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PanOptix: Did you adjust or explant? How happy were you with the change if exchanging?
I am 52 years old and received PanOptix toric in both eyes, LE on 9/9/2021 and RE on 11/30/2021.
I did have the beginnings of nuclear and cortical cataracts, although they were not bothering me that much, and my doctor encouraged me toward going ahead and “taking care of those” while also addressing my extreme myopia and astigmatism. Much regret about this, but here I am and deciding how to move forward. He did not tell me what lens I was getting, and I was too uninformed to ask; I just knew I wanted to be as free of corrective lenses as possible; otherwise, there wasn’t much point since my cataracts were not yet severe. My doctor told me that the lenses I would receive had the side effect of halos—which I accepted because my extreme myopia has always given me starbursts. He did not mention any other trade-offs from the lenses I would receive. The LE took two tries—the first lens implanted in July 2021 was too much of a refractive miss, so my doctor explanted it uneventfully and replaced it with the correct power on 9/9, so the LE has already undergone a lens exchange once, early in the post-op period. Now that my RE (dominant eye) is done, I measure 20/20 both near and distance and show no signs of astigmatism. My doctor is happy and considers it a great result.
My original manifest refraction, is below. I am not savvy on exactly what everything means in practical/scientific terms; I just knew I couldn't see 2" past my nose without my contacts, although my correction with them was very good except for needing readers up close. At my last exam in May 2021 the correction had dropped off slightly to 20/25 and I had presbyopia in addition to mild cataracts. I was noticing needing more light to see in the evenings. Other than some expected lattice degeneration which was examined pre-operatively, my eyes are otherwise healthy.
How I wish I had left well enough alone.
My overall quality of vision and quality of life are worse, in spite of the technically "perfect" result, and I am wondering if I should risk exchanging one or both of these lenses to restore a better quality of vision and reduce the number of visual side effects. I know on paper everything looks great, but I am frustrated and upset every day. I am experiencing these side effects in my vision:
Shadows/blobs/offset gray images around text, especially light text on dark backgrounds. Additionally, all text looks faded and pale.
Glimmers and shimmers in peripheral vision, especially in low light or when seated by a window. Very disorienting.
Poor intermediate vision that drops off after about 28” and makes it difficult to impossible to make out
labels on store shelves, in my refrigerator, on bulletin boards, or when looking over my students’ desks to see their papers or computer screens. Everything from about 28” to 8 or 10 feet is less sharp and detailed and slightly unfocused, then it gets better again in the distance.
Halos around bright points of light even in the daytime (example: looking at my silver stud earrings in the mirror, they have halos or double edges). I had expected night halos, but not daytime too. Focusing on a shiny surface or object--forget it.
A double edge, ghost edge, faint transparent projection of the outlines of every object I Iook at up close. Everything looks slightly out of focus and nothing has sharp, clear edges.
Especially when I am indoors, objects look slightly out of focus due to the double outlines; it is hard to describe, but things almost have an electric glow around them, or look like a printed image that ought to be viewed with 3-D glasses in order to merge the outlines.
A projection of road signs so that I see the sign and then a faint copy of the sign on one side, especially on bright days
Dryer eyes (which I know can also affect vision). I use preservative free eyedrops probably 10-12 times a day.
Worse fuzzy vision in low light.
The good: I can see acceptably well/clearly outside in bright daylight. I can see to put on makeup and work at my computer (14-16” away from my face). Nothing is as sharp and clear as before with my contacts, however.
I do understand neuroadaptation takes some time, up to a year for some people, but I am not sure I am ready to accept strange glowing shadow outlines around everything and "soft focus" for the rest of my life. I do have decent near vision and can see to read and use my computer (although with the ghost letters) and can see well enough to put on makeup, so I hate to lose that, but the overall quality of my vision is much less sharp than I was used to with contacts, and between that and all the strange visual effects, I am just not having a good time. I am in a bit of a dilemma because I want to see if time helps, but I have some PCO that my doctor wants to YAG and know treating might help a little, but would make exchange more dangerous, and that the sooner you exchange, generally the better.
I am a detail person and tend to notice everything; I do photography, needlework, calligraphy, artwork, antique restoration, crafts, and a lot of reading. I also do a lot of things like cooking and gardening that require clear vision a few feet farther out. My current vision, both its lack of sharpness and the weird visual effects that may or may not resolve, is very distressing. A pair of trifocal readers helps somewhat with the intermediate, like when I am in a store, but does not entirely resolve the double outlines and weird reflections. At many points in the day things just look "off" and I struggle to focus.
