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
Beth-R RonAKA
Posted
I am 66 with an astigmatism and I wear tri-focals. Yesterday (11/18/21) I had the PanOptix toric lens put in my non-dominant right eye and today I am seeing 20/20 in that eye. I haven't driven at night yet, but looked at a spotlight on the ground from a 2nd story balcony and saw radiant light when I blocked my other eye (no halo effect at all). My other eye has a cataract just starting and the spotlight had a haze around it, while the PanOptix eye was a sharper image of radiant light. Neither seem to bother me. Two days ago I would have needed my computer glasses (near & intermediate vision) to type this message and tonight I am typing without glasses! My other eye is adjusting to the change. Since my vision in the other eye isn't very bad, my doctor said this might happen. I took out the lens for my right (PanOptix) eye on my computer glasses, but I see better without any glasses at all. It takes time for the brain and eyes to adjust, but I guess I'm just lucky they felt like working together today. I am looking forward to only needing sunglasses and maybe cheap readers for fine print!
I'll try driving at night over the weekend just to see how it is... I'll know more then. I know it can take 6-8 weeks for the eyes to fully adjust to the change, you might want to check with people who are past that time-frame.
Good luck with your decision making and surgery.
RonAKA Beth-R
Posted
It sounds like you are having good outcomes with the PanOptix. Some do, but not all. I have a friend that had them put in both eyes 2-3 years ago. She did not make out as well. Her distance and intermediate vision is good, and she drives during the day. She does not feel safe driving at night due to the huge halos she sees around the headlights of oncoming cars. But, her biggest disappointment was her near vision. She uses +1.75 D readers to read and do any close work. She claims to have about a dozen pairs of reader glasses planted in all the vehicles, trailer, and all the rooms in the house, and thinks she could have gotten the same outcome with just normal distance monofocals.
jack64606 RonAKA
Edited
Sorry for late reply, busy, my Eye MD appt. is next week so I have to get ready. Few responses, my Lasik corrected both eyes for distance. My ability for close & near vision is presbyopia is not bad yet. I play sports (VB) outdoors, and also don't see a big need for a lot of night driving. When I had Lasik I did have halos and stars, but I just checked my eyes and I really don't see that affect any longer so it could be true that your eyes/mind adjust.
Here's some data from optometrist and ophthalmologist regarding eyes. The optometrist just gave me some sample contacts and wasn't concerned about astigmatism since she new I would be getting cataract surgery and this was just a temporary script.
Opt (sphere, cyl, axis): OD: -0.75, -0.5, 005 OS: -4.0, -1.25, 175 (Glasses)
OD: -1.00 OS: -5.25 (contacts)
Opth: OD: SC 20/25-1 OD: -1.25, +0.5, 069
OS: SC 20/100+1 PH 20/50+2 OS: -6.75, +1.25, 103
These were done a few months apart, but I wonder about the differences?
My RE (dominant) does have a cataract, but minor so no telling when it would qualify for surgery. And it does seem that if people talk about differing IOLs they would use target the dominant for distance.
So right now it's a decision on the LE. Current recommended IOL is Vivity. Let's face it, it's probably the only premium IOL they feel safe in recommending. I plan to ask if they feel confident in Vivity why wouldn't I just go with the Synergy and get it all? Currently the only eye that works for reading distance is the LE (and I think dominant in phone use) so I fear I will lose that. Fortunately the RE works "good" for near/distance. I guess at the end of the day if I needed readers for reading that wouldn't be horrible, assuming near/distance improved overall.
And Ron, what reservations to you have on the Vivity? And any other questions you would have me ask the Eye MD?
Thanks and happy holidays!
RonAKA jack64606
Posted
OK, just to be clear, your right eye is dominant and your vision is pretty good? The left is non dominant and vision is poor with a cataract?
.
