need feedback re: cataract surgery & correcting for near vs far vision

I also thought about doing this, but decided to have both lenses be the same, both set for distance. That has not worked out as I expected .... so far!

We will see what the surgeon says after a few weeks or months.

From what I understand, if you opt for slightly myopic, they'd just put you in glasses to correct for the intermediate & far vision = basically what I have now except my lenses would be a lot thinner since the myopia wouldn't be nearly as bad as it is now. Is that not correct? If it is correct, I'd wear glasses the vast majority of the time, like I do now, & I'd continue to remove my glasses when doing "close" things such as reading, knitting, removing a splinter, etc. In your case, with 1 eye set for far & 1 set for near vision, does it not put a lot of strain on your eyes since basically only 1 eye at a time is seeing clearly? It seems to me it would, & I think I would have a lot of headaches due to the eye strain. I guess you were already used to it since your eyes were pretty much that way after your lasik procedure in 1998...but at THAT time, did it take some getting used to? Do you feel as if you have good vision at ALL distances now, with both eyes, or does it always appear as if you are "seeing" better on the L or R?

It certainly seems as if your eyes should have stabilized before now, doesn't it? 15 months & 5 months post-op & you're still having problems! I hate to think about that happening, as I've already not been able to drive for over a year & it has GREATLY impacted my life (& I'm not quite 57 y/o). I live 20+ miles from the nearest small town, so it has been horrible.

The one thing i would want to ask is how myopic would you be and i wonder if they could even tell you that,  You wouldn't want your distance vision to be worse than it is now.   See i went for distance in both eyes but one ended up not good distance about 20 40 but I could see up close with that eye.   The other one is good distance 20 20.  I never chose close up vision it just happened that way . Before I had cataract surgery I ended up with a cataract on one eye, could only see close up well and not good in distance., so i went about 4 years with one eye for distance.   It felt fine could never tell that I was seeing with one eye for distance , it all blended together. I think I'd be worried how far in the distance i would be able to see if I chose close up   You should see if they'll give you an answer to that or maybe they won't know till it's done.  Nothing seems to come out as planned

Please DO that I ended up not being able to get near vision on my other eye with contacts apparently a surprise to my surgeon as I had a lazy eye as a child and even though I had early surgery in childhood it ambliopized 

is a horrible feeling not to be able to see up close 

my surgeon tried to convince me to monoficals both for distance but the idea at 48 not to see my child if I could not find my glasses and not be able to read a word is truly horrible

just got an exchange to symphony Tori and unfortunately blurred with and without glasses now

not sure what my options are scared to get surgery in my other eye now 

Any thoughts anyone ????

I should add that I said -1.5D is around computer distance, but that varies, in my case I'm using a desktop computer with large monitors, more common I guess for software developers these days than the general public. Many  people may use laptops and read them closer in, so it might be more like -2D or higher. If you measure the distance to your computer from your eyes then -(100/ distance-in-centimeters) would be the diopters that your eye would be set at to focus at that distance. 

Thanks for your reply! I'm in the US, a fairly remote area of CO. Moved here from AR after retirement. I was a pharmacist & was "in the know" with the medical community where I lived/practiced all those years, so moving to a different state means I'm no longer "in the know" & that causes some apprehension. If I still lived in AR I would know immediately who to go to for this surgery & would know how much I could trust their recommendations. Here, not so much.

I've read a bit about the Symfony & it sounds as if it would be a better fit for me than what is currently available, but I don't know if I can wait that long for the FDA to approve it. I know it's expected to gain approval within the next year, but as a pharmacist, I know how the FDA can be about dragging their feet too! I'm not able to travel abroad, as I'm caring for a parent who has advanced Alzheimer's & have no other family to take up the slack, so I'm stuck here. I'm to the point of having constant headaches from eye strain & don't that I can continue like this until the FDA finally grants approval for the Symfony, so I will most likely need to go ahead with surgery.

I saw the ophthalmologist/cataract surgeon for my initial eval this past week. He travels here a couple of days/month for consults & to perform surgery. My first eye is scheduled to be done on 4/26, so I have a bit of time to make decisions. This doc uses the AcrySof brand of lenses. Have you heard anything about that brand that I should be aware of?

The doc mentioned the toric lens (AcrySof IQ Toric). From what I've read, most docs don't consider implanting a toric unless the degree of astigmatism is >1.0 (I'm approx 1.0, both eyes). Apparently  the margin of error in correcting astigmatism with a toric is great enough that there's a pretty good chance I'd still need correction with eyeglasses, so I think I'd do just as well to save the extra cost of the toric & do all of the correction in the glasses. Especially since the toric is a monofocal lens & he said I'll most likely still have to wear glasses the vast majority of the time anyway. Did you have astigmatism? If so, what are your thoughts?

