Need advice on IOL selection process...
Posted , 20 users are following.
I am 70 years old and was diagnosed with a cataract in my right eye (non dominant) nearly a year ago. My vision in my left dominant eye is still excellent, but my optometrist says I can expect to get a cataract in it too at some point. I am moderately myopic and have had a +2.5 add for reading for a long time. Long wait in my area of Canada (Alberta) to get an appointment with a surgeon, but I will have my first pre-op consultation a week from now. I did a bunch of research into my options when first diagnosed and then let it slide. Now push is coming to shove, and I will have to make a decision. For those who have been through this I would be interested in getting some advice as to whether I am thinking this through properly and if there are options I should be considering that I am not. Although I will have to pay for anything over the cost of a basic lens out of pocket, cost is not an issue I worry about.
For needs, I drive, some sports. I use contacts for snorkeling. I do some shooting and target shooting with my right eye (which now has the cataract), and really want excellent distance vision. With age I have found driving at night more and more difficult, and I also want excellent night vision for driving. I have tried monovision with contacts, but gave up on it. Partly it was because I really don't like contacts, even though I have been wearing them on and off since 1975. But the main reason was I did not at all like the night vision and flaring of light I was getting from it. I was afraid to drive with my contacts at night, even though my day vision was excellent. While it would be nice to be glasses free, to me excellent vision is a higher priority. I use the computer a lot, and my progressive eyeglasses work very well for me to do that.
So, what do I do? I have a friend who went the multifocal route and she likes it. She says she can do most things without glasses except for reading small print on OTC drug labels and the like. She uses readers for that. She is also adverse to wearing glasses. My thoughts are that this is not me. While I would like to be glasses free, I also want as perfect vision as possible for both reading and distance. This has lead me to think a lens that corrects for distance only is the best route for me. I have some astigmatism and I expect I would also benefit from a toric lens to correct for astigmatism. My research to date has indicated the most popular choice for this type of lens is the AcrySoft IQ Toric IOL. It is claimed to be the most stable in position and easiest to locate correctly. The negatives I have seen on it is the issue of glistenings. But, that seems to have been addressed with improved manufacturing quality control -- or at least the mfg claims that.
So, for those that have been through this, what do you think? Is this thinking sound? Alternative that I have overlooked? Other factors I should consider?
1 like, 106 replies
Joe_M RonAKA
Edited
Ron -
I cannot specifically comment on those lenses, but I can provide some input on the PanOptix trifocal toriq lenses.
I am about 7 & 8 weeks post op to having these PanOptix lenses implanted in my eyes. I am 55 and had cataract in both eyes (right was worse) and was having really bad issues with headlight glare at night to the point that it was almost totally whiting out my vision. So, it was time to do something.
I had many of the same considerations in my IOL choice as what you have outlined. Far vision was always a must, but I also do a fair bit of shooting and a lot of computer work so both close and intermediate distances were also important. My vision made seeing the front sight on my pistols difficult. If I wore glasses, I could see the sight but the target was blurry; no glasses and the target was clear but sights were blurry... I was always using +2 readers for the computer work.
So, given my lifestyle, I opted for the trifocals that were supposed to provide improvement at all distances, and the toriq lens also corrected for my astigmatism. I really did not want to take a step back and HAVE to wear glasses which would have been the case with the monofocal lenses.
So 7 & 8 weeks post-op, highly pleased with the results. I have 20/20 & 20/25 in R & L respectively for my far vision, and 20/20 for near. I can see everything clearly from about 8 inches and beyond. LOVE the vision results. The down side for me is that I get concentric circles around lights at night. Annoying more than anything, but MUCH better than the whiteout I used to get with my original lenses with the cataracts. I knew that these kinds of issue could be the result of my multi-focal lens choice. Some get these circles, some get starbursts, some halos, some nothing...
So all in all, I am 95% happy with my choice. They say that over time my circles may diminish, but I am not holding my breath. It is just the physics of optics, and I am getting what I think they call Newton rings.
Sorry for the long-winded response. Hopefully there is some useful info in there to help with your contemplation. Good luck!!!
