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

If your vision at all distances is blurry, that isn't typical and is unlikely to be related to the choice of IOL model. It suggests either a problem with healing like swelling, or that you were left with residual refractive error like astigmatism (which causes blur at all distances) or far less likely you have enough hyperopia so that even distance vision isn't clear (though it would be unusual for the lens power to be off that much). Alternatively perhaps you have some other eye problem unrelated to the cataract surgery that is causing the blur in that eye. 

I had the Symfony implanted in both eyes early Dec. 2014, so I'm 2 years +1 month or so postop. I've mentioned my results on this site before, and I just got another check about 9 days ago.  I tested at least  20/15 at distance (they didn't show a line below that to see if it might be a bit better than that. I should have asked out of curiosity, that  line was easy to read). I'm 20/20 at computer distance (plus a bit on the line below). 

In the past I consistently tested 20/25 at my best near distance using a handheld chart, but in this case they didn't have a line for that. The used a fixed exact distance rather than a handheld chart,  and  tested at 40 centimeters and I was 20/30, though I saw some of the 20/20 line below that, which suggests that I may be at 20/25 at that distance (and likely for my best near distance thats what I'd be still).

My near is aided by a very tiny bit of accidental myopia in my right eye that provides most of the near (making up for hyperopia in the other), which is less though than what people shoot for with micro-monovision: 

OD: -0.25D -0.25D X 127 

OS: +0.5D (no astigmatism). 

The right eye   sees 20/15 at distance despite that tiny myopia, oddly the left eye can't read the 20/15 line. I neglected to find out what my best corrected distance vision would be, since I did see some improvement with the refraction. Since I was highly myopic before surgery, the lens power was hard to predict which is why I wound up a bit hyperopic in one eye unfortunately (which reduces near vision). 

Since you mention newsprint, that is easy to read, and I have no trouble with using a smartphone with the usual fonts.

I am still waiting to have the left eye done--right eye was done in September 2016--because my doctor wanted to get my fist eye fully corrected before proceeding with the second eye, in case some monovision is needed.

The problem with the first eye is primary that I have 1.0 D residual astigmatism, which is a bit odd because I had 0.9 D astigmatism to begin with. I have the toric Symfony implanted; I assume it must be pretty far off axis. Anyway, I'm scheduled to have LASIK surgery in a week to address this, as well as a small amount (0.25 D) of residual myopia. My current uncorrected vision in this eye is 0.25 -1.00 @ 97.

I'm hopeful about the LASIK, as my vision when corrected with glasses is excellent at distance, ~ 20/15. Intermediate is very good. Near remains less than I'd hoped for, and things get blurry inside of 20 inches, so I must hold e.g. newspaper print at nearly full arm's length. But I'm hoping the finer-grained correction available with custom LASIK might improve that a bit.

I'm guessing that unfortunately its too late to easily rotate the toric Symfony into position since its healed in place, and they don't think its worth the risk to try to reposition it or replace it? Obviously its better to not have astigmatism, rather than to have the cornea try to counterbalance astigmatism in the lens, there is likely more distortion added from that combinaton of 2 distortions trying to imperfectly cancel each other out. 

I'm curious if it is better to use an incision to attempt to correct the astigmatism (or if perhaps that is what they intend to do) rather than using lasik to ablate tissue. An incision tries to get the eye to reshape itself, but it is less precise, even when done with a laser, since they rely on statistics to guess at how the eye will reshape itself. However it seems likely the reshaping is therefore smooth on the surface. The laser, like a printer, doesn't smoothly hit every point on the surface, even if does enough to make things mostly continuous. That irregularity is one of the reasons they tend to be cautious about using multifocals with people who have had lasik. However the laser equipment has gotten better over time (just as we have higher resolution displays and printers) so that is less of an issue now, and with a tiny corretion the irregularity is even less of a concern (which is why they do laser touchups on people who have multifocals). However its still presumably not as smooth as the eye reshaping itself could be, though I hadn't confirmed this. 

