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
jack64606 RonAKA
Posted
Hey Ron,
Not sure if you are east or west coast CA, but surgery early tomorrow. Would you happen to know what my distance vision would be (estimate) if we hit -0.5D? Would it be 20/25, 30, ...?
Thanks!
RonAKA jack64606
Posted
Based on the Vivity defocus curves the estimate of distance vision with a -0.5 D target would be 20/23. With a target of -0.75 it would be 20/25. But keep in mind these are averages. YMMV! And also keep in mind that with monovision your binocular distance vision will be mainly determined by your distance eye and should be 20/18 with a -0.25 target, with a monofocal AcrySof IQ Aspheric.
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Good luck with your surgery. I'm in Canada on MST...
RonAKA
Edited
I gave my surgeon's secretary a call today to get an update on my status in the queue for surgery. She has received my referral from the optometrist for my second eye, and thought I was a month away from getting a consult and if I go the private clinic route (instead of the public hospital where my first eye was done), surgery would be about three weeks after the consult.
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I took the opportunity to ask about the availability of the Clareon option (monofocal but with the "new and improved" material), and the Vivity. Based on her knowledge of the lenses it appears they can order the Clareon but it is possible the surgeon has never used one... It uses a CO2 propelled insertion system as opposed to the manual injection system that the AcrySof IQ lens uses. I have that one in my right eye already. From my wife's recent experience I know that the surgeon was willing to do the Clareon and it costs $300 extra over the AcrySof IQ (or at least it did a couple of months ago). I asked her about the extra cost of the Vivity which she looked up. It is currently $2175 extra.
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So now I need to choose between the Clareon which my surgeon seems to have limited experience with, or the Vivity which may have some issues with night vision. The AcrySof IQ is technically an option too, but because of our public health care system in Alberta I would likely have to get it done in the hospital which is backed up with COVID, and my wait would be several months if not years....
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Next step is to get an in person or phone consult with the surgeon to clarify some things and get some help on making this decision. Any thoughts you may have are appreciated. My current plan was to get the AcrySof IQ or Clareon under corrected by -1.25 to -1.5 D, or the Vivity at -0.75 D. I keep telling myself that this is a lifetime decision and I should not let cost influence it. I have also told myself that spending more money is no assurance of getting a better outcome, just a different outcome. So cost is not going to be any kind of factor in the decision. I just included the costs as they may be of interest to others. I was frankly a bit surprised by the large extra cost of the Vivity. I was expecting more in the order of the $1050 per lens extra cost that my wife paid for her toric lenses.
RonAKA
Posted
I see this thread is getting older, like me. I posted that I was 70 when I started it, and now I am 72!
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But, the story goes on. I went for a preop appointment today. Did not get to talk to the surgeon, and all they did was take measurements of my eyes again. But, that is a good thing as the last time they were measured was two years ago. I was a bit disappointed in that they used an IOLMaster 500. I was hoping they had the newer and more advanced IOLMaster 700. I don't remember perfectly but I think the measurements taken a couple of years ago must have been on an IOLMaster 500 too.
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Next appointment is Feb 3, and will be with the surgeon, and I hope I can get to a decision of going with a Clareon lens in monovision or a Vivity in monovision. Optimistically I may be in line for actual surgery by the end of February or so....
RonAKA
Edited
Since my last post I have had one more appointment with the surgeon and a couple of phone calls. I have to say I am not impressed with the process compared to my first eye. My first eye and the consult appointments were held in the specialized optical department of our city hospital I think the measurements of both eyes were taken with an IOLMaster 700, but not sure. In any case when I saw the surgeon there he was able to show me the graphical display of the topography of my eyes, and point out that I had irregular astigmatism. He did not recommend a toric lens and just a monofocal AcrySof IQ Aspheric one. He told me there were two choices of power to be used and recommended one. I agreed and the process to get it done was slow but easy.
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That was 2 years ago, and now things are much different. The surgeon's father who was also an ophthalmologist passed on about a year ago, and appears to have left his practice, office, and equipment to his son. He appears to be in the process of transitioning to a private practice by using his inherited office and equipment. But the facility and equipment he has is not suitable for doing the actual surgery. He is doing that in another facility that is very new and just opened. So his practice is now split three ways between the public hospital, his private office, and a second private clinic which he must have some agreement to use a couple of days a week. Patient records are split between the hospital and his private office. He is unable to display the data from the instruments at the hospital. When you go to the office he is pretty much flying blind.