RonAKA Joe_M
Posted
Thank you for the very helpful response. I can understand your issues with open sight handguns and the problems that would present. I do very little shooting with open sights though. My main activities are with a target rifle using a 24X adjustable objective scope, and also a rimfire with an 18X AO scope for varmints. No need to see the open sights and I think to some degree the focus adjustment and AO on the scope corrects some of my vision issues. But, I still need good distant vision for it all to work. I have also done some shotgun shooting of sporting clays, and pheasant hunting. But, my pointing dogs are gone now, and I doubt I will return to that. My big issue there was that I am right handed and my left eye is dominant, so I could not do the both eyes open sighting. I can't say that is a priority now.
I will do some research on the lenses you are using. At this point I am not sure what options I will be offered by my scheduled surgeon, Dr. Chris Rudnisky. He has connections with Alcon/Novartis, so I may get pushed in that direction. I believe the PanOptix lens you have are also made by them, so it could be an option he would recommend.
janus381 Joe_M
Posted
Ron, you are wise to do your research beforehand.
Based on your needs, I think the two most likely options to carefully consider for you would be
(a) mini-monovision, where dominant eye set for distance, and non-dominant eye set to be a little myopic -- but not a big difference between the two eyes. W-H has a lot of posts on this option. should give you good intermediate to distance vision, or
(b) a premium tri-focal lens.
Note depending on the condition and measurements of your eye, a premium lens may not be a recommended option.
I would also say don't worry too much about which manufacturer. I don't know how it is in Alberta, but based on my experience (Toronto) and experience of other Canadians who have posted, I think you choice is mono-focal or premium, and your eye doctor will decide which lens is best based on your measurements and which lens your doctor likes to use.There are pros and cons with each manufacturer, but the two most common ones used in Canada would be Alcon and Tecnis (J&J), although only Alcon has a tri-focal approved in Canada.
You are wise to consider the downside of premium lens, but note that premium lens have improved substantially over the last few years. The Alcon PanOptix tri-focal has only been used in Canada since 2017, and was only approved in the US late last year. But tri-focals including the PanOptix have been used in europe for many years.They are not for everyone, but they are much better than older multi-focals (which your friend is happy with), and US surgeons have the advantage of learning from the prior experience of surgeons in Europe and Canada.
I have a fairly long post on my experience with PanOptix. It's now on the second page. it's titled
"Cataract Surgery Just Completed - Sharing My Experience - PanOptix Tri-focal". Not trying to sell you on going to premium IOL route, but you can read my experience.
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RonAKA janus381
Posted
Janis, thank you for your post. I had responded to Joe a while ago, but I guess the post got hung up in moderation as I included a link that had a bit of info about my scheduled surgeon, Dr. Chris Rudnisky. Based on my research he has done consulting for Alcon/Norvartis, so I am expecting that is what he is experienced in. He also has published a couple of videos on YouTube on how to load and insert an Alcon lens. Yuck, I'm not sure I should have watched that!
Your suggestion on a mini monovision is interesting. I have tried monovision with contacts. My non dominant right eye got under corrected by 1.25. I found it pretty good, but as I think I mentioned before as I get older I have gotten less tolerant of contacts, and I did not like the night vision I got at all. Not sure how much to apportion to the issue of just using contacts and how much to the monovision. The complications as I see it are that I could not procrastinate (which I like to do) about using the under correction, as my right eye is not dominant and has the cataract. So I would have to go all in with under correction on the first eye. The other issue is that my right eye is the one I use for shooting and there is no easy way to change that. It is the one I would like the best vision in. That said I will research and consider the option.
I have been doing some research into the PanOptix Tri-Focal option and will consider that as well. I've got to touch base with my friend and get her latest thoughts. She had hers done in Calgary about 9 months ago now. Not sure what exact lens was used other than it was a do it all multifocal type of some kind.
More research to do...
Ron
RonAKA janus381
Posted
To Joe and Janis,
I touched base with my friend that had both of her eyes done in Calgary, 9 and 8 months ago. She did have the AcrySoft IQ PanOptix lens put in both eyes. The short story is that she is not at all happy with them. She says reading glasses and very bright light are mandatory for reading. Reading in dim light is impossible. She says she has huge halos around lights at night and she is afraid to drive. On the more positive side she says vision at distance while driving during bright daylight is excellent. Her thoughts were that she made a mistake and now wishes she had have gone with the distance only lens, and resolved to use reading glasses.