If you can reconcile the risk of a Vivity it may be a good choice for your left non dominant eye. I would ask for it to be under corrected by about -0.5 to -0.75 D to ensure you get better close vision. In theory the Vivity is a good lens. The only reservation I have about it would be the risk of starbursts and halos especially with your prior Lasik. I would not suggest the Synergy or PanOptix as that would be a much higher risk. Your other option would be to get a monofocal lens and under correct it more in the range of -1.25 to -1.5 D. This would reduce the risk of night vision flare and halos, but it would compromise the distance vision in that eye more than the Vivity would.
.
Down the road if you get good reading vision with a Vivity or the monofocal, you may want to consider just a distance monofocal in your dominant right eye. This can compensate some for the reduced contrast sensitivity of the Vivity.
jack64606 RonAKA
Posted
Thanks Ron! I'm feeling a little more confident on my decision and I'll let you know what happens with the Ophthalmologist and final IOL decision. I do believe the challenge with post Lasik eyes is calculating the IOL power. And while I am currently functioning with extreme mono-vision, mini-mono would probably be a great improvement, I am concerned that requesting an under correction in either option might not be that accurate. I guess that will be one of my primary questions. If post Lasik IOL power calculation is the challenge how far off might they normally be?
For your reading pleasure check out this eyewiki, search on Intraocular Lens Power Calculation after Corneal Refractive Surgery. It is actually fascinating, but also disturbing in that there are many methods to determine IOL power. See this quote from the summary:
"Because there are many methods of calculating IOL power after previous refractive surgery, the cataract surgeon is faced with many choices. It is useful to obtain a consensus of several methods by computing the average or median recommended IOL power. Several IOL calculators (see Additional Resources section below) provide an easy way to do this. When there is a wide range of recommendations (typically in cases of refractive surgery for high or extreme dioptric correction), it is wise to hedge in the direction of myopic results (choose higher IOL power or select lower corneal power estimation to use in IOL calculation)."
That creates another question for me. "Based on formulae used is there a relatively close consensus on IOL power?" FYI I don't believe my Lasik was for "extreme dioptric correction". Also when the author states "hedge in the direction of myopic results", does that mean they would hedge in the direction of near vision? I guess that would be my instruction to the MD - hedge toward near vision if required. And if I MD states (I will ask) there was not relative consensus with the formulae used I am going to ask if there are other tests or tools available at the clinic or elsewhere to better determine IOL power. I'm taking charge and I don't want a best guess IOL implanted!
Thanks again! Your research has helped empower me to continue digging on this matter and taking some control of my vision outcome 😃
RonAKA jack64606
Posted
I have not ventured into the world of IOL power calculation, other than knowing it is more difficult when you have extreme myopia (-9 D or more), or if you have had Lasik. @rwbil has gotten deep into the calculation methods and can comment. I believe at the end of the day you depend heavily on the experience of the surgeon especially when there is extreme myopia or Lasik involved. The extent of my knowledge is being aware of a 1970's vintage method of simply adding your eyeglass Sphere diopters to 19 to get the IOL power. For example a -4.0 D eye would require a 15.0 D IOL.
.
The one advantage in a lens like the J&J Eyhance or Alcon Vivity is that it has a somewhat flatter defocus curve on the minus side (closer) of plano. It is not flatter on the plus side, so if the surgeon goes over into the far sighted range there is no better forgiveness. But if you target for example -.75 D with the Eyhance or -0.5 D with the Vivity there is more room for error in eye measurement. This would be worth a discussion with the surgeon. You may want a bit more than this for the close eye, and a little less for the distance eye.
.
If you can get your head around using a defocus curve, this becomes a bit clearer. The limit of good vision is about 0.2 on the logMAR scale. To get distance on the defocus scale you divide 40" by the defocus position. 1.0 D is 40", and 2.0 D is half that at 20", and so on. See this article to see the defocus curves for standard monofocals as well as the Eyhance and Vivity.
.
Review of Ophthalmology 15 APRIL 2021 IOL Review: 2021 Newcomers
.
