Need advice on IOL selection process...

If you have any kind of ocular pathology that can limit your options. Like if you have glaucoma most doctors will rule out a multifocal IOL. But beyond that it's simply a question of your lifestyle and expectations. Pre-op myopia or Lasik doesn't rule out any options. Although Lasik makes hitting the refractive target a little less predicable so a more "forgiving" IOL like a monofocal or Eyhance might be a good idea. But it doesn't really rule any options out. So you just have to think about your lifestyle, occupation, expectations, priorities, tolerance for imperfection, and so on and choose from there. This is a discussion you will have with your surgeon.

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It basically boils down to monofocal (best possible image quality but you will need glasses sometimes) or EDOF / multifocal (widest possible range of vision so you will rarely or maybe never need glasses but you sacrifice some overall image quality especially in low light). It's basically quantity (range of vision) vs. quality. What is more important for you is ultimately a question only you can answer.

I guess the most important information is your priorities in vision after cataract surgery, and your age I guess to a lesser degree. Do you want to be eyeglass free? Previous Lasik is a bit of a complication as it can make the eye harder to measure accurately to determine what power of IOL lens you need. It is good that the lazy eye issue was addressed when you were younger. My wife has that issue, and it is not clear yet how successful an IOL will be as it was not addressed when she was young. The cataract can affect your vision in various ways one of them is to make your close vision better. Some call that second sight. Mine were the opposite. They seemed to improve my distance vision, and increase astigmatism. It is irritating how fast vision can change and need new eyeglass prescription changes.

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What IOL's have been recommended to you? Have the surgeons suggested you need a toric lens? In any case if you can provide some more detail I will try to help. I am not a medical professional. I just have done a bit of research as I have currently one eye done. My wife is in the same situation, but will get the second eye done in about 3 weeks. Not sure when my turn will be...

Thanks for the quick replies. Basics, age 60 so I think strategy would assume IOL in dominant eye sometime in the future. So I want to see distance for sports, sand volleyball and maybe that career is not forever, but I still got a few good years and I think having 2 eyes with distance is a plus (and Lasik corrected both for distance), computer/laptop yes, and functional reading/phone vision a plus - all without glasses. Right now I can do about everything functionally, dominant eye does distance, near, and both eyes work together for close. When I recently had eyes checked, optometrist gave me some sample contacts and I kind of hated it, like when I was at the grocery store without readers and had trouble reading labels. I would be OK with readers for small print, but phone and laptop at 12-24 inches I would prefer no glasses.

Recommended IOLs. 1st MD, Top Doc in Phoenix. I kind of got this discussion going in the wrong way; I lead her a bit. I was thinking Panoptix - who wouldn't (based on literature)?! She did provide some qualification, did a topography, said lasik area was mostly under eyelid ... could work, no guarantees. I understand halos from Lasik so sounds good. They were ready to schedule surgery!!! I delayed for research. I think that very day I found out about Symfony!!! Since that MD was not "selling" that IOL I found and MD that was. Net result at that next MD, after I brought up Symfony, was that he would never recommend me for a multifocal IOL. I had aberrations something like 5-6? and limit in his opinion for multifocals was 2 max - something to that affect. Recommended Zcboo, I believed this guy, and was ready to move forward, but his surgery center did not accept my insurance!? OK, on to MD #3, where I had my Lasik, kind of an eye factory, but running out of covered options. Tests as usual, then saw an optometrist, recommended Vivity. I actually asked if there were any limiting abberations (yes I used that word) and he said I was good - you'll love them 😃 I realize they're upselling the premium IOLs, but if it gave me substantially better function I'm a buyer. I mean it's your vision, right!

So I did check out the Vivity and it might be good, more forgiving with prior Lasik (lots of MDs won't do multifocals on Lasik eyes) and hopefully functional close vision. What I'm also wondering though, is what is the 2 eye strategy? I'm not sure when the the good, dominant eye will need IOL and would I want that eye to have the EDOF, multifocal, or monofocal. My bad, in that I didn't have all these questions ready for these MDs, but it does seem like these eye docs are not taking a lot of time to work with patients - not anything like my experience with primary care physicians. I feel like I really need to take a very proactive role in this decision.

That's my story so far. I appreciate your help and also allowing me to vent a bit. 😃

OK, I understand better where you are coming from and what you hope to achieve. I have not had an Lasik and can't comment from experience, only what I read. I believe the scar tissue or what is left from the Lasik makes it difficult to calculate power of the IOL. It may also contribute to the flare and halos one can see with MF IOL's for that reason some surgeons may not want to do MF IOL's.

