Need guidance on IOL selection for the second eye

That is very encouraging NeluG. I have natural monovision. And I got near vision correction in my right eye. I have been managing my reading needs without glasses until recently when I started having some issues with my intermediate vision. Perhaps due to the left eye cataract advancing. Like your example, I have come across many articles about success with one eye for near and one for distance. And no glasses needed for any gaps! Not sure how that is achieved but I am hoping that in my case it should be more achievable because I requested my surgeon to try to target for more than 18" for my reading eye as I mostly read on phone and computer. With that properly done, I am hopeful that after the surgery, the left eye will again support the right eye with intermediate vision. Keeping my fingers crossed. Will update here on the actual result.

It is not likely that a distance set monofocal will help at all with close reading vision. I have an AcrySof IQ set for distance that tests out at 0.0 D spherical for eyeglass prescription, and gives me a bit better than 20/20 without glasses. With it I can see a computer screen down to about 18". I see dash instruments in the car and truck perfectly. But that seems to be a bit unusual. Some with a monofocal set for distance start to jam out at 3 feet and closer.

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I have a consult appointment with my surgeon for my second eye on Friday next week. I think I am down to a Vivity or a Clareon. Since I have 20/20 distance in the first eye I am sure I will under correct either lens. Probably by -1.25 or a bit more in the Clareon, or -0.75 D or a bit more in the Vivity. Under correction is not a good option for you unless you want to lock yourself into needing glasses for distance. The Clareon is essentially the same as the AcrySof IQ aspheric monofocal but is made with a newer material. If I learn anything more I will try to remember to post. My surgeon recommended against the PanOptix for my first eye, and said he would not consider putting it in his own eye. Will be interesting to see what he says about the Vivity. It was not available when I had my first eye done.

I have started to get more serious on my research of the Vivity and Clareon lenses. In the research I stumbled on an interesting article that may be of interest to you. You should be able to find it by googling the following:

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CRST February 2021 OPTIMIZING OUTCOMES WHEN THE TARGET IS LOW MYOPIA

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I guess it is a bit too late now, but it seems there are differences in the formulas for IOL power calculation when the target is low myopia needed for monovision. It sounds from your description that your surgeon may have missed somewhat and left you somewhat lacking for myopia and reading ability in your right non dominant eye. From what I see in this article the best formula is the Barrett Universal II. It is not only the most accurate for the myopic target eye, but also the distance emmetropia eye. It is a bit tricky communication wise with your surgeon, but you may want to ask if this Barrett formula was used, and if he/she would use it for the next eye if it was not used. The trick with getting a good outcome with a distance eye is to get close to 0.0 D, but never into the + range. The normal target is -0.25 D. If you go into the + range it starts to hinder reading vision as well as less than optimal distance vision.

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On the use of a Clareon lens instead of the AcrySof IQ I also found another interesting article. You should be able to find it by googling this.

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The Open Opthalmology Journal Comparison of Visual Outcomes and Patient Satisfaction Following Cataract Surgery with Two Monofocal Intraocular Lenses: Clareon® vs AcrySof® IQ Monofocal

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PCO is not an uncommon problem with IOLs. It seems the Clareon may be a little more resistant to PCO than the AcrySof IQ lens. You may want to ask your surgeon if Clareon is an option.

Thanks RonKA for sharing your experience. I have chosen a busy doctor who does a massive number of cataract surgeries every day. He is a man of few words. For my right eye he was originally targeting near vision for reading at 14" and under. But I requested him to target around 18" (mini-monovision) since my left cataract wasn't too bad and I was hoping to find a new IOL which will take care of all zones. Now, my surgeon says since I got AcrySoft IOL in my right eye the only option I have is PanOptix (same family). They are using standard solutions for their patients I am guessing. But will try to ask about Clareon too. He assured me that whether I choose PanOptix or Monofocal for distance for the left eye, I am likely to be without needing glasses for any zone. But there is no guarantee. I have a few weeks to decide. If I decide to go with monofocal I want to be able to watch TV and drive without glasses. I don't mind using glasses for computer. I am a software engineer and work 6-8 hours a day on PC. I might be better of using prescription glasses for that. Hoping that my right eye will take care of at least the intermediate vision. Let's see. I have been researching for 6 years and found no solution without a trade off.

PanOptix, Vivity, AcrySof IQ, and Clareon are all made by Alcon. There is no reason in my opinion that they could not be used in any combination for each eye. In that study I gave you the title to, they implanted an AcrySof in one eye and a Clareon in the other eye of each subject, so obviously they can be mixed.

