Need Advise on Lens Choice

Thank you! Yes, my left eye is dominant. I am now monovision naturally, left eye distance and right eye close. My right eye cataract is the worst, so it is being corrected first. I have eye measurements next Friday. I don't anticipate with them having problems determining the powder of the lens needed.

That is good that you already have experience with monovision and are OK with it. I currently simulate monovision with a contact that under corrects my non operated eye by about -1.25 D. I like it a lot. My plan is to make it permanent with a monofocal IOL targeted for -1.25 to -1.50 D, or a Vivity targeted to -0.75 D. You you know by how much the surgeon is targeting your right eye for monovision?

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There are issues with measuring and calculating the power for eyes which have had Lasik done on them. There are special formulas used to do the calculation.

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Have they talked about any need for a toric lens? I guess they would not know that until after the measurements are done. I believe both the Vivity and AcrySof IQ are available as a toric. The newer Clareon monofocal, is not, at least in Canada.

I'm not sure what the target is for my right eye. I will ask at my measurement appoinment. I have pretty steep (?) monovision. In my right eye, I can't see except really close up. In my left eye, I can only see semi-good close up but real good mid and long distance.

The Lasik is what bothers me. Even with special formulas, you can still get focusing refractive errors.

I had astigmatism correction with Lasik. He did say I have some minor astigmatism. I will find out more at my measurement appointment. If he uses a Femtosecond laser for cataract, it can fix low level astigmatism during the cataract surgery.

After reading on this site, I have quite a few more questions. I might end up cancelling and going to a doctor in a city close by who may offer more than my clinic does.

There are toric IOL's to correct astigmatism if you have a significant amount. You won't really know until they take the measurements. Astigmatism corrected by a contact or eyeglass has to correct the total astigmatism in the natural lens plus in the cornea. When the lens comes out during cataract surgery, that component of the astigmatism is gone. However, it may be offsetting to astigmatism in your cornea which now includes some created by the Lasik. So it can get worse and more correction is needed as a result of the lens being replaced. The eye measurements should tell the story.

That is my question too. I called another eye doc in St Louis and I am having an exam tomorrow. They said they would lay out all of my options. My current doctor didn't discuss anything with me. When I said my OD said I could do monovision with monofocal lenses, he gave me the brochure on Vivity and said these were better. No further discussion. I wasn't in a frame of mind at the time, nor had I done any research, to ask further questions. Now that my husbands heart surgery is out of the way and he is doing well, I started questioning and researching. Once I have the exam tomorrow, I will be able to make better decisions. I will post here what they tell me.

My research indicates that to get good reading vision you have to under correct the close eye in monovision by about -0.75 D with a Vivity, or -1.25 to -1.50 D with a monofocal. The advantage of the Vivity monovision over monofocal monovision is that the Vivity should give better distance vision as it is under corrected by a smaller amount.

If the offset with Vivity is only 0.5D or so I take back what I said above. I'd prefer than to monofocals with a big offset. I was thinking he was going to do a big offset with Vivity which makes no sense. But that's almost surely NOT his plan.

My manipulation of the defocus curves shows that a Vivity at -0.75 D under correction gives about the same close vision as a monofocal with -1.25 D under correction. The difference is that the Vivity maintains better distance vision though.

I am having another exam tomorrow in St Louis where they also do LAL. They said they do eight different tests. They said doc will sit down and go through everything with me and lay out all my options. That sounds a lot better to me. I can also go to Chicago if need be. My doctor only gave me the Vivity brochure and said it was better than one distance/one close up monofocus lens. No discusssion either way. I wasn't in a great place to question him at that time. Now I am. I think my OD said my right cataract is far enough along. The MD said yes and he can justify to insurance doing my left eye too. I'm sure my vision is affected by the cataracts, but I can see. I think their attitude is, if we can justify it and insurance will pay, why not do it now rather than later. I believe I am going to procrastinate and wait until I have all of the info I need to make an informed decision.

Actually yah I assume when the doctor says Vivity monovision he's not talking about FULL monovision but more like a half dioper or so offset. THAT would make sense. I'd talked in other threads about being hesitant to do any offset with Vivity BUT if my choice was a 0.5D offset with Vivity or full monovision with monofocals I would 100% choose Vivity.

**My doctor only gave me the Vivity brochure and said it was better than one distance/one close up monofocus lens.

I tend to agree, though Vivity might have some Contrast Sensitivity loss. The reason I agree is I just had cataract surgery and in one eye I have a Tecnis MF and in the other I have the Synergy. And for close vision, I can do the 1 eye cover at a time thing and I see J1 for each IOL individually, but bilaterally I see J1+. So I think having 2 very similar images sent to brain the 2 eyes work better IMHO.