Regarding the multifocal lenses (AcrySof IQ ReSTOR), I've read that people who desire the most crisp vision usually don't get that with a multifocal. The doc said I'd probably be more satisfied overall with a monofocal, since I told him I DO want good, crisp vision. He said halos & glare are more common with multifocals too (which I also read) & I've had issues with halos & glare, even when my eyes were young, so I sure don't want to continue having those issues if I can help it. So those are the main reasons why I don't think I want multifocals. There is another ophthalmologist/cataract surgeon who travels to a small hospital about 1.5-hours from me, so maybe I should check to see if he uses the Tecnis, which you mentioned, if you think it is a lot more advanced than the AcrySof IQ ReSTOR. Do you think it's worth pursuing? The problem with these docs who travel to this area is that it takes MONTHS to get an appointment (I waited about 6-months for the appt I had this past week...but no ophthalmologists anywhere near this area, so you do what you have to do).

You mentioned the Crystalens. A couple of things concern me about it. The muscles in an aging eye (& I'll be 57 next week) work less & less to allow "accommodation", so I'm not sure that lens would be much of an advantage in the long run. Also, since I could easily live another 3 decades, I have to wonder about "wear & tear" on a lens that "flexes" back & forth all the time. Don't have to worry about that with these other lenses. 

The Tecnis I haven't heard of. Perhaps I need to check it out.

You mentioned a trial of monovision contact lenses. Perhaps that is something I should check out. I started wearing glasses when I was about 9, then switched to "hard" contacts at age 16 (mid-1970's) & LOVED them. I've never had vision with glasses like I had with those hard contacts! I wore them approx 20-years, until my eyes dried out too much, then tried toric soft contacts (this was when they first came out, so the technology wasn't that great). They rolled around & around & wouldn't stay put to correct my astigmatism, so they didn't work for me. So I've been back in glasses approx 20-years & in bifocals approx 15-years. The reason I question monovision making me dizzy all the time is due to how my eyes are now. The cataract in my non-dominant eye is worse than that in my dominant eye, so I sort of feel like I'm living with monovision already & it bothers me quite a bit. I know it's probably not a fair comparison to true monovision, so perhaps I really should check on a trial of contact lenses, as you suggest. But since I'll apparently have to wear glasses the majority of the time, no matter which route I choose, would I accomplish much if I chose monovision? What do you think?

That brings us to setting for distance versus near:

Apparently the vast majority of myopes are set for distance in both eyes, BUT... I don't remember not being myopic, so suddenly becoming essentially the opposite REALLY concerns me! I've always been able to remove my glasses & see very well to read, knit, paint, apply makeup, remove a splinter, remove a foreign object from my eye...things that are done within about a foot of my face. I've tried, but really can't imagine not being able to do that! What if I'm set for distance, then for whatever reason the doc is unable to correct me well for near (is that even a possibility)??? WHAT would I do??? This terrifies me! You were more myopic than I am, so I'm sure you know what I mean. Did you have both eyes set for distance? If so, what was it like to adjust to the change? What about all of the things I just mentioned (reading, removing a foreign object from your eye, etc)- if both of your eyes are set for distance, do you have trouble doing those things? 

Another issue I've thought about regarding setting both eyes for distance is having to lug around a bunch of reading glasses. I've read a lot of complaints about that very thing. People saying they end up needing quite a few different strengths, depending on what task they're performing since different tasks are performed at different distances. So a pair/strength for reading, different pair/strength for knitting, yet another for computer work, & so on. That would drive me CRAZY! 

 

I've read a couple of opinions of ophthalmologists/cataract surgeons who ended up having the surgery themselves & commenting on what they'd do differently. They were both myopes prior to surgery & had worn glasses for years. Both said they'd go with monofocals. One said he'd have both eyes set for near & wear glasses the vast majority of the time to correct everything else, since it was basically what he was used to. The other said he'd set 1 eye for near & the other "a bit farther out". I guess that would mean "intermediate" (not sure exactly how far out that would be)? What they both said, combined with the fact that I'm obviously concerned about losing near vision, really gave me pause about correcting for far. Am I being unreasonable, or missing an important point? I keep thinking in the back of my mind...there MUST be a reason the vast majority are corrected for far vision in both eyes, but WHAT is that reason??? Thoughts?