Has anyone here exchanged one or both PanOptix lenses for a monofocal? If so, how long did you wait? I am interested to hear if the exchange resolved your problems, improved your vision quality, and made you happier. Did the additional procedure make your eyes even dryer? Were there any complications? How close is your near vision after the exchange? I am an extreme myope and have long eyeballs; does that affect the range of clear vision with monofocals? What lens did you receive instead? Were they able to exchange for another in-the-bag lens, or did they have to use a sulcus or other type of fixed lens and aren’t those more risky/worse outcomes? And finally, is there anyone with monofocal lenses who is able to wear contact lenses for near and intermediate without having to take them out to drive or do outdoor/distance activities? I understand I could get progressive glasses, but really would prefer contacts and am not sure if they can be inserted in the morning and worn throughout the day without affecting some other distance I need. Or do you regret exchanging your multifocal lens?
If you kept your PanOptix, did the disturbances eventually resolve? After how long? The two that bother me most are the ghost outlines and lack of sharp edges. I have read that they are always there but you learn to tune them out, the way you tune out tinnitus (which I also have). I do not think I can live with "visual tinnitus" if that is the case.
I am afraid of trading one set of problems for possibly worse ones and exposing myself to the added risks of explanation, but am very distressed about dealing with these visual disturbances forever. At the same time, I wonder if I should leave well enough alone and just learn to accept it.
Any real-life experiences are most welcome as I weigh my options and consult with professionals in my area.
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There are a lot of things you mentioned that are a bit disturbing. IMHO a person with extreme myopia and astigmatism is not a good candidate for a diffractive IOL. I also do not understand why a doctor would go ahead and implant another PanOptics in your other eye if you had issues with the first implant. I would not do a YAG if you are thinking of doing an IOL exchange.
Worse fuzzy vision in low light is pretty much a symptom of all diffractive IOLs as the incoming light is split or elongated.
My only advice would be to get a 2nd or even 3rd opinion from a Top Opthalmologist. If in the US, look at US New Report Top Opthalmologist.Contact them by phone or email and see what they advice and then see them to determine your best options, even if you need to travel a distance to do it.
Thank you; that is good advice. i already have an appointment with one of the too rated doctors in my state in a few weeks, and plan to seek a couple of other opinions as well. I am in NC, USA, so I am going to inquire about a referral to Duke Eye Center which is a top hospital in the country. I am also disturbed and feel so upset by things I have learned since my surgeries and the risks I am now needlessly exposed to years earlier than necessary. My surgeon said all would be well if I could settle down and neuroadapt and that I would see better once both eyes were done . I can't help feeling like I was either used for profit (would he have been so enthusiastic had I requested basic lenses?) or for his own ego to see if he could "heal" my poor vision. I will see him in April (the soonest I can get in, in spite of calling, messaging, and expressing my distress) and am afraid I will be blamed for not adapting or told to give it more time. I hope someone can help me.
I have PanOptix in my right dominant eye and Light Adjustable Lens (LAL) in my left, implanted about a year apart with the PanOptix done first. Biggest factor with the PanOptix is neuroadaptation as you know. You now have three different images being focused inside your eyes and your brain has to learn which one to use.
In my case, doing only one eye meant it took longer to adapt as my brain just leaned on my other eye to compensate. I'm still adapting. But the gray blur surrounding text now takes a moment to fade in when reading, but otherwise I don't notice it very often. Likewise the halos and star bursts also go largely unnoticed unless especially pronounced or I'm looking for them. I've just gotten used to them.
We're probably in the same boat as being detail oriented probably should've been contraindicated for the PanOptix as our personality types can have difficulty with the neuroadaptation. Neither of the two doctors I consulted even mentioned this. But I can report it is still possible.
My suggestion if you're considering lens exchange is to postpone YAG for as long as possible. If you end up needing to do an exchange it's lower risk if the capsule is intact. However, the longer you wait after surgery also increases the risks doing an exchange. It's a very personal decision.
For me, I decided to stick with the PanOptix as the LAL has essentially given me back everything I lost and I'm doing very well combining the two - PanOptix gives me excellent distance and near but reduced near contrast sensitivity and weaker mid-range focus, LAL is tuned for intermediate to mid-range (arm's length out to about 10ft) but also has some distance and improves near contrast. This mixed option could also be something to discuss with your doctor should you ultimately decide to make changes.