Keep in mind that J&J and Alcon are like the Coke and Pepsi of the IOL businesses. Some surgeons will deal with one but not the other. The manufacturers apparently will financially support some "preferred" surgeons by providing them with the fancy tools needed for measurement and surgery. These surgeons become somewhat captive in the process. I believe this is why some will be very bias to one brand, and will even go so far as to bad mouth the other guys! This was explained to me by my surgeon who will do either brand. It looks like you may have run into that in your shopping around. For clarity the brands are in increasing depth of focus order:
J&J - Tecnis 1, Eyhance, Symphony, Synergy
Alcon - AcrySof IQ, Vivity, PanOptix
Guest jack64606
Edited
The best formula right now for post Lasik eyes is the G. Barrett True K with TK on the Zeiss IOL Master 700. I believe it was specifically designed for better results with post Lasik eyes. I think it measures both anterior and posterior corneal power whereas the regular True K formula only measures the front of the cornea.
jack64606 Guest
Posted
Hi David,
So had pre-op measurements done yesterday. The primary device used was the Lenstar 900 (I assume the BIOS was 2.1.1) along with Eyesuite Biomettry software V 2.6.1
It outputs a bunch of IOL options. Each with varying ranges of IOL (D) options and/or Toric options. All using the TrueK formula. Do you think this device compares with the IOL Master 700???
This was performed by a Tech. I'm sure the MD can plug in other formulae - I meet with him today. The interesting thing is that this practice is where I received my Lasik surgery years ago and they do have my records so they should be able to "plug" in my pre-op corneal measurement data. This is a question for the MD - whether the pro-op measurements are better than the Lenstar 900 data or if the IOL Master 700 is better than either of those options.
The other interesting aspect in the IOLs that were provided by the device/SW. It kicked out a bunch of IOLs. I recognize some as being the monfocals, some with toric options. And a few premiums that were the Symfony, Crystalens, and the Vivity. Strangely it did provide a Vivity Toric option (it did provide Toric options for Symfony). There was no Panoptix (I'm fairly sure they offer this IOL) and no option for Synergy which I don't think they currently offer. So lots of questions for the MD today. Anything you or Ron would add?
The other interesting aspect is that regardless of the IOL the device had and IOL (D) of 16.5 -17D. And my fairly good eye was also measured and that kicked out IOLs with 16-16.5D. I guess not that surprising since your eye geometries are probably similar.
The Crystalens sounds interesting, but I guess success has been mixed.
RonAKA jack64606
Posted
I am no expert in the measurements aspect of cataract surgery. @rwbil has spend some time trying on this, and perhaps can comment. The only thing that seems a bit odd is that your eyeglass and contact prescriptions differ considerably between the eyes, but the software recommended IOL power does not seem to differ between the eyes. But, that may be due to the error being in your natural lens aggravated by the cataract, and is not in the cornea.
Guest jack64606
Posted
I think ideally the formula you want with post-Lasik eyes is the Barrett True K with TK. The TK stands for Total Keratotomy and they say "total" because the scan measures both the front AND back surfaces of the Cornea. TrueK only takes the front of the Cornea into account. Which is fine for most cases. But apparently the "with TK" formula has been shown to have better results with post-Lasik eyes.
.
If you do a search on YouTube on "True K with TK" you will fine a short video of the man himself (G. Barrett) talking about this formula.
jack64606 RonAKA
Posted
So talked with MD today, net/net selection is for Vivity close to plano. Or if the ORA provides a different reading maybe round down - to nearest -.5 D. Since my original Lasik was not extreme (small correction) his biggest concern in IOL performance is not IOL D selection, but the ELP - Effective Lens Position. After the lens bag heals and does shrink wrap a bit, the IOL can reposition and/or tilt. This one is a total crap shoot, usually not much affect to outcome, but can also be severe. I'm betting when we encounter some of the horror stories on this site it relates to ELP.