I have to admit the 1 guy who said he'd do near & intermediate made me wonder... What would be the advantage of doing near & intermediate? What would be the advantage of doing far & intermediate? Would either or both of those choices be much different than doing monovision? Would they be easier to adjust to than monovision & also preserve depth perception? Do you have thoughts on any of that?

I know I've asked a LOT of questions, but these are my EYES & I want to make an informed choice! Again, thanks so much for taking the time to help me achieve that goal. 

 

[u]I compliment you on asking these questions BEFORE your cataract surgery [/u]so you will know the right questions to ask and decisions to make. Wish I had! (you've probably read my post by now advising I got what I feel was the wrong lens (set for distance) in my right eye. I'm now no longer able to read without glasses and my temp glasses are not doing the job. I'm looking for a different doc now as my cataract surgeon was dismissive about my concerns. So applause to you. I think your explorations are helping  many people.

I'd say most people get corrected for distance since that gives them useful driving vision, and lets them pick the right readers for whatever near vision they need. I think most people who have poor vision when younger also just get used to having their vision corrected for distance so that is the default they stick with. Most people don't bother thinking through the option of setting their eyes for different distances.

btw, monovision merely means each eye set for different distances, which could be near&far or intermediate&near, etc. Setting intermediate&near (or two different parts of the intermediate range) could let you function around the house without glasses for most things with just glasses for driving, and for perhaps any rare need for really close near. The level of depth perception you retain just depends on how many diopters different your eyes are. The more you use 2 eyes for a distance, the more 3D things will seem, though most people likely don't really notice the difference since they get used to it. I didn't notice that monovision had cut down on 3D perception until I switched to multifocal contacts and realized things seemed oddly more 3D than they had before that.

re: "What if I'm set for distance, then for whatever reason the doc is unable to correct me well for near (is that even a possibility)???  "

Don't worry about that, that is never an issue. If you have good vision at any distance, then glasses/contacts can always be used to give you good near vision. In terms of lugging around lots of different reading glasses, it seems like one option is progressive glasses where the "distance" focus is set at intermediate and the near focus is near (or bifocals with the same arrangement).  It does sound like you might be more comfortable with your eye's set for some intermediate range, and then you'd have distance correction for driving and then reading (/progressive) glasses if you needed more near. If you have a smartphone, there are magnifier apps for them these days (though I haven't found a need for one yet). At a Barnes&Noble I've seen foldup reading glasses that will fit in a pocket, but I hadn't felt a need.

re: "a fairly remote area of CO"

I'm in Boulder, near Denver. I take it you are too far from the Front Range to get to a doctor in a city? Unfortunately FDA approval timing is unpredictable, and the Symfony is in a new class of "extended depth of focus" lenses so it isn't clear if that will lead the process to take longer since its the first one in that category. Even if you got the Symfony you could still target your vision at intermediate if you wanted even better near, the wider range of focus is useful regardless of what distance you target your eyes at.  The new low add bifocals tend to have lower risk of halos than the older bifocals that turned some surgeons off to them, but they still have a greater risk of halos than a monofocal so it sounds like they aren't a good option for you. If I were getting surgery in the US now I'd likely have gone for the Tecnis +2.75D bifocal.

I would suggest trying monovision if you can,  but it sounds like your cataract may interfere with that. It   does sound like your issue now isn't really with monovision but with reduced vision due to the cataract clouding things and making them blurry. I suspect there are contact lenses these days that are better for dry eye issues than what was available before.

Overall I've heard better things about the Tecnis lenses than the Acrysof lenses. I found the data they submitted to the FDA before, and although they may have asked questions differently so the data may not be exactly comparable, it looked like even the monofocal Acrysof lens had a higher risk of halos than the Tecnis low add multifocals, with the Tecnis monofocal having the lowest risk. Also the Tecnis lens material has  a higher Abbe number which corrects for chromatic aberration, and the Acrysof lenses have a higher risk of "glistenings" (though there is debate over whether that has much if any visual significance or its not really noticeable). The Acrysof lenses are "blue blocking" lenses, which many surgeons think is marketing hype and since we can always wear sunglasses, I'm not sure that its a noticeable difference since it mostly blocks UV rather than visible blue light.