So, it was not a good reference, but one data point only.
flower2016 Joe_M
Posted
Does these circles/haloes appear only at night or you see them during the days as well? From what I read, they seem to really bother drivers, but I'm not a driver, so I wonder if they would be a problem for me.....
RonAKA flower2016
Edited
I don't know if Joe_M is still following this thread. My understanding is that the halos and flare with MF lenses are a night time issue. If you don't drive then it may be a bit of an annoyance but not a safety issue. The daytime issues are more likely to be how well you can read with them, or if you need readers as well.
el1812 RonAKA
Posted
Ron, it is great that your vision in another eye is still excellent! I have had three consultations with different eye surgeons already, and this is a not easy decision to make... It looks that you need the best quality monofocal lens to match your healthy eye. No glare, no glistening, optically good enough 'for pilots and jewelry makers', with good protection from PCO and absolutely crucially must have not only UV filter, but both Blue-Light and UV filters to protect retina the same way as your natural lens from Macular Degeneration. My Mother has it after clear lens was implated... This is the issue most surgeons are not interested at all, as they do not see the potential damage with 'clear' UV only lenses on the long run. There are some Japanese studies about it for 14 years period, and there is no dispute in their results. My good Consultant told me that for himself he would choose only yellow tinted Blue-Light with UV filters lenses. The two others said it all the same and wanted to convert me to trifocals., at the extent (at Optimax Clinic) I was told my healthy eye had a cataract as well..... Not... The 'yellow' tint is not visible when implanted, but gives a better night vision without any colour distortion. Alcon (I am still thinking about it, but a bit afraid of glistening) took the idea from Japanese company HOYA, and my consultant highly recommends it. Firstly HOYA specialises in monfocals and toric monofocals. Secondly HOYA lenses are glistening FREE. Thirdly their last generation HOYA Vivinex range offers special protection from PCO as the lens is treated with oxygen and has even better designed edges. And finally, most of them have either Y yellow (uv plus blue-lighr filter) or clear (uv only), so it needs to be specified while ordering. Just Google it to see on their website which lens you like and ask your surgeons.
P. S. You are just 70 years young. You need to plan the best for your eye at least for 30 years. My Mother had a clear IOL implanted, and very soon after her AMD had started. Another eye was with yellow tinted IOL without problems. All the very best to you, and good luck!
RonAKA el1812
Posted
Thank you for your comments. I will look into the blue light and UV issue. I believe the Alcon AcrySof do that. I am diabetic so susceptible to retina damage. So far my exams have shown no issues in that respect. My BG is very well controlled, and I sure hope I can avoid that kind of stuff. I am also afraid that while my good eye vision is excellent now and is saving me, it probably is not going to stay that way. A few years ago my optician said cataracts were likely to develop, so I suspect the good one is not going to stay good from a cataract point of view.
mjcg RonAKA
Edited
Hi Ron - It's going to be important that the IOL between both your eyes are in sync, so make sure you talk to your surgeon about his/her recommendation for a lens. I had only one eye done due to a cataract that developed after a vitrectomy (to repair a detached retina). My surgeon told me that the other eye likely wouldn't develop a cataract until I was in my mid-80's (I'm 65). Because I've worn glasses/contacts nearly all my life, I was ok with going the traditional route and opted for a near vision lens (this is not what most people do!). The new lens that was inserted was close to the prescription in my "good" eye so that they'd be "in sync" and I'd avoid double vision issues. I'd read a number of near-sighted people who went with distance lens and missed their close up vision. So I played it safe. But I can tell you that I saw three different surgeons and each one had a different opinion. Ultimately, you have to go with what YOU think will work best for you. That's not an easy decision to make. I can also tell you that the vision in my 'operated' eye is amazingly clear. I mean I see close up, and wear progressive glasses for mid/distance sight, but the world is more crystal clear. My "good" eye has a slight yellow tinge to everything I see that I had not noticed before. So... once you have your surgery you are going to be really, really pleased no matter what lens you go with.
I don't think there is a "cure" for the night driving issue we have as we age. I've seen starbursts and glare all my life so it's nothing new to me. It's hard to drive at night especially when it's raining out. But I think this is an issue with how our pupils dilate and take in light as we age.
You are right to do your homework now. I think it sounds like you should go with a distance lens and then depend on reading glasses for close up vision. But, again, talk to your surgeon. Don't be shy about calling the office and asking a few questions.