One of the reasons for mentioning it is that I have seen mention that a tiny % of people who get lasik see their best corrected vision reduced slightly, presumably due the irregularity of the result. Unfortunately most statistics are based on those who get several diopters of correction, and I'd suspect there is far lower risk of losing best corrected vision with a small tweak, but I don't haven't taken time to see if there is any data on what the risk is exactly. It'd be a shame to change the refraction to try to get an extra line or two of uncorrected vision.. and see that then countered by a loss of a line or two due to the impact of lasik making the surface less regular. It may be worth the risk since its likely very low, the question is merely whether there is even less risk using an incision to correct astigmatism, and then considering lasik if the incision doesn't do a good enough job.

I am curious about the risks involved in laser tweaks (since I keep wondering about one for one eye that wound up sightly hyperopic, +0.5D) but  I hadn't found it high enough priority to see if there is better risk data than what I see in a short search. 

Its also unclear if you need to correct the sphere in that eye (which might argue for just using lasik for the astigmatism at the same time). I'm suspecting you have a typo/miswording in what you wrote, though I don't know which way the mistake is. You state you have 0.25D of residual myopia, though you then state that your uncorrected vision is "0.25D" which without a "-" sign would indicate hyperopia. You seem to be indicating you would prefer more near, like for a newspaper, so if its myopia it isn't clear you'd wish to get rid of it, or perhaps even increase it.

If its hyperopia, it isn't useful and may make sense to tweak. It its -0.25D of myopia, it isn't clear if that would be an issue if the astigmatism is taken care of since that likely has little impact on distance, while giving at least a tiny bit more near. That small a tweak also raises again the issue of whether a slight gain from the focus change might be offset buy a reduction due to the irregularity of the laser.

My right eye is "-0.25D -0.25D @ 127" but is at least 20/15 at distance, and 20/25 at best near (at least 20/30 using  40cm near distance,  for that they didn't have a 20/25 line, and I read some of the 20/20 line). Each eye's best potential of course varies, it might be you'd need to be closer to 0D to get as much distance vision as you'd prefer.

My understanding is that re-aligning is best done early on for toric IOLs, in the first few weeks after implantation, before the lens "heals in". Plus, given how tricky alignment can be in the first place (I've seen reports of 10% loss of cylinder correction per 3 degrees off axis; also...my own experience first time around), I decided I didn't mind missing that opportunity.

So, at this point, my options are LRI incisions or LASIK. Since the main residual problem is the astigmatism, my doctor initially wanted to do LRI, and we even had scheduled that to occur earlier this week. (By the way, you had a question about my prescription: it's +0.25 -1.00 @ 97 (in negative cylinder), or -0.75 +1.00 @ 7 (in positive cylinder), for a slightly myopic spherical equivalent of -0.25.) Initially I was skeptical of LRI, and I asked the doctor lot of questions about it. My primary concern was that it can be fairly unpredictable compared to LASIK, or at least that was my belief. I also was concerned, less so, that at best it would correct only the astigmatism, but not the small amount of spherical error remaining (but I since read that due to a "coupling effect" some spherical change can be induced as well depending on how the incision is done). But in the end I accepted his recommendation to go ahead with LRI incisions.

Ironically, Monday of this week, the day before the LRI surgery was to occur, I got a call from the doctor's office saying that, after reviewing my situation more closely, the doctor wanted to do LASIK instead, so the LRI surgery was cancelled and I'm now scheduled for LASIK nex week.

I feel better about it for the most part, but your comments about LASIK causing some loss of acuity worry me. Have you come across reports comparing outcomes of LASIK vs LRI that would suggest LRI might be better in a case like mine? Frankly, until reading this I had been expecting I'd likely have a better outcome with LASIK.

Since the   spherical equivalent is slightly myopic that would tend to boost near slightly on average, but obviously that is reduced due to blur from the astigmatism. I don't know where an LRI would leave the sphere, I hadn't looked at the issue that closely, but obviously it matters in a case like this. 

Sorry, unfortunately I hadn't compared LASIK vs. LRI. I didn't have much astigatism to begin with, and my residual astigmatism isn't enough to be worth worrying about.