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Some surgeons will only deal with one supplier of lenses. In North America the other big manufacturer is Johnson and Johnson. Their current lens models are Synergy, Symfony, Eyhance, and Tecnis.

I had my consult today but did not get to see the surgeon. Just had my eyes measured again with the IOLMaster and a couple of other instruments. Will not get to see the surgeon to discuss the monofocal Clareon vs the Vivity, so have no further information for you.

Thanks for the update RonAKA. Today, I decided to experience the monovision scenario by removing the right eye lens from my glasses made for distance and wearing them around the house. Just as we expected, the intermediate vision is hugely impacted. I am having difficulty reading at all distances (except for big letter at a distance). I can read my phone at 18+ inches but that too is causing strain. Maybe because I am still adjusting to this new scenario. Distance is okay (not great) for TV watching and possibly for driving too. Again, may be due to the cataract in the left eye. This makes me wonder if monofocal IOL in the left eye is at all a good option for me even after I get accustomed to the monovision! My older brother who has the same situation as mine (Right eye corrected for near vision with Lasik and left eye cataract has matured) is considering LAL his surgeon has advised (perhaps the RxSight UV light adjustable lens for the left eye. LAL being fairly new it may come with its own trade off(s). And LAL may still not offer what trifocal or MF lenses offer. What else I can experiment with before considering any option. Thanks in advance for your help.

btw: I am typing this note with the experimental pair of glass. Getting a mild headache and not enjoying the vision at all.

Just so I can understand better where you are at, I presume you have a current pair of glasses that correct for distance vision and perhaps are progressive to let you read? And this is the pair of glasses that you took the right lens out of? If so, do you know the prescription of these glasses for each lens? That would help me grasp better what you may be seeing.

They are not progressive. Just for distance vision. I used them for only watching TV and driving. Now I am wearing them all the time inside the house (with right lens taken off). My most recent prescription is OD -1.25 Cylinder -0.50 Axis 135 and OS -1.75 Cylinder -0.75 Axis 040. However, the prescription glasses that were made six month ago using this prescription Right Lens -1.25 Cylinder -0.25 Axis 142 Left Lens -1.50 Cylinder -0.75 Axis 025 seem to work better even now. So with my distance pair with right lens taken out I am getting used to the normal activities but don't feel great about any distance. The TV watching is no fun. Reading on phone is causing strain. It feels as if both eyes are trying to do their job independently. I feel that without support of the left eye, the right eye with monofocal lens for intermediate is struggling too. I feel that I can adjust to mini-monovision. However, I doubt it will do a good job after cataract removal and monofocal implant in the left eye. I feel that phone reading will continue to be an issue. Thoughts?

If I under stand this correctly you are myopic in your right eye with -1.25 D spherical, and -0.5 D cylinder (astigmatism). I roughly estimate the equivalent power of this by adding 50% of the cylinder to the spherical. So in this eye it would be a total equivalent of about -1.5 D. This should be ideal for the close eye with no correction lens. How is your reading with this eye without any correction lens? I would think it should be pretty good?

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If you can see well for distance in your left eye with the eyeglass lens and nothing in the right, I would think this is a close approximation of monovision in theory. I went a week or so with a lens removed in my glasses and again while it should have been OK in theory, I did not like it much. After that I got a contact lens for my non operated eye to make the correction my eyeglasses were providing. I liked that better. It seems more natural.

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So my thoughts would be, if you have time, is to get some trial contacts for you left eye that will correct for distance to see what that feels like. You could either get a toric with correction for both spherical and cylinder or a non toric, which I would estimate to be about -2.00 D or so. That is probably the best trial to see if you can adapt to monovision with a monofocal IOL for distance vision in your left eye.

Thanks, again! Yes, the right eye without any lens and the left eye with a lens for distance is what I am testing with. Today is the second day and it is slightly better. I am not getting any headache. The right eye can read on phone and computer with slight strain. When I remove the lens for distance from my left eye, the right eye vision improves. So hopefully when cataract in the left eye is removed and the left eye is corrected for distance vision I am hoping it would be better. With the lens for distance on the left eye only, I can watch TV but it is not as good as it is with lenses for distance in both eyes 😦. Will this improve after cataract surgery with monofocal IOL for distance in the left eye? As you suggested, I am going to test this with a one day contact lens (-2.00 D) if it is available off the shelf. Otherwise, how do I order that? Once test with contact lens works out, do you suggest I should go ahead with monovision or still consider a trifocal (PanOptix) to get better results?