**I think their attitude is, if we can justify it and insurance will pay, why not do it now rather than later.

I doubt your insurance will cover the Vivity IOL, unless your doctor is willing to do it at a monofocal price and saying it is a monofocal. This is something you need to check on. If on medicare, I am not sure their rules. My insurance did cover the other cost, minus the deductible, associated with cataract surgery.

Also depending how what your current corrected vision is another reason to procrastinate is they are constantly coming out with better IOLs.In your case where you are thinking of the LAL, they are clinically trialling EDOF and I am sure a few other.

I saw the doctor in St Louis today. He said I am seeing 20/25 in my left eye and it needs nothing done to it. My doctor here in town said he could justify cataract surgery on my left eye to insurance, but this doctor says it does not meet the standard where Medicare will pay. I could even read with my left eye dilated. My left eye is doing most of my close up vision too.

(I know Medicare/Insurance won't pay for Vivity as it is a premium lens. They gave me the cost of the lens.)

My right eye is the hot mess. My cataract is on the back portion of my lens. He doubts my vision is actual monovision. He thinks the cataract is causing all of the vision distortion.

He said he would not recommend Vivity for my right eye. He did use the lens but doesn't any more. He recommends the Johnson & Johnson ZCB lens followed by PRK in 3 months, fixing for distance. He will make adjustments if necessary for one year. He said he would fix the moderate astigmatism too. He recommends this over the LAL as he said he has had a couple of patients who didn't get good results with the LAL. He has had consistent results with the ZCB.

My next option is to go to Northwestern University Dept of Ophthalmology. They do not do LAL but they do research and studies, so it might be good to get their opinion.

All I know is I am cancelling the surgery I now have scheduled.

"They gave me the cost of the lens"

How much are they asking? Vivity's wholesale price is ~$900 (compared to ~$200 for the Eyhance).

The Tecnis ZCB00 is your basic tried and true monofocal. It will probably have less risk than any premium IOL, but not provide for great intermittent vision or for close vision. Probably will be able to see good out of that IOL up until 3 feet or so.

I would suggest getting 2 or more IOL Master measurements on different machine on different days (and get a copy of results) to make sure your Axial Length and Astigmatism measurements are consistent and maybe use a doctor that has the ORA system to help nail your refractive mark so you don't need PRK afterwards.

You mentioned St. Louis and Chicago, so I just did a very quick search looking at Newsweek Ameirica's best eye doctors 2021 list and their seems to be a few highly rated doctors in your area.

"He recommends this over the LAL as he said he has had a couple of patients who didn't get good results"

That is interesting. Out of curiosity did he say exactly want problems they had.

What was your astigmatism? Are they planning on using a toric IOL?

I always recommend to get a 2nd or more opinions, as all doctors are not the same. You want to find a top doctor that you also have confidence in and are comfortable with.

The cost of the lens is $1050 and the surgeon wants $1550 more for using it, so $2600 more over what Medicare/Insurance will pay.

He said he would go for distance in my right eye because my left eye is handling close up and distance. I can see up close to about 11 -12 inches with my left eye. Any closer and it gets fuzzy. I can't see anything with my right eye until it is about 5-6 inches from my face.

The doctor in St Louis is great in person and he has 830 5 star Google reviews, but he doesn't take insurance and it is expensive. He touts his cost covers the surgery, all appoints for one year and all laser enhancements. As far as the LAL, he said the patients didn't get the vision results they wanted. He also said the timeline Rxsight gives for wearing UV blocking glasses (3 weeks) to the end of the laser adjustments (He said up to 5, but I've read it is up to 3.) is too short. He said most patients are not healed enough at 3 weeks to start. He mentioned up to 3 months wearing the glasses. He said he was the first doctor in MO and IL to use the LAL. He would use it if I wanted it, but he recommends the ZCB over it.

They did one IOL Master measurement yesterday within the 8 tests they did. I asked for copies of my tests and the doctor's notes, but I have to formally request them and pay.

I plan on going to Chicago to see one of the top doctors there. I'm not adverse to go somewhere else in another state. If you had your choice, who would you go to?

The surgeon who is offering the Tecnis ZCB00 and promising to make further corrections for the power and astigmatism is not confidence inspiring. It is usually best to get the power of the IOL right at the time of surgery, and by using a toric lens to correct astigmatism if necessary. Did they give you any idea how much astigmatism there is?

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Sometimes optometrists can be helpful in screening the choice of surgeons. I would ask for ones that have lots of experience in doing eyes with previous Lasik.