While researching things sometimes I run into data unrelated to my issues and glance out of curiosity, but I hadn't in this case.  

I also unfortunately in a quick search saw   a huge range of claims regarding the risk of loss of lines of best corrected vision, and hadn't taken time to sort through what the most recent credible data says. Its compounded by the issue that some sources refer to the risk of losing > 2, or >=2    lines of corrected acuity, rather than the risk of even losing 1 line, and  even losing  1 line is a concern when you are just doing a minor tweak. That said, unfortunately the results also tend to be on those doing the usual large laser corrections. I don't know if a tiny tweak means the risk is propotionately smaller based on the #diopters change, or almost non existent with small changes, or comparable to the risk with a large diopter change if the issue is the irregularity. I'd be curious about it, but hadn't taken time to research the issue.

I'd be concerned about LASIK's risks of side effects in general, including dry eyes, glare, and halos.

Taking a quick look out of curiosity for the issue of "limbal relaxing incisions" and "spherical equivalent" I see multiple sources saying that due to a "coupling effect" that the spherical equivalent shouldn't change. That suggests an LRI would seem appropriate in this case. I would guess that clearing up the blur might leave your near vision a bit better even if the spherical equvalent didn't change, and then you could consider whether you want even more near. Of course such incisions aren't perfectly predictable.

In terms of lens rotation, google "Toric IOLs: Four Options for Addressing Residual Astigmatism". I was surprised to see that lenses are rotated later than I would have guessed (unless guidelines have changed since this 2012 article, I'm not curious enough to research to find something more recent):

"Rotate early. If rotation is indicated, or if the patient needs an IOL with a different refractive power, the surgeon should act promptly, before fibrotic healing can interfere with the procedure. While Drs. Hill and Chu indicate that the rotation can take place as early as one or two weeks after surgery, Dr. Berdahl advises waiting slightly longer: “Ideally, within the first month. But not before two weeks, to be sure that the eye’s refraction has settled down after surgery.” But all three agree that, depending on how fast the patient heals, the rotation should be performed by three to six months after the initial surgery"---

One thought  comes to mind in terms of why laser ablation might be better than incisions, but it depends on the status of the technology and I'm not aware of how it works now. It seems like a rotated IOL might, like lenticular astigmatism with a natural lens, lead to an irregular astigmatism pattern that perhaps an LRI wouldn't match with since its a combination of the corneas astigmatism and the astigmatism of the lens.

However I don't know if there is any method for guiding  a laser using that combind   pattern, I hadn't explored the state of laser technology and the methods they used to guide it. With astigmatism on the cornea in theory they can use a  corneal scan to guide the laser (I assume in reality they do so),  but in this case part of the astigmatism is coming from a rotated lens. I don't know if they can combine scans of the IOL and its position, or a theoretical model of the IOL and its position, with a corneal scan to drive an accurate astigmatism correction. Unfortunately I'm suspecting the approach isn't yet that sophisticated, but I don't know.

I don't have a good explanation from the surgeon why he recommends going with laser correction in this case, although I've learned that he plans to do PRK and not LASIK as I said earlier. I'm OK with the recommendation; to me it seems preferable due to what I understand to be it's better predicability and precision compared to LRIs, and the fact that it could also address the slight residual mypia. I hope I' right and will update here with results. Thanks!

Why would you be worried if others could see a reflection????

The majority of concern (if not all) is to achieve the best vision possible. That after all is the point of RLE.

Webdev good luck. It's really hard when you can't understand the surgeon's reasoning for electing a particular treatment.

My vision is still blurry at all distances and I've been told to wait three months and then they will use lasix to correct my residual astigmatism and myopia in LE.

​if you search the youtube,  iol lens refelction, there are some videos show the reflection, you might understand what I worry about. actually many person complaints this.

I've never had anyone able to notice anything different about my eyes, with the Symfony in each, aside from eye doctors. My impression is that with the vast majority of patients, no one has a clue they had surgery and its only an eye doctor looking into the eye that sees it. A friend of a friend apparently doesn't tell people about his cataract surgery  (my friend wasn't supposed to have overhead) thinking it makes him seem old (even though cataracts happen at any age, mine was a problem starting at age 49). No one has guessed or seems aware of it. 