Good luck and keep us posted!
RonAKA mjcg
Posted
Thanks for your comment. For some reason some of your response seems to have been truncated, and I can't quite follow it. Yes, I know that part of the night driving issue is that our maximum pupil size decreases with age. That allows less and less light into the eye, and I agree there is no way around that part of it, that I know of.
mjcg RonAKA
Posted
I actually "reported" my own post because it posted only part of my answer. Looks like it's fixed now though. Hopefully you can read it all. Please keep us posted on your decision and your operation, ok? Your experience will help others who come to this forum looking for support and answers. Best wishes!
RonAKA mjcg
Posted
Thank you for the response. I had not considered correcting this eye for my close vision. It is something I will have to think about some. For sure that would require distance eyeglass correction for my shooting hobby.
Based on what my optometrist told me, I can expect to get a cataract in my current good left eye sometime in the next year or two. I was warned about some evidence in both eyes about 3 years ago, and sure enough one of them has gone south big time. Probably just a matter or time for the second one.
I am a bit concerned about how I am going to handle the situation of having an IOL in my right eye and still have the other eye well corrected with eyeglasses. My current plan is to wear a contact in my non cataract eye for the 6 weeks or so for the recovery of the IOL eye, and then get a new eyeglass prescription for both eyes. I'm thinking that is going to be somewhat temporary as the cataract develops in my "good" eye. With our health care system in Canada, I'm sure they will not be willing to do anything with the good eye until the cataract has an impact on my vision.
In any case you have given me a bit more to consider. That is my goal at this point -- to become as well informed as possible, so I can make the best decision on this first eye. Thank you again...
RonAKA mjcg
Posted
mjcg, I am curious about something you mentioned in this post.
"It's going to be important that the IOL between both your eyes are in sync...The new lens that was inserted was close to the prescription in my "good" eye so that they'd be "in sync" and I'd avoid double vision issues."
I am wondering if you require correction for prism, and that is the reason for the concern? I have never had any correction in my eyeglasses for prism. I had not considered that correcting one eye to full distance vision while the other eye needs contact or eyeglass correction would be a problem?
RonAKA
Edited
I recall this was my first post at this forum and it is now time for an update. I finally got my call and a date for the surgery on my right eye. It was supposed to be in early August, but now it is October 7th. COVID caused the 2 month delay, and I was worried it was going to be much longer than that.
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I reviewed the posts in this thread and now realize that this is all very good information. The final decision on my lens has essentially been made in my mind, and I am just waiting for a call from the surgeon to confirm the details. I considered the PanOptix, but the surgeon was not supportive of that choice. My friend that had PanOptix in both eyes is still not happy with them. She was reading outside the other day in full sunlight with reading glasses. I asked her what power her reading glasses were and she responded that they were +1.75. It almost seems they may have had a bit of a miss on the power for her lenses. In any case between my surgeon discouraging me (he said he would not put them in his own eyes), and the experience of my friend, I decided against them. I do appreciate that there are many here that are very happy with the PanOptix though.
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So my choice in the first eye will be a Alcon AcrySof IQ Aspheric Monofocal lens for optimum distance vision. This lens has blue light filtering, which I decided was a good idea, as it matches the natural lens filtering the best.
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My long term plan when my currently pretty good left eye goes south is to consider mini monovision. When my operated eye full heals I plan to get my eyes tested and see where I stand. I will try a contact in my left eye with an undercorrection of 1.0 to 1.5 D to see if I can tolerated monovision. What I had feared was that my surgery was going to be delayed so long that my left eye was not going to be good enough to evaluate monovision simulated with a contact. It appears now that I should be able to do that. Have not had my eyes tested for glasses in a long time now, but I think the left eye is still close to 20/20. In any case monovision will be a deferred decision. Hopefully the contact lens trial will determine if I can tolerate it or not.
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The only thing that is giving me a bit of concern is I have realized that I often look over the top of my progressive glasses to get the best close up vision. With a distance lens, that will no longer be and option for me. But any way I slice it, I'm sure I will end up with glasses for the best vision at all distances.
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So, thanks to all who gave me advice that guided me to the end point of this first phase of the IOL journey. It is not easy and it is not hard to see that there are many good solutions and the best one will vary with each individual. The advice given here was very good, and helpful.