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If you are going to go for monovision with a monofocal lens like the ZCB00 it will have to be under corrected in your right non dominant eye, usually by about -1.25 to -1.5 D. Or, if you use a Vivity it could be less, in the range of -0.5 to 0.75 D.

What the surgeon is proposing is called crossed monovision where the dominant eye is used as the closer focus eye. It is not the conventional way of doing it which is to use the dominant eye for distance. Some studies have determined it can work, but it is the less preferred way of doing it. Google this one for example:

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Healio November 16, 2016 Crossed monovision may be as effective as conventional monovision

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My left eye is dominant, and I am currently simulating crossed monovision by using a contact that under corrects by -1.25 D in this eye, making it the closer vision eye. It does work, but I notice one issue. For close work the left eye does all the work, and for far distance the IOL right eye which I have 20/20 vision with works very well. But, I think for some intermediate distances like 25-30 feet away my brain has trouble deciding which eye to use. I can see well when I concentrate, but vision is not as immediate.

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I got into this kind of the same way you are headed. Before I knew much about monovision the surgeon recommended a distance monofocal in my right eye as it had a bad cataract. He convinced me that down the road he could do the left eye for closer vision and it should work. Now with my over a year experience doing it with a contact, I can say from experience that it works, but it is not ideal. If there is a choice I would put the distance lens in the naturally dominant eye.

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It sounds like this surgeon uses J&J lenses. I think a better choice for the right eye in the J&J brand may be the Eyhance lens. It is most similar to the Vivity but does not give as much close vision. It would probably have to be under corrected by about -0.75 to -1.0 D to give good closer vision, and more true mini-monovision. The surgeon is likely to want more $$ for that one over the J&J ZCB00 monofocal.

Where to begin:

LAL

The LAL is definitely a revolutionary IOL and with that comes the risk of new technology, but I am a bit surprised by what the doctor said. The clinical trials showed it achieved superior results, but clinical trials are not everything. From what I have read, normally they don’t even start adjustments until after 3 weeks. I also read they are coming out with a new LAL that has a UV-blocker built in so you don’t need or reduces the need to wear the UV blocking glasses. You can read about that on Healio in an article titled, “UV-coated Light Adjustable Lens ‘is the future”.

There is also a really interesting Panel Discussion on the LAL on Youtube from Summit Eye Care titled, “The Light Adjustable Lens Live Panel Discussion”

But the doctor might have a point stating some patients take a long time to completely heal and wearing UV-Blockers for months might have issues.

So as always you have to do your own research and weigh the risk.

CLOSE VISION

In some ways you will be doing monovision with the non-operated eye providing close vision. After having my 2nd cataract surgery I now realize something that I kind of general new before but now see 1st hand. I always knew 2 eyes work together to provide better depth perception. When I had healthy eyes I never did the cover 1 eye up at a time to see how each eye’s visual acuity individual compared to bilaterally vision. And when I had my 2nd cataract surgery my eye had been so bad so long I was use to just seeing out of 1 eye. I was not even 20/200 in my eye. But after surgery I was doing the 1 eye at a time thing and surprised how the 2 eyes working together to produce an image better than each eye individual can see. I can see J1 with each eye individually, but yet can see J1+ super sharp bilaterally. The brain is not just picking the best image to use, but uses both eyes to create the best picture it can.

The point I am trying to make all current IOL options come with tradeoff and it is important to know and understand them so you pick what is best for you.

“They did one IOL Master Measurement yesterday within the 8 tests they did. I asked for copies of my tests and the doctor's notes, but I have to formally request them and pay.”

Wow, I did not ask for a copy of my doctor’s notes. I just asked for a copy of the IOL Master measurements and he also sent me the Toric IOL Calculator sheet. It was 2 sheets. How much did they want for making a 1 minute copy? Actually it is worse in my case as they had stored my old records away in an offsite location, so they had to dig them up and did not charge for that either.

My toric rotational angle was not consistent and I emailed my doctor about that and asked to have additional measurements taken and he had me come back in and took several measurement and did not charge me a dime for that.

“if you had your choice, who would you go to?”

Most people aint me. Most people just get a recommendation from a friend or their primary doctor and just implant whatever IOL the doctor recommends. Heck most people do not even know there are a variety of IOLs out there. I on the other hand researched everything to death including the IOL material. Yes IOL material makes a difference.

True story, when I had my first MF IOL implanted I talked to another person that had cataract surgery and he got a monofocal and I asked him why did he decide on a monofocal and he was like that was what my doctor implanted. He knew nothing about other IOLs as his doctor did not tell him their were options.

