyperopic and astigmatic, which is causing his poor near vision.  The surgeon I'll probably use uses several different lens power calculations to check the results against each other, and does another test during the surgery, yet still says to expect being off by up to 0.5 diopters in either direction, so if he aims for -0.5 D myopia he might hit it or end up somewhere between -1 and plano, which would mean I'd not get the near vision I'm hoping for.  In your case, since you'd be doing the distance eye first, there's less downside to being slightly off, and by the time you get the other eye done, the calulations might be much more accurate.

re: "softwaredev ended up hyperopic and astigmatic, which is causing his poor near vision."

I'm guessing you are referring to webdev (I know its confusing, but I was here first I think :-) ), since my near vision is decent. I did wind up hyperopic in one eye, +0.5D, though with 0D astigmatism, which does reduce near in that eye so its only the other eye that provides the near. The better  eye hit the target  at 0D (though actually with perhaps -0.5D astigmatism which I guess I should mention since it might provide a sligtht boost at near, being the spherical equivalent of -0.25D, though perhaps the slight blur from   astigmatism counters the slight boost).

Oops, sorry about that!

Hi rgCalifornia,

I'm 58 and my manifest measurements which are older (about a year old) than the autorefraction measurements a couple posts above are OD: -2.75-1.00x066, OS: -1.25-0.50x070. Which I was told the cataracts in my right eye was pretty bad. My right eye is now -5.00 so I've become more myopic due to the cataracts progressing but in general I think I'm lowly myopic. It's interesting how different a manifest and autorefraction measurement is. I believe at my age I'm fully presbyopic, not sure if that will affect my ability to see comfortably with the natural eye that I may leave alone. I'm not sure how much difference will be but hopefully if I take the cataracts out of my right eye, it'll become less myopic.

As for a dominant eye I don't believe i have one although I read about the importance of setting your dominant eye for distance vs. your non-dominant for a better visual outcome, although I was told merely the difference is the adaptation process since people adapt to see with their better eye regardless of dominance post surgery.

Hi Jason,

If you have surgery in your right eye and end up plano, the difference in your eyes would only be about 1-2 dopters, so I don't think that would bother you at all (especially since you had a difference most of your life).  With only 1-2 dopters of myopia in the left eye, you'd probably need reading glasses or a contact lens to read, especially at 58.  You could try a single vision contact lens with a small amount of add, to get monovison, or a multifocal contact in that eye.  Especially if you have the Symfony in the other eye, that could work nicely.

Since you have a low degree of myopia, odds are you'll be on target in the right eye after surgery.  However, if you did end up a bit myopic in the right eye, if you have the Symfony, you'd probably be fine, and would be able to read out of that eye, and not need glasses for anything (even if your distance wasn't 20/20, it'd probably be good enough to not be a problem).  If you ended up hyperopic, than monivision might be more problematic, but a multifocal contact in your left eye might work well even then.

I have standard non-toric monofocals set for distance in both my eyes and can see perfectly at all distances without glasses, including tiny print (I can read J1 print without glasses, but for extensive reading I would probably wear a pair of over the counter readers to avoid eye strain). My distance vision at present is 20/25 (cataract surgery was done in August 2017 and September 2017 and it's now November 2017). I have read of several people who had the same result as I did and I found several studies to back this up, so this is not a rare occurrence.