I was fortunate that although I was highly myopic, I didn't have enough astigmatism to worry about. Postop I have 0 astgimatism in one eye, -0.5D astigmaitsm in the other which still left me with at least 20/20 distance vision in that eye. Surgeons can often correct astigmatism with an incision as part of their surgery, e.g. an LRI (limbal relaxing incision) which causes the eye to reshape as it heals. It tends to be less predictable than toric IOLs, but some surgeons prefer it for low astigmatism, you don't mention how much yours is. (though some use laser incisions for even a few diopters of astigmatism). I have the impression that toric lenses or incisions do a fairly good job so you likely wouldn't need glasses. Unfortunately I don't know that they have approved any toric multifocals in the US, though they have approved a toric version of the Crystalens, the Trulign.

 

In term of the Crystalens, they've used it in older patients with good results. Presbyopia isn't a problem with the muscles that accommodate, they suspect its more to do with the natural lens itself.  It is true that the issue of movement led me to prefer a lens which doesn't depend on moving, but personally I'd likely have risked that over a monofocal, but I hadn't researched it enough to be sure.

In my case I was so myopic that I always wore correction, especially since I greatly preferred contact lens correction so I rarely wore glasses. I wore contacts every waking hour (and for some periods of time I wore extended wear lenses 24/7). Even when I wore glasses during periods where allergies caused problems with contacts, I didn't find it useful to take my glasses off to do things since the focal point was just too near, about 6.6 inches for my better eye and closer for the other. So for me I compare the results of surgery to what vision was like wearing correction. To me its like early presbyopia, I don't usually need to hold things at a different distance to read them,  but with say the small print on an eye drop bottle I do need to hunt for the right "sweet spot" to see it. Both my eyes are targeted for distance, though unfortunately in a high myope sometimes their formulas are off so my more myopic eye wound up postop slightly farsighted,    +0.5D which reduces near a bit, so I might consider a laser tweak to -0.5D for micro-monovision.

So sorry about your problems! I'm becoming frustrated in my quest, especially when I try to get answers to questions from the doc's office. Seems as if you get a different person each time you call & get a completely different answer each time too. I'm almost to the point of giving up...

Hello again!

My astigmatism is approx. 1.0, each eye. Not sure if that is a huge amount or not. I've read that the incision made during cataract surgery can correct a bit of astigmatism (a bit of reshaping as it heals). Not sure if that is true or not, as I don't see how such a tiny incision could have much impact. Since placement of toric IOL's apparently requires a lot more precision than non-torics, my current thought is that I may want to stay away from the toric (to avoid more variables than absolutely necessary) & do any astigmatism correction through eyeglass lenses, especially since  the doc indicated I will most likely have to wear glasses after cataract surgery anyway. Plus the fact that torics are just monofocals to begin with (might as well just go with a standard monofocal?).

I called the doc's office in Pueblo (he travels here to Alamosa from there, so the Pueblo office is his "main" office & is much larger than the Alamosa office) today to inquire about a trial of contact lenses to simulate some degree of monovision. Took them all day to get back with me. Don't know if I ended up speaking with the village idiot or what, but I am very frustrated after speaking with her. For starters, she acted as if it was the craziest inquiry she'd ever heard. She told me "All cataract patients are only corrected for far vision. That's how it works". I told her Dr Murphy had specifically mentioned correcting for far-far, near-near, or far-near last week. She said I must be confused. I told her I am CERTAIN there are options other than "just far-far". I again asked what I need to do to have a trial of monovision with contacts. She said I should probably call the OD in Alamosa & see if he can evaluate me & prescribe a set of contacts. So, I basically got nowhere today with my contact trial inquiry. I may stop by the OD's office on my next trip to town & see if anybody there seems to know what I'm talking about, but it doesn't sound promising. She also told me I need to hurry up & decide what I'm going to do, or cancel my surgery so somebody else can have that spot. Like I said...village idiot? Ding-a-ling? What?

Anyway, I've become really frustrated over this whole thing today.  

Since "far" seems to be what is being pushed: Do you think there would be any advantage to setting 1 eye for far & the other for a bit "in" from that? Or if I need to just go with "far-far" & hope for the best with correcting everything else with eyeglasses?

 

 

I have been finding your comments and unbelievably wide scope of knowledge really helpful.  Thank you. I have replied to MarioD as to my own situation as it may be helpful.  I have appts with 2 cataract surgeons for 2nd opinions in the coming month.

re: "Not sure if that is true or not, as I don't see how such a tiny incision could have much impact."