I normally do everything with one eye IOL corrected to distance, and my other eye corrected to about -1.25 D with a contact, glasses free of course. With that arrangement I can read my iPhone, see the computer screen quite well, read most text, and at the same time watch TV 12 feet away or so. When I watch TV my overall vision is quite good, but if I close my distance IOL eye and look only with my -1.25 D eye, there is a definite drop off in sharpness. With both eyes open, my distance eye obviously ignores or somewhat ignores that lower quality image. I also have some new progressives eyeglasses which correct the -0.75 D residual astigmatism in my IOL eye, and also correct for the -1.25 Sphere, -1.25 cylinder (astigmatism) in my non operated eye. The TV is slightly sharper when using these glasses. My computer screen is also slightly sharper. But, as you likely know with progressives you have to look through the bottom of the lenses (which are +2.5) to see well close up. Now that I have gotten used to being eyeglass free, I find that really annoying on my computer. I have tilt my head way up to see the screen clearly. And I have to move my head instead of my eyes if I look back and forth between the top and bottom of the screen. It works but is no where near as natural and comfortable as my simulated monovision.

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I get my contacts at Costco. They are quite generous in giving out packages of 5 sample lenses. I think they get them from the manufacturer at no cost to them. They seem to have quite a wide range of trial powers in stock in increments of 0.25 D for sphere and 0.25 D for torics. I suspect optometrists also get these free trial packages from their suppliers and should offer the same service. I live close to a Costco and that is the most convenient place for me. I'm currently using their Kirkland Signature contacts which are made by CooperVision. I tested out about 6 different types and settled on these ones. If you have not used contacts before I would advise you to avoid the Hydrogel types. They are super flexible and really hard to handle. There is a newer Silicone Hydrogel material that is much better. They are less flexible, easier to handle, but still comfortable. In the J&J line I like the Acuvue Oasis (available in toric), but avoid the Acuvue Moist (they are hydrogel). The Alcon Dailies Total 1 are good, and the Alcon Precision 1 should be good too, but I have not tried those. But of these I like the Kirkland ones best. They are CooperVision MyDay dailies.

Really appreciate you for complete detail and very helpful advice on contacts. I am not a Costco member but I recently got my glasses made at LensCrafters. I guess they will offer a good service on contacts too. I am continuing to use my experiential glasses at home and for driving. I am getting used to it. however, I find the overall distance vision not so great. I also noticed that I am missing some intermediate vision between 22 inches and 36 inches range. I noticed this because when I was sitting next to my wife while she was working her computer and I could not clearly read anything on her screen from 28 inches distance. Since I am easily adopting to monovision, I think I will go for it after my contact lens trial works out good. My thinking is that I will get progressive glasses made after my cataract surgery and use them when ever I need to focus on computer reading or driving. Otherwise I will hopefully be able to function without glasses most of the time. Fingers crosses 😃

Yes, I would think LensCrafters should be able to set you up with some trial contacts. I believe the manufacturers give free trial packs out quite freely to optical supply places.

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In my case my distance IOL eye takes over at about 20" so I have no trouble with vision at that distance. Your cataract may be preventing you from having the best vision at that distance now.

Oh, wow! So distance vision can be set from 20" onwards or it just happened in your case? Is there a trade off when a cataract surgeon sets one eye (say dominant eye) to see from 20". Would there be trade off in terms of distance as opposed to a young person with normal vision generally has. I would really be a happy camper if that works. Thanks.

20" was just how it turned out for me for closer vision. It was not my objective. My recollection is that my surgeon predicted I would end up at -0.35 D, or slightly myopic with the power he recommended. He said if he went one step in power down I would theoretically be very close to 0.0 D. But, he said it was not advisable to target 0.0 D as there is a possibility it could end up over 0.0 in the + zone. He said that nobody ever thanks him for leaving them in the plus zone (far sighted). That impacts near vision negatively. So he targeted -0.35 D and I ended up with a residual spherical of 0.0 D. He missed his target, but I got the perfect outcome. If he had used the "perfect" power I would have ended up at -0.35 D.

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But on the other hand he said it would be under -0.4 D for cylinder (astigmatism). I ended up poorer than that at -0.75 D for astigmatism.

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So, out of this I have been able to see down to 20", which seems to be closer than most people report here with a monofocal set for distance. It is possible that the -0.75 D astigmatism is helping me see closer. There is a LRI procedure to correct low amounts of astigmatism that I investigated, but I cooled off on it, when I found out it would likely negatively impact my close vision. It might improve my distance vision a bit if I reduced the astigmatism. But, I can see the 20/20 line comfortably and some of the 20/15 line, so I am very happy with distance vision as it is.

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I think the moral in this is to have a discussion with your surgeon on the options for lens powers. It will almost always come down to a choice of two powers. It is better to error on the minus side rather than risk going positive.