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Edit:
Just talked to the doctor and confirmed the distance monofocal AcrySof IQ Aspheric lens. He says he will use a -15.5 power which in theory leaves me slightly myopic at -0.34, but he is afraid to go more as it is not so good to go over corrected.
Chris53317 RonAKA
Posted
Best of luck with your procedure Ron. It has been a long journey getting to this point for you, but it has given you time to completely asses your options. It has also allowed you to provide many people here with insights from your research. Well done!
With a good surgeon I would speculate that 99% of the choices made, whatever they are, will have a good outcome.
RonAKA Chris53317
Posted
Thank you for the encouragement. Now I need to come up with a plan to cope with one IOL eye, and one natural lens eye, that is pretty good. Seems like my choices are to remove the lens in my eyeglasses from the IOL eye, or to start wearing a contact in my natural lens eye. While I started wearing soft contacts back in about 1974 or so, I really have difficulty with these new super thin ones. I guess with practice I will get better... I suspect however that contacts will not be a permanent solution. I really do not like them that much.
My "good" left eye prescription is:
Sphere: -1.50
Cylinder: -1.00
Add: +2.5
I suppose I could just not wear glasses at all and see what I can see. My left eye is close to what a monovision solution would be, except for the cylinder. However, I always roughly estimate the total correction with astigmatism to be the sum of the Sphere and Cylinder, or -2.5 D. The issues is that I would lose the astigmatism correction, and I expect my eye still has some ability to change focus distance even though I am 70. That would make it better than what a similarly corrected IOL would. However, it may be a solution. I will also have to look at what I have for contacts. They are toric, and perhaps by chance one of them may get me closer to a simulated monovision. Without glasses my close vision is excellent with my left eye, but my distance at 10 feet or more is poor. Since my left eye is dominant, perhaps wearing no glasses would be good training to switch dominance to my right eye???
soks RonAKA
Posted
good luck!
RonAKA soks
Posted
Thank you.
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My "good" left eye prescription is:
Sphere: -1.50
Cylinder: -1.00
Axis: 080
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I would think a monovision contact for this eye would ideally be:
.
Sphere: -0.25
Cylinder: -1.00
Axis: 080
.
I have a supply of contacts that are:
.
Sphere: -0.75
Cylinder: -1.25
Axis: 110
.
Far from perfect, but I can actually see quite well close up, and half decent at distance. It makes me optimistic that if I get proper power contacts I may see quite well with an IOL in the right and monovision power contact in my left.
soks RonAKA
Posted
you could even go -0.5 for your good eye and still maintain the good near with it through the contact lens. this combination is better than iol monovision because natural near vision is a lot better and wider range than iol one.
the iol diopters are 0.35D. in your case 15.5 is giving you -0.34D. 15 would give you +0.01D. so 15 would give you dead accuratw on distance vision. they always err on slightly myopic to not waste diopters to account for measurement errors hence the 15.5 recommendation. seems like you have a good plan.
RonAKA soks
Posted
Yes, I cannot simulate IOL monovision perfectly as the natural eye I'm sure still has some ability to focus closer. I will get some advice from my optometrist and surgeon on how to best simulate IOL monovision with contacts. At this point I am not sure how seriously I will consider using a contact for my remaining good natural eye. My main purpose will be to evaluate whether or not to actually go for IOL monovision when it comes time to do the second eye.
My surgeon said exactly the same thing about using the -15 to get emmetropia. His comment was that patients are never happy if he goes over, but are ok with slight myopia.
janus381 RonAKA
Posted
RonAKA:
Best of luck with your surgery. I've read your posts on and off, and no doubt you have done your research and are making the right choice for you, your needs, and your personality.
Two comments you make in many of your posts.
(1) Your surgeon would not use a tri-focal in his own eyes, and thus he does not recommend them.
(2) You have a friend who was initially pleased with PanOptix, but now is not as pleased as she needs readers.
Not posting this to try and change your mind, as premium lenses are not for everyone, and it seems clearly not for you, but I would make the following comments:
Some eye surgeons in North America discourage premium lenses because of poor experience with bi-focals (which were the premium lens option in the US and Canada for many years).My ophthalmologist also used to discourage the choice of premium lenses, but she is very happy with the experience her patients have had with the tri-focal that has been available in Canada for over 2 years now (PanOptix).