 I doubt the issue is at all common, if there is some rare issue causing a reflection to be noticeable in certain eyes it also isn't clear that it would be any different with a monofocal than it would be with the Symfony. You already note a different IOL where someone claims to have the issue, the Restor, and I suspect the grandmother you mention had a monofocal.  

There are > 20 million cataract surgeries each year around the world, if some few have visible reflections and wind up on youtube that says nothing about the % risk of it.  A Youtube video of course can be artificially staged to highlight something no one would notiec if they weren't looking for it, or where the light is placed just right.

While there may be some real cases where a reflection is noticeable to someone who wasn't looking for it,  I suspect in most claimed  cases (perhaps even including that grandmother) it is due to people's suggestibility, being told there is something different now about  the person's eye and then convicing themselves it must look different. Or people merely fearing others see something different. I suspect its like anorexia where someone can put on a couple of pounds and is convinced everyone thinks they are fat, when in reality they are thinking they are still too thin.

Thank you software, I feel better actually,,, I tried to paste the URL of the youtube, but this forum seems does not allow it. The following is what I found from the internet:

A friend recently had cataract surgery. I notice a different reflection in her eye than before. She had boht eyes done weeks apart. Now that the second eye has been done I see this different reflection in the second eye also. What is it? Thanks      

-------------------------------------------------------------

My vision in the operated eye is great and I am really happy with it. Day six and three people have commented on the evil look as my eye flashes at them. So yes, it does affect ones sense of self. One friend said, Oh my god I can't look at you it's spooky, so I understand why people are upset. I hate to think what I will look like when I have both eyes flashing at people. My eyes have always been my only redeeming feature in a somewhat plain face, and have been used to people complimenting them. Now I guess I'm just plain.        

----------------------------------------------------------

My acrylic AcrySof IQs do have a noticeable reflection (youthful glow?) in certain lighting conditions.  If this is something that you want to avoid, I've read that the new acrylic one-piece Tecnis monofocal does not have this type of reflection.  Neither do silicone IOLs.      

------------------------------------------------

I've had the same problem, and I've noticed that almost every doctor says "it's no big deal," "you're being too sensitive," or some other patronizing remark like "now you have a twinkle in your eye." When you look in the mirror and see what appear to be white holes in your eye, you do feel self-conscious, and even worse when people make comments like, "ooh evil eye." I completely understand why Gail says she avoids looking people in the eye.

------------------------------------------------

Hah!  This glare is UGLY and ABNORMAL looking and I believe it was an AWFUL side effect and I am APPALLED I was never informed that they have OPTIONAL lenses I could have gotten that had no glare.  This is BAD.      

-----------------------------------------------------

?the above is what I found from the internet, I have heard one of my friend said, her friends got cat eyes after cataract surgery.

?I guess Symfony does not have this problem.

That threat includes people with monofocals, e.g. the AcrySof IQ  is a monofocal made by a different company than the Symfony. It also includes doctors and patients explaining that the vast majority of IOLs can't be seen by others.  The issue isn't enough of a big deal for surgeons to have even bothered doing studies about it or writing in their trade journals about how to talk to patients who have the issue, since it just isn't common enough (assuming it does actually happen, and isn't just a trick you can get to work for a video, or something suggestible people see, but not usually visible).

Again, I doubt the Symfony is any different from other IOLS in terms of this, no better or worse, that this problem is rare with any IOL and likely whatever tiny % have the issue with the other lenses have it with the Symfony.  The Symfony is the same size and shape overall as the Tecnis monofocal (and Tecnis multifocals). Picture it as being like a company that has 1 eyeglass frame design  and the only difference is the details of how the lens is ground for different optics. If you look closely at the IOL you'll see diffractive rings on the Symfony or multifocals, but its doubtful those would have much if any impact on what someone outside the eye sees, only what the person with the lens sees.