I went to many Ophthalmologist before finding my surgeon. Some of these doctors I would not let operate on my eyes in a million years. In fact I was not sure I was even going to be able to find a local doctor and was looking to travel for surgery. I cannot stand doctors that are to “above the little guy” to return my call or return my emails. They were scratched off the list.

I also wanted a doctor that was involved in clinical trials. These doctors also tend to write research papers and give seminars to other doctors, typically discussing their clinical trial results. I figure manufactures what the absolute best outcome from a clinical trial and are going to do their own research and find top doctors.

A few sources to get started is; Newsweek America's best eye doctors 2021; and Castle Connolly Top Doctors. You can also go to the FDA site and see which clinical trials a doctor participated in. But remember that is only a starting point. I then researched that doctor further, including looking at review, but as we all know reviews are many times faked. At the end I found a doctor that did clinical trials, had written research and even did a Ted talk and donated his time to an organization that did free cataract surgery for the poor. But on top of all that I had an instant rapport with this doctor. I felt he had my best interest in mind. In fact he had done clinical trials on diffractive IOLs and implants them when the patients want them and was aware of the risks / tradeoffs, but he out and out tells me he is not a fan. I even have his email, which he responded to.

My optometrist is part of a group and she referred me to one of their surgeons. I asked her about others outside of the group and she had no recommendations.

Since I don't need any surgery in my left eye, I assume they are in it for the insurance money since the surgeon said he could justify doing cataract surgery in my left eye.

I am not going to the surgeon who offered the ZCB lens. I just wanted a extensive exam, which I got. And, his findings matches what is happening. I see fine without correction in my left eye. I am not going to have surgery on it if I don't need it.

I have a lot of research to do. Thank you for the suggestions.

I am not going with the doctor from yesterday. I just wanted a through exam and another opinion, which I got.

I've requested many health records, Sometimes I am charged, other times I am not. It all depends on the practice.

I don't need any surgery on my left eye. I see 20/25 without any corrections to it. It handles close around 12 inches, mid and far distance.

I plan on going to one of the top docs listed in Newsweek or Castle Connolly and I will go to the FDA site to check if they have done clinical trials.

None of the doctors in Chicago or St Louis who are listed in the top 100 in Newsweek do LAL.

I would guess that most of the doctors listed in Newsweek, do clinical trials as they have to be well known to have been nominated.

As for LAL not that many doctor's do it as it requires specialized equipment.

Just my gut feeling. But unless you have issues like severe myopia, a Top Opthmalogist especially one using the ORA system and the latest IOL Master Machine should be able to nail or be darn close on hitting the refractive mark.

Personally, I rather have a top rated doctor than a doctor who does LAL if you cannot find both.

OK, I did a quick look and a Dr. Navin Tekwani is very impressive on paper. Again this is just a start. He is the type of doctor I would make an appointment with and see how he addresses all my concerns. If you can dig up his email you can email him with your concerns about hitting the refractive mark and see how he responds.

I just pulled up a map and if you live near St. Louis, MO, you have a lot of major cities within a 4 hour drive. In fact Indianapolis seems as close as Chicago and a quick look there is a Dr. Francis Price in Indianapolis, who also looks very impressive on paper with a boat load of publications and research studies. In fact you are lucky as you have a lot of top doctors within a reasonable drive.

Thank you for all of your help.

I read about the new LAL RxSight is offering, ActivShield, that is UV coated and reduces the use of UV blocking glasses. I emailed RxSight, and they said the ActivShield lens is available now.

Everything I read and listen to, I am still thinking the LAL will be the best solution for me. I still plan on researching and getting a couple of opinions from top docs.

St Louis is the closest. Indianapolis is further from me, but not too far. We have kids (and new grandchildren) in Chicago, so that is more desirable for us.

Thank you again for your through answers and recommendations.

Thanks. I guess the $1550 extra surgeon fee comes from a "premium lens package" of some kind, since, as far as I know, implanting a Vivity isn't much different from doing a monofocal. Hope they at least do additional tests and/or give better preop/postop care for it.

Some thoughts:

1. LAL is an attractive option for the dominant eye, as it can be set for distance. Not sure how it would work out for some myopic offset (for near vision) in your non-dom right eye.
2. From what I understand, LAL with EDOF setting is available in Mexico ("Cadet vision"), but not in the US yet.

Perhaps you may want to check with RxSight and/or surgeons on these questions. Also, it should help to look up clinical reports on the LAL, and RxSight maybe able to provide some recent ones.

Staying with your kids for a month or so while you heal and undergo LAL corrections should give you rest and make it easier to maintain the UV light shielding regimen.

All the best and please keep us posted!