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When we first met in his new office he gave me the pitch to get a toric lens. I reminded him of the irregular astigmatism diagnosis and he was surprised. He also tried to sell me on the PanOptix. Two years ago he told me he had trouble recommending them because he would not consider putting them in his own eyes. After me telling him about the irregular astigmatism he said he would have to phone me from the hospital where he could see my detailed records. His private office only has an IOLMaster 700 which is not capable of displaying the irregular astigmatism. He did phone but it was a rushed call where he flip flopped between recommending a toric and not. He didn't want to recommend a Vivity because he had bad experience with one in a demanding and knowledgeable patient, (insinuating like me). With the flip flopping on the toric or not, and his unwillingness to discuss Vivity at all, I made a decision that I could no longer trust this guy. It is difficult in Canada to shop around and I would be set back months or years if I did not go ahead. So, I told him that I would keep it simple with the Clareon monofocal non toric. I then asked him what the power choices would be for me. I drew a blank. He had no idea, and admitted he had not done the calculation. So I got frustrated and simply said OK well I am looking for -1.5 D myopia and he agreed. This discussion was all rushed as he had patients waiting with dilation drops in their eyes. Not impressed at all.
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I thought it was done, but in a couple of hours he phoned me back and said he had done the calculations and there were two choices of power (Hill RBF formula is what he says he uses). A 19.0 D would give me -1.6 D of myopia, while a 18.5 D would give me -1.30 D. He also said without a toric lens I would end up with -1.0 D of astigmatism. After some discussion he recommended the 18.5 D power because the astigmatism would give me some closer vision. I agreed. I sure hope the surgery goes better than the consult and discussion process. I am now very nervous about where I will really end up for close and intermediate vision with this monovision arrangement. I do know that me distance eye is very good and I can see down to 18" or so. All I need is for this second eye to deliver from 12" to 18". Fingers crossed!
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I will have trouble recommending this surgeon to anyone wanting anything more than just a basic cataract surgery with low expectations of outcomes - just get rid of the cataract. While a monovision solution doesn't need any premium priced lenses to make it work, just basic monofocals, it does require a premium service. He is moving to a private clinic business model, but does not have his act together in delivering on the premium service part.
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If I had to do this all over again, I think I would spend more time with my optometrist asking exactly what services the available surgeons have and how they deliver it. The very minimum would be a one office/clinic location, with an IOLMaster 700 instrument, and willingness to take the time to do a thorough consult.
Bookwoman RonAKA
Edited
Ron, I think a lot of these surgeons are simply unused to having a patient who has done the research and knows something about the procedure and possible outcomes. I'll bet 90% of their patients are just happy to take their advice and never question it.
My surgeon, who has also been my ophthalmologist for the past 35 years (I have a great relationship with him), was a bit surprised I knew so much, but spent plenty of time going over options with me. I remember that when he talked about doing 'a procedure' to correct my minimal astigmatism and I said "limbal relaxing incisions?", he laughed. I may have been one of the few patients of his to know what that was!
Frankly, most people know very little about their bodies, medical procedures, etc. and even if they do research, it's usually not very rigorous. Doctors are used to this sort of uninformed patient and can be surprised or even annoyed to be questioned.
RonAKA Bookwoman
Posted
Yes, I agree. I briefly discussed LRI with my surgeon yesterday. He said that he does not do it as he has not had good success with it, but he could refer me to someone that does it. He also suggested that laser would be an option to correct astigmatism. That is something I will keep in mind depending on what the actual outcome is of the Clareon IOL. I got my appointment today, so I am on for February 23. That is the one upside of this new private business model. Wait times are a few weeks instead of months and years.
RonAKA
Posted
As an update I had my cataract surgery in my second eye yesterday, and am in the recovery period. This is to be my close eye in a mini-monovision configuration. I went ahead with the Clareon monofocal lens which is non toric. It was targeted for -1.30 D sphere, and an estimated -1.0 D residual cylinder. Just over 24 hours later I am composing this message with no glasses. The text is not perfect but readable. Distance is fine as my first eye gives me a nice sharp 20/20 image at 0.0 D sphere. I'm hoping that vision will still improve significantly over the next week or two. I see the surgeon again on the 15th to get an evaluation. But so far it is looking good. Hoping for this to be the end of the road for the eye, but leaving the door open for a touch up with Lasik or the like.
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Unlike my first eye which was done with an sedative administered by IV, this time all I got was an Ativan pill under the tongue. This time I was much more aware of the procedure. I can't say I felt any effect from the Ativan. But, I also did not experience any pain or even the pressure that some describe during the procedure. After it was done, I stood up and walked out of the room. The next morning I experienced some pain from any bright light, but not as much as the first eye I had done. An exam was done right at 24 hours, and the surgeon says everything looks fine.
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I would like to say that I am done with this eye, but it will probably be a minimum of 6 weeks before things will be stable. Here is to hoping this is done and I will have very good glasses free vision for all but the smallest of print.