I have high myopia and some astigmatism. I will be going for a consultation for LAL. can you offer your personal experience with LAL? Can I ask which facility you had it done?
I went to Dr. John Doane at Discover Vision Centers in Kansas City. He was investigator on the clinical trials when the LAL came to the US.
My experience has been positive. It has almost completely compensated for the shortcomings of the multifocal in my other eye. While it is a single focus lens, it has some extended depth of focus so in bright daylight my distance and near vision in the LAL eye are also pretty good. But it is primarily tuned for mid-range as that's where the PanOptix is weakest.
The ability to adjust the focus after surgery is pretty amazing. We started with it set to distance and adjusted it a little closer (-.5) which landed it right where I wanted it. One adjustment is all I needed but it's possible to do several to try different powers, especially useful if doing both eyes so you can try monovision or mini-monovision without commitment in case you can't tolerate it. There's also no worry about getting a toric lens misaligned as the astigmatism correction is also performed in the adjustment.
My only complaint which nobody mentioned either in exams or in material online is I now get lens flares in the LAL lens from bright lights, most noticeable at night or in dim light. They aren't halos or starbursts around lights, but indeed flares that move relative to the light source. It's by far not a deal-breaker, but it was a surprise. I don't know yet if they'll reduce with time.
Overall I'm very satisfied with the results and would do it again. I think if someone is looking at doing a premium lens with extremely predictable results and is OK with the possibility of needing spectacles for some tasks, it's a great option, especially if there's extra eye complexities for the individual that might cause otherwise unpredictable or unintended results.
thank you so much for your input. I was originally thinking about Panoptics but was afraid of all the negatives I was reading about. Also reading about doctors not using the correct power or the power selected is not working for the patient. I, like most would like to eliminate glasses as much as possible. I will also try mono again with contacts first.
I suggest asking your doctor questions around how the implant(s) you choose will impact your common tasks, your chosen career (or alternatives), things you spend the most time on. I also suggest getting a second maybe even third opinion if circumstances permit. My regular eye doc recommended PanOptix, but he was younger than me (I'm 39) so I questioned his experience. So I saw another doc who had much more experience, and also recommended the PanOptix. I ended up getting the surgery from the second doc. While his calculations and surgery were perfect, my distance and near are both 20/15 in that eye, his practice left me soured. When it came time to do the other eye, I actually changed health insurance providers (I was on an ACA plan and obtained an SEP) so I could see Dr. Doane.
A lot of the negatives I read about the PanOptix tend to be reported shortly after surgery. This in my opinion is simply too soon to judge. While I think it's wise to basically ignore all the marketing material, the outcome does rely heavily on neuroadaptation, and that takes time. You're genuinely rewiring your brain to use your eye(s) differently.
Everything you see is a construct of your brain. Your eyes just provide raw messy input. Consider optical illusions: you can see things that aren't there, and not see things that are there. What you see is literally all in your head.
I think that the system I've built with the PanOptix and LAL combined is a great combination. But, I had almost a year to adapt to a PanOptix already before adding the LAL, so my overall situation is probably unique as most people get both eyes done over just a few weeks. The PanOptix is far from perfect, and if I had it in both eyes I would not be able to perform in my career.
Bottom line is that for me, I sought and encourage multiple opinions before spending upwards of $10,000 on premium implants. Forums like this are great, which is why I dropped by to offer up my experiences for google to crawl, but it's no replacement for multiple professional consultations and evaluations.
Thank you for your reply, and apologies I am just now replying. I have visited 3 different specialists now, including two at Duke Eye Center. The first one at Duke used an autorefractor and discovered that I indeed had some error, and prescribed some +0.5 glasses which helped a lot with sharpening distance. I also have a tiny bit of astigmatism (-0.5) in my right eye. I tried a cheap progressive pair with a 1.0 add, which help at near/intermediate, but only if I hold them up/out because it is impossible to get the placement right due to the add already built into PanOptix.