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It sounds like you may have gotten into a form of monovision with Lasik surgery, where one eye is set to see closer and the other for more distance? If so, be aware that is an good option with IOL's as well. If you know your eyeglass prescription for your eyes it will tell you how much monovision you have. It is typical to have full distance correction for the dominant eye, and about -1.25 or so myopia in the non dominant eye. If that is your case it is a good preview of what you can get with monofocal lenses in a monovision configuration. If you can still see fairly well you can simulate monovision with contacts. You don't have to wear them for a long time, but just enough to see if you like monovision or not, and whether it works for beach volleyball or not. I would expect it would.

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On MF choices I think both the PanOptix and newer Synergy are good options. I see them as a Coke and Pepsi choice. They do have drawbacks though. Night vision is almost certainly to be compromised with halos and flare, and the spiderweb combination of them both. If you don't drive at night or are not bothered by those side effects they can be a good option. With the Lasik it may be harder to get the power of the lens correct. One possible issue with the MF choice is that getting progressive glasses to correct for any error may be more difficult. Remember that no surgery ends up perfect. Measurement is not without error, and IOL only come in 0.5 D steps of power compared to 0.25 steps for contacts and glasses.

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I looked at Vivity for a long time, and I think have finally decided against it. It is not as risky as the MF options but does seem to have some issues. Eyhance is an even more subtle EDOF, and could be considered as well.

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You may have read in my posts that I am simulating -1.25 D monovision with a contact in my non operated eye. I am liking that a lot. I can read text on paper, my computer monitor, and even my iPhone with no glasses. I do keep some +1.25 readers around for difficult very small text reading.

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I hope that helps some. I have become bias, so there are other options. But, my suggestion would be to try simulated monovision to see if that meets your needs. Ideally you do the dominant eye first with a monofocal for full distance (-0.25 D target). Then you consider a second monofocal or possibly even an EDOF or MF for the second non dominant eye after you see what you get with the first eye.

What I'm also wondering though, is what is the 2 eye strategy

For Vivity I would ask for both eyes to be set exactly the same. I think you'll get the best quality of vision from them when they are perfectly in sync with each other working together. No mini or micro monovision offset. That's what the clinical trials tested and what the manufacturer recommends. The Vivity loses two triplets of contrast (Pelli Robson chart) monocularly in clinical testing and also shows low peak contrast in bench testing. But it's fine binocularly. So I'd set them the same to make the most out of their limited peak contrast.

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I think this would be especially important for volleyball (distance vision in lower light since I assume you play indoors). I know anecdotally of someone that did Vivity with a 0.5D offset (a LOT of surgeons are using Vivity this way) and he says that watching indoor sports is challenging with poor visual acuity unless he puts in a -0.5D contact lens to cancel out his offset.

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Eyhance has dramatically higher peak contrast so I'd be more comfortable using a slight offset with Eyhance. I don't think Vivity needs an offset as long as your expectation is just FUNCTIONAL near not perfect. Good enough to glance at the time or a notification but not for extended reading.

My thoughts on this would be quite different. I have pretty much ruled out using the Vivity in my second eye, but I have looked at it very carefully as an option. I will ask the surgeon about it, but it may be a brief discussion unless he tells me it is the best thing since sliced bread.

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Having the Vivity in both eyes is not an option for me now as I already have the monofocal AcrySof IQ Aspheric in one eye with a 0.0 D spherical outcome. I think if I was to put the Vivity in the second eye, the AcrySof IQ Aspheric would compensate to a large degree for the loss in contrast sensitivity with the Vivity eye, and much more so than if a second Vivity was possible. One Vivity and one AcrySof IQ was not tested in trials, but I strongly suspect that is a better combination. And if I was to put a Vivity in the second eye I certainly would ask for a target of -0.75 D, and not 0.0 D plano. I believe the Vivity set to plano would most likely come up short for reading standard size text on paper.

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If I was to use the Eyhance in the second eye, I think it would have to be targeted even more myopic than the Vivity, and a target of -1.0 D may be optimum. However I am suspicious about the claims that Tecnis make about the contrast sensitivity of the Eyhance. There has to be a cost to getting the 0.5 D of EDOF, and they are claiming there is none. Hard to believe.