Actually your astigmatism is in the range where I think most surgeons would choose to use incisions rather than a toric lens, though some would still prefer a toric lens. Astigmatism is merely the eye being a tiny bit shaped like a football (American) instead of a sphere. Actually in the old days cataract surgery used to require much larger incisions just to do the lens replacement than it does with modern surgery and as a side effect it could potentially create more astigmatism than you have, Surgically Induced Astigmatism. These days they use such tiny incisions that there is little astigmatism induced so its not a concern,  but they try to  plan the incisions to counter a tiny bit of existing astigmatism. Adding additional incisions can counter small amounts of astigmatism. 

One thing you might need to be aware of is that the astigmatism you have now may not be what is relevant when determining whether you need a toric lens, since the astigmatism may be slightly higher or lower than the measurement from your prescription. Sometimes people have astigmatism in one direction on the cornea, which is countered by astigmatism in part by slight astigmatism of the lens in the other direction (or added to by astigmatism of the lens in the same direction). Since they are removing the lens, the only thing relevant is corneal astigmatism.

They need to measure that with special instruments. Older equipment  only meaured the surface of the eye, the anterior corneal astigmatism. Ideally you should make sure your doctor has up to date equipment that also measures posterior corneal astigmatism (the back of the cornea) to come up with total corneal astigmatism. Until a few years ago surgeons didn't realize that posterior corneal astigmatism was large enough to make a difference, but based on surgical results it does. Not all surgeons keep up to date. Unfortunately it sounds like your doctor options may be limited.

re: "stop by the OD's office"

At least around here I'd guess almost all  ODs are used to the issue of monovision contacts for presbyopia, and the majority are likely also used to prescribing  multifocal contacts by now (though it sounds like that is less of interest).  For just trying monovision, high volume ODs are more likely to have more trial lenses in stock, like the ODs at Walmart. You don't need an MD just to try contacts. 

If an MD insists you must be corrected for far vision, I'd avoid them if at all possible and find a better one. I would suspect most competent doctors  these days would at minimum raise the issue of at least some monovision, one eye far and the other eye a little bit in.  That suggests either their thinking isn't very flexible if they are experienced (perhaps stuck in their ways and they don't keep up to date) or that they aren't that experienced if they haven't considered the option. Either way I'd personally prefer to risk my eyes to a surgeon who is knowledgeable, experienced, and with flexible thinking skills. Its a routine safe operation, but in rare cases issues can arise so using a good doctor makes sense.  

Unfortunately it sounds like you have limited options, you are "remote" as you say out in Alamosa.  I'm not sure what to suggest,  since you mentioned you are a caregiver for a parent  and can't travel (the Symfony is available in Canada fyi).   I'm guessing even travel driving a bit further to Pueblo or  Colorado Springs or something might be an issue (though you will need someone to drive you home after surgery btw, at least most places sedate you and don't consider it safe to drive afterwards, in addition to usually having a patch over the operated eye the first night usually). 

There is a  toric version of the Crystalens approved in the US, the Trulign. Outside the US most multifocals and the Symfony have toric versions, though I don't think the US has approved any toric multifocals yet and I don't know if the Symfony toric is up for approval.

re: "really frustrated"

I'd guess that however you get your eyes set, the odds are  the improvement in vision from getting rid of the cataract will leave you happy with the results. If you are used to dealing with wearing correction at times, at most a change in what you need might be inconvenient but will be something you get used to easily. I'd suggest thinking about the issue as just hoping you can plan things so they are more convenient rather than a bit less. 

In my case after needing to wear correction all waking hours for so many years I guess the quest to perhaps not need glasses much or at all the rest of my life was worth some effort. (oddly since I have a high deductible it turned out to even be cheaper to have traveled to get my surgery than it would have to get it here since I went to a low cost country but still used one of the best docs in Europe in the Czech Republic and still came in under my deductible. Initially I was just trying to find the best lens and it wasn't available yet in Canada or Mexico, I hadn't counted on it being lower cost as well, though I did get a special introductory price so it may not be quite as much a bargain now). 

is early for me ; 10 days after lens exchange from simple Tori for distance which I hated ; I could not tolerate the contact for near vision ( seems my left eye can't get to see near )

i now got symphony on my on my right eye and everything at any distance is blurred and fuzzy 

laser tweak ?

it ended up that my cataract is incipient and maybe I did not need cataract surgery at all but have really bad astigmatism 

i am very confused ,went to a reputable second opinion but surgeons don't seem to like the extended visits with questions and concerns 

I am a pediatrician and my experience has been somewhat shocking 

Thought I must get educated first before getting a now third opinion 

I wonder if at least for distance I will need something done to my left eye soon ( LASIK ? ) as I have  too much astigmatism un corrected now on that eye