Piggy backing a symfony lens

Thank you.  I realise it would have been better to have the symfony lens in the left (non dominant eye), but it is not available through the NHS, and, for ethical reasons, the surgeon didn't mention it could be done privately. 

Presumably it would be risky to exchange the monofocal iol in the left eye for a symphony ?

The main concerns about a symphony, at -1.0D in the right eye are

1) would it work well together with the monofocal in the left eye ?

2) Would the symfony have less contrast than a monofocal? That could be a problem with night driving, and with playing the organ or piano in dim light - which is occasionally happens.

3) What is the likelihood of rings around lights for night driving?

I also need to decide whether to go back to the surgeon who did the left eye cataract op (but he may not be used to fitting symfonys, even privately), or to find another surgeon who is familiar with them?

To sum up, I would like the versatility of a symfony, but without taking a risk, as I think a subsequent exchange with a monofocal would not be safe. 

In answer to your quesions:

1. There is no basic issue with having a monofocal lens in one eye and a different type lens in the other eye. I have a monofocal lens in my left eye and a Symfony lens in the right eye, with no associated issues because of that. Similarly, my wife got a Crystallens in her left eye (before Symfony was certified) and then got a monofocal lens in the right eye, again with no issues. The surgeons don't suggest that, but don't raise any objection to that because there is not reason to do that.

2. There may be a slight difference in contrast between a monofocal lens and a Symfony lens, but I have not noticed it. If you get the prescrition of -1.0 D with the Symfony lens for the right eye and you have good distance vision with the left eye, you will be really seeing a lot better in the distance with the left eye and thus, the right eye distance vision will be much less important.

3. I think that with the Symfony lens at -1.0D in the right eye, the likelihood of seeing rings around lights or being uable to drive at night will not be much more than what you have right now (with the lens in the left eye good for distance) or will have with a monofocal lens (at -1.0D) in the right eye.

With this setup, would I need to wear glasses for midstance music reading (c.50-58cms), and for close reading and smartphone ?    If so, would they be set up so both eyes were in focus ?  I am not sure I would be happy reading, if only one eye is in focus !

With the Symfony lens at -1.0D in the right eye (together with the existing monofocal lens for distance), you should be able to read music at 50-58 cm distance. You will probably need low-power reading glasses to read fine print at about 40 cm.

Thank you. I think the difference between the prescriptions in both eyes might be a disadvantage with night driving, as points of light might be distorted in the right eye. I imagine my brain would filter out the left eye when playing music or reading close?

I plan to ask the surgeon whether he fits the symfony lens, which is presumably the least likely to cause halos or starburst effects ?

The Symfony lens is more likely, and not less likely, to have the halos effect than the monofocal lens. What I said was that "with the Symfony lens at -1.0D in the right eye, the likelihood of seeing rings around lights or being uable to drive at night will not be much more than what you have right now (with the lens in the left eye good for distance) or will have with a monofocal lens (at -1.0D) in the right eye."

If you will like to have the best chance of being able to drive at night without any night vision issue, a monofocal lens set for distance in the right eye is the best choice. However, in my opinion, you will be needing the glasses for near and intermediate distances, which may not be the best overall solution. So, you should go for the the Symfony lens at -1.0D in the right eye (together with the existing monofocal lens for distance)

Yesterday, I had another cataract consultation with a top local eye surgeon at a very high rated clinic associated with a local university.

He does all the major toric IOLs I'm interested in including Alcon & Tecnis monofocal toric, Tecnis Symfony Toric, and Trulign (accomodating) IOL.

My right eye has the significant cataract and the left eye only a very early stage one. Both have astigmatism, left=2.0D, right=2.75D cylinder and the cornea measurements they did yesterday confirmed close to that.

For the right eye, he recommended either a monofocal toric or the Trulign IOL.  I asked him about Symfony but he lumps that in with multifocal IOLs and didn't like the night vision artifacts and some loss of contrast sensitivity compared to the ones he recommended.

I asked him about a monofocal toric in the right eye for distance and later in the future perhaps a Symfony Toric in the left eye with mini-monovision, but he was against mixing types of IOLs. 

The Trulign IOL is a more difficult process after implantation, he keeps the eye dilated for a week and lots of eye exercises to get the eye muscles to make it move up to +1D for intermediate vision.  Also the highest corneal cylinder model for Trulign currently is only 1.83D which