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After using -1.25 monovision for a year now, I have lost any hesitancy I had about it. That may not be the case for everybody though. It is always best to simulate it first with contacts. I am not in the camp that both eyes have to have the same outcome and there cannot be any split between them. The brain seems to handle it quite well until the differential hits 1.75 D or more. I think another issue that is sometimes misunderstood is focusing on the amount of split, instead of the absolute value of myopia in the non-dominant eye. As an example say the dominant first eye is done first and ends up a little more under corrected than intended at say -0.50 D. If you want -1.25 D monovision that does not mean you would target the non dominant eye to -1.75 D. Instead you would still target -1.25 D for the second eye. It is the absolute value of the myopia that lets you read, not the split between the two eyes. In this example the split would be only 0.75 D.

My thoughts on this would be quite different

I'm aware. LOL. And I knew you would reply. But we will not agree on this. I've studied all the literature and sat in on many webinars and talked to people that had an offset w/ Vivity and talked to three different surgeons locally and personally I would not do an offset with Vivity. That said a small offset (absolutely no more than 0.5) is commonly done regardless. But I wouldn't do it especially if (as the original poster says) playing an indoor sports like Volleyball is critical.

Yes, we have done our research and come to different conclusions. I have no option to put Vivity in both eyes as my first eye is already done with a AcrySof IQ Aspheric monofocal. However, if I had a choice I would not put a Vivity in both eyes. I believe it is more functional with it only in the near eye. I certainly considered that, but when I compared it to a monofocal in the distance eye and a second -1.25 monofocal in the close eye, the two monofocals look even better, than the monofocal + Vivity combination. They are close however. The Vivity combination would likely give better distance vision, and about the same close vision. I still plan to ask the surgeon about it when it comes time to do my second eye, but I am strongly leading toward a two monofocal, mini-monovision solution.

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This comes from the perspective of having simulated -1.25 monovision for over a year now. I do not see any loss in depth perception, and I don't have any kind of hole in the vision range. With my closer -1.25 eye I can read my computer text very well from about 6" out into the 15-20" range. With my distance eye, I can start to read the monitor at about 18". When I look at it with both eyes I can read it at any distance until I am just too far away to to see the text large enough.

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Interestingly I forgot to wear my contact the other morning which leaves the close eye at about -2.0 D. That definitely did leave a hole at about the same distance as I normally sit from my computer monitor (12-15"), and would be very annoying.

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My thoughts are that people seem to fixate on getting close and far vision in both eyes and make compromises to do it. But, the other option is to optimize one eye for closer vision, and the other eye for distance vision. There are fewer compromises with the second solution in my opinion. And, with monovision there is always a plan B and second option for vision. You simply get progressives and wear them for any real challenging situations. I currently have progressives as an option, but virtually never wear them. I also do not carry around readers. They are a once a week or so solution for something with very fine print.

Are you sure that your near eye is really at -1.25? The math doesn't support it. The focal distance for -1.25D is a little over 31". With a range of 6-20", it sounds like you're going out of focus with your near eye by the time you get to that distance, when your focus should be improving as you approach it. Having a wider range of focus may depend on the eye, but it seems like the focal distance is a pretty straightforward calculation for a given diopter. You might want to get your eye with contact measured to see what's really going on. It would really stink to put all this effort into trials with contacts and get a nasty surprise after surgery.

I will just tell you what I have done, and you can let me know what you think. This is a bit of a moving target because I have an active growing cataract in the eye I am using for close vision, and there is nothing really precise about these numbers. I have been basing my calculations on two refractive tests taken fairly close together but by different optometrists:

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Oct 27/2020 - Sphere -1.50 D, Cylinder -1.00 D

Dec 8/2020 - Sphere - 1.25 D, Cylinder - 1.25 D

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A method I found on line for converting eyeglass prescriptions to contact lens prescriptions indicates that for low levels of astigmatism you can approximate the correction required for a non toric contact by adding 50% of the cylinder power to the sphere power. So for the Oct 27 number this works out to be -2.0 D for a non toric, and for the Dec 8 it is -1.875 D. From these numbers I reduce have reduced these numbers with both a -0.75 D contact and a -0.50 D contact. Based on the Oct 27 numbers This leaves me with -1.25 D and -1.50 D respectively. With the Dec 8 prescription this is reduced slightly to -1.125 D and -1.375.

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Through use of these lenses I have found the -0.75 D gives me the best balance of vision, but the -0.5 D is OK too. As a result my plan is to ask for a range of -1.25 to -1.50 D myopia, subject to my surgeon's blessing.