The most recent surgeon I saw is one of their IOL specialists and does many explants per year. He said that he no longer offers PanOptix because he has had to explant so many of them, that Vivity doesn't come in the power I need, and that the only thing he would confidently offer me would be a monofocal, most likely the Acrysof IQ toric. He said that he has not had a patient unhappy with PanOptix who did not end up happier with the monofocal, and that he looked at it as a quality of life issue. Apparently "failure to adapt" can be covered by insurance, although I would have to pay out of pocket for the toric lenses. I have postponed YAG which every doctor said was the right thing to do, and the surgeon I am consulting with said he can attempt to clean the capsule during explant, and if that is not possible, we would allow everything to heal and then do YAG. In his opinion after examining me and doing several hours of measurements and tests, I am on the low end of risk factors for explantation, even though it has been 9/7 months for my eyes. He also said that while my personality certainly isn't helping, some of my problems are also due to the physiology of my eyes (though he didn't elaborate). In addition to his MD in Ophthalmology, he holds a PhD in Neuroscience and degrees in Physiology and Biophysics, and his undergrad was Materials Engineering, so I feel pretty confident he knows what he is talking about.
I have noticed that the gray shadows behind letters on white backgrounds have diminished. I still see double letters around light text on dark backgrounds, halos during the day and night, glare off all shiny/reflective things, and ghost edges around smooth lines, particularly when they are against a contrasting background. Outside or near a window on a bright day I can see well, but indoors or even in the day I am unable to see things just a couple of feet away, like a name on a colleague's badge or signs on a bulletin board (except for very large print). The peripheral shimmer is almost gone, mercifully. I find myself frequently frustrated with the clarity of my near and intermediate vision, and definitely the arm's length out to about 10 feet that you describe. The exception is reading illuminated screens in bright lighting at the exact points that PanOptix sets the focal points. I still notice the overlapping edges of objects and their backgrounds which is very bothersome and interferes with fine, detailed work.
I have a couple more months to consider this, according to the surgeon. He spent a long time consulting with me and answered all my questions, but I am preparing a list of ones I have thought of since my visit which his assistant will give to him. I have a lot to think about and will update once I have made a decision, and the results. Thank you again for reaching out and sharing your experience and encouragement; it means a lot!
A couple of comments. The fact that a prescription of +0.5 D helps you vision would suggest that the power was missed and you went into the plus side. That has an negative impact on near vision. You mentioned that you have a small amount (0.5 D) of astigmatism. That is probably as close as you are going to get with a toric IOL.
Sounds like you've found a pretty good doc. If you do decide a change must be made, it might be worth considering doing what I did and mixing technologies. So just explanting one eye, possibly even with an LAL so you can tune it to the weak PanOptix mid-range. This is still working great for me. I do wear +0.5 if I'm doing extended reading to bring my LAL eye into focus, and wear +1.5 if I'm doing work 1-2ft in front of my face that requires crisp vision. Otherwise it's actually kinda interesting how in the first few weeks after adjustment I could tell when my brain was switching eyes based on which one had better focus. Now it's pretty seamless. I still get lens flares particularly at night, but will have to wait until winter to see how big of a problem it really is. So that's something worth considering given it'd be only the risk and cost of doing one eye. Doing dominant or non-dominant would just be something to figure out.
I am computer professional spending 12 plus hrs everyday. Early cataract, surgeon said Panoptix is great and Synergy is best for near vision on Tablets etc. Got Panoptix in Left eye, sharp computer vision but horrible night driving. Halos, Starburst, almost head on when a truck on opposite side made left turn in front me me, couldn't see his yellow turning light due to Starburst and spiderweb...got Synergy in right eye. Sharp computer vision but 0 difference in night vision. I was.told my brain can't seem to adapt to 2 different technologies (tri focal and edof). Synergy was also blurry for few days before clearing up. Panoptix was clear vision in 2 hrs after implant. Vivity was no good for my top priority of tablet vision. surgeon said Vivity is good for pilots and truck drivers who need sharp distance vision. Anyway, last Friday got rid of Panoptix popped 2nd Synergy. Again 2 days after still blurry, some retinal swelling...will see... Frankly, there is NO perfect IOL. I was hyper myopic so wanted to enjoy glasses free...that I was with Synergy and Panoptix. Had it not been night driving hell, I would kept both Panoptix and Synergy. I will update in 2-3 weeks on Synergy in both eyes.
Are you saying your night vision is good with Synergy?
what doctor did you go to?
I don't have PanOptix in either of my eyes, but I do have Symfony in one eye and Synergy in the other. Starbursts and cobwebs are 3 times greater in Synergy's eye.
Interesting. I have Symfony both eyes - Synergy not available when I had my surgeries.
I hope you see improvement! How are you doing now?
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