I think the Vivity will be good since my bad LE does assist my non-corrected RE in near vision. And fingers crossed I'm hoping for really great binocular distance vision and the effect on my VB game! 😃
Ron, I think the difference in the scrip corrections vs. the IOL Ds might be twofold. One is the IOL is in a different location, nearer the retina vs. contacts/glasses being further away. And secondly the contact/glasses D is based on how your lens is actually contracting/relaxing. IOLs are just based on the position it will be placed in relation to your cornea and retina. This is pure speculation based on my newfound optical expertise 😃
I also got the perception that this MD, at least, is recommending Vivity over Panoptix or Synergy probably because it has better outcomes with far less adverse outcomes. You can imagine how things could really bad with ELP shift and concentric rings.
Scheduled for next Thursday and will be posting updates. I really appreciate the direct feedback and all the other posts that helped me make a fairly educated decision.
All the best!
RonAKA jack64606
Posted
Normally movement of the lens is more of a concern when a toric lens is used. The angular position is critical, and the lens does not have to rotate much to make the vision worse instead of better. FWIW the Alcon material used in the AcrySof, Vivity, and PanOptix has a reputation (deserved or not) of being "more sticky" and staying where the surgeon puts them.
Guest jack64606
Posted
Yes the final lens position (front to back)… or ELP is the one variable we have no control over and it can affect the end result by a quarter diopter plus or minus. The other variables used in the formulas are corneal topography, axial length and a-constant but the first two can be measured very accurately these days and the a-constant is just a known property of the IOL.
RonAKA jack64606
Posted
The concern I would have with the Vivity set to plano in your left non dominant eye would be that your reading vision may be limited. I think an under correction of -0.5 to -0.75 D would be a safer option.
jack64606 RonAKA
Posted
Hi Ron,
I kind of agree. I would like near vision to improve in LE and maybe "functional" close. But let's take a look at this statement from an article about post LASIK IOL power calculation.
" The formulae use the corneal power in two ways. First, corneal power is directly used in the vergence calculation to predict the postoperative refraction. Second, corneal power is used in the prediction of effective lens position (ELP), which is the depth of the IOL relative to the cornea. Refractive surgery alters the corneal curvature and introduces error into both the measurement of corneal power and the prediction of ELP. Both types of error lead to an underestimation of the required IOL power in eyes that had previous myopic refractive surgery and an overestimation of the required IOL power in eyes that had previous hyperopic refractive surgery."
So I was nearsighted pre-LASIK so I'm assuming I fall into "myopic refractive surgery" category??? If that is correct, then any IOL power error would lean toward the "underestimation" of IOL power. My concern in asking for under-correction is that it could add to the already potential underestimation. Do you read this the same?
Thursday is the big day! My thought is to ask the MD to confirm the above statement on Thu and see if he agrees or if he believes the combination of calcs and ORA (during surgery) have him believing he is highly confident on the IOL power. If yes, I'll ask about going down -0.5. Thoughts?
RonAKA jack64606
Posted
"Both types of error lead to an underestimation of the required IOL power in eyes that had previous myopic refractive surgery"
.
Having no real experience or training in the cataract and IOL field, I am not sure how to read this statement, and what they mean when they say underestimation of required IOL power. IOL's are measured on a different scale than eyeglass or contact power where zero means no correction, and a - correction is for myopia. In an IOL as I understand it a zero correction is about 19 D power. To correct myopia you use less than a 19 power, and for hyperopia then more than 19. I believe the whole range of powers goes from about 5 to 35. For example a -4 would approximately translate to a 15 D power IOL. Would an underestimation be that the measurement would predict a -16 D? Or would it mean it would predict -14 D? I am not sure.
.
My thoughts would be to ask the surgeon to determine the power he really expects is needed (considering the issues above) to achieve plano, and then ask to be under corrected by about 0.75 to 0.5 D. If the target for plano is 15 D, then instead ask for -14.5 to -14.25. Or probably better still, leave the IOL power numbers out of it and just ask to be left with -0.5 D to -0.75 D myopia. This is not much of an adjustment as the normal target for plano is to be -0.25 D. I think at the end of the day you want the surgeon to be the one doing the adjustments in error caused by the previous Lasik, not you.
RonAKA jack64606
Posted
"ask for -14.5 to -14.25.
.
Correction: I should have said 14.5 to 14.25. All IOL powers are positive.