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I also did one trial with some toric contacts with a 0.0 D sphere, and -1.25 D cylinder. This contact at least in theory leaves me with a clean -1.25 D vision. It did give me a little crisper letters for reading, but really not much. And since the torics were significantly more expensive, and less comfortable I did not go with them.

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Complications? For sure there are some. One is that vision in this eye is impaired to some degree with a cataract, but milder one. The astigmatism I have has been diagnosed by the surgeon as irregular (not symmetrical) and when it comes time to do this eye he is not recommending a toric IOL. I do however wear glasses with cylinder and they seem to help some. But, I will follow his advice. The other complication is that it is still a natural lens, so may have some accommodation. I am 72, and have been presbyopic since I was in my mid 40's, so I think it is probably not much, but really no way to measure it...

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My surgeon has not been involved in my monovison simulation. I left it with him that I would find out what I like best with the various contact powers, and he said he would figure out what power of IOL would be best based on that.

Just as a bit of an update, I went for my annual eye exam today. Prescription has not changed. It is still the same as this one:

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Dec 8/2020 - Sphere - 1.25 D, Cylinder - 1.25 D

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However my corrected vision has dropped one level due to growth of the cataract. It was enough to get me a referral to the surgeon, which is good news. Current plan is to get an Alcon monofocal in the new Clareon material.

Before surgery, my "near" eye measured at -2.50 +1.00 x 180. After my distance (first) eye surgery, I'd try on readers to simulate what vision would be like with different targets and an IOL with no accomodation to compare with the eye with the natural lens, albeit with a cataract. When I wore readers with the eye with the IOL, I noticed that even with targets in the -1.75 to -1.5 range, I had less blur at distance with my unoperated eye, although I was seeing the world through a layer of schmutz and it measured as more nearsighted (and I'm old enough to not have much or any accomodation.) I also was able to read things at a much closer distance with the natural eye--probably in the 6-10" range. What I ended up with after surgery for my 2nd eye was MUCH closer to what I saw with the eye with the IOL and readers than it was to the eye with the cataract. So just be aware that the eye with the cataract can be a dirty stinking liar about what your final vision will be like, even with contacts or glasses. My near eye after surgery most recently measured at -1.75, and the Jaegar chart starts losing a little focus at about 17". The J1 line is unreadable starting at about 14" or closer. This actually tracks pretty well with the defocus curve--I should be hitting 20/25 around 17 inches, and 20/40 at 14 inches. Your astigmatism makes things tricky, but it might be worth getting some cheap readers in varying powers and checking out what depth of field you get with the eye with the IOL when you start making the target more nearsighted. It may end up like the eye with the cataract, but it's cheap insurance to check it out.

Good thought. I will try it when the sun comes up here and the lighting is better. I have some +1.25 D readers that I will put on and see what I can read with my IOL eye which currently measures at 0.00 D sphere, 0.75 D Cylinder. On a quick check I can just barely read the J1 paragraph in poor indoor artificial light, at about 14". I find lighting level has a major impact on how well one can read closer up.

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I use these readers when I have my contact in my non IOL eye and I see really well using both eyes. One will be at. Never thought to close my non IOL eye and see what it is like with only the IOL eye!

Never really got good sunlight today as it stayed cloudy. However, I did compare my left eye with the contact to my distance IOL right eye with +1.25 readers in the same cloudy outdoor light. I cannot read the J1 paragraph quite as close with the IOL eye. I can get get down to about 10-11" instead of 8". But, I think more importantly I can read J1 at 14". The vision with the IOL eye is brighter and with more contrast, probably due to no cataract, and I can see better than the contact eye at arms length. I also have no problem reading my iPhone 8+ at a normal distance, or my computer monitor with the IOL eye. It was a worthwhile exercise to see if the IOL eye behaves any differently.

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I think the big issue here is that there is a lot of variability person to person in what they can see and not see. Some of the defocus curves show an error bar, and it is pretty significant. I remember one from the Vivity package insert that compared the Vivity to a standard monofocal (the one I have). If you see at the high end of the error bar range for the standard monofocal, you actually get the same vision of the average person with a Vivity. For reasons I don't totally understand I seem to be able to see closer than average with my IOL eye and still get 20/20 plus about half of the 20/15 line. I think this indicates that if at all possible each individual should evaluate monovision to see what works personally for them and whether or not it can be tolerated.