As I mentioned in another post, your friend really should be seeing the eye doctor to see if there is something else going on -- either PCO and/or dry eye.
I think your plan to try mini-mono-vision is the right choice for you and is a very good option for many people.
RonAKA janus381
Posted
I agree with most of what you have said. My conclusion is that multifocal lenses like the PanOptix depend a lot on the personality of the person that is using them. I think some have higher expectations than others, or are willing to compromise more for the freedom of not wearing glasses. My surgeon, friend, and myself may be among those types of personalities. I don't think my surgeon is uninformed as he has been a paid consultant for Alcon and should be very informed as to what they offer. I suspect he would put the PanOptix in if I insisted, but I am not.
I have briefly discussed my options for my second eye with the surgeon. He says I have enough astigmatism to warrant a toric IOL for it. However, he says he is not sure it would be a good idea for me as my astigmatism in that eye is irregular. It does not look like a symmetrical hourglass shape on the topography map. Apparently toric lenses do not work all that well for irregular astigmatism, and they can create optical aberrations that can lead to halos and flare effects. Makes me wonder if some of the issues that people are having with multifocals may be the result of irregular astigmatism. This is something I will look at carefully before I proceed with the second eye. I suspect my surgeon is going to suggest non toric lenses and laser surgery to correct the astigmatism. And, I am not so sure about that option either. I'm quite sure that I am going to want prescription progressives in any case to get the best vision for driving, and small print reading. That may be the best solution for the astigmatism as well.
In any case, my fate is now cast for the first eye. And one thing I can say for sure about my surgeon is that he is certainly not pushing premium lenses.
Chris53317 RonAKA
Posted
Ron, there may have been a contradiction in your recent post that you may want to clarify for the record. You first implied "... are willing to compromise more for the freedom of not wearing glasses" and then said "I am going to want prescription progressives in any case to get the best vision".
People like me who choose trifocals want to avoid glasses if at all possible. Mini-monovision was my second choice, recommended by my optician, but that option may not have eliminated glasses. As has been discussed many times, there is no guarantee, choose what seems best for you.
RonAKA Chris53317
Posted
I may not have worded it well. My thinking is that the potential compromises of trifocals are the halos, flaring effects at night. And, being able to read in lower light may also be a compromise. My thought is that a trifocal gets less light to the eye at near distances. Some are willing to risk those issues to be able to go without glasses at least the majority of time.
I would like to go without glasses but it is not as high a priority as having the best vision. If my monovision does not give me the best possible vision I am quite willing to wear glasses to get the best possible vision in the more difficult circumstances. I am adverse to go with the Lasik surgery for fear it will complicate future work needed to maintain my vision. That has been a fear for some time and it has allowed me to go for IOL's with no previous surgery and associated damage that may introduce to the eye.
The nice part about glasses is that the fitting is a trial and error process. The optometrist just tries different correction types until you find the one that works best. IOL surgery is pretty much of a one shot deal, and you get what you get. I see glasses as a viable option to make the final fine tuning of the correction. And with a progressive I can have my undercorrected nearer focus IOL fully corrected for distance, while still having the ability to read. I have never had issues using progressives, other than when working overhead close up.
I hope that is clearer. There are compromises with any choice we make. One has to be prepared to live with them. My only point is really that while some lenses are described as "premium" and carry a higher price tag, that does not necessarily make them better for everyone. They are different with their own set of pros and cons. I am not sure they are always sold that way. Sometimes they are sold on the good, better, best scale of quality, and that if you can afford the best you should get these "premium" lenses. It is not quite that simple.
robert80020 RonAKA
Posted
I'm guessing you didn't consider the RxSight light adjustable lens or did i miss It?
RonAKA robert80020
Posted
No, I did not consider that lens and it was not offered to me by my surgeon. On a quick internet search I don't think it is available in Canada. Seems like a good idea though if the correction remains stable throughout the life of the lens.
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I did discuss the option with my surgeon of going with a Tecnis lens instead of the AcrySof due to the potential issues with glistenings in the AcrySof material. In the end I decided to go with the AcrySof for the potentially better resistance to PCO and for the blue light filtering. The Tecnis may have been available with blue light filtering, but I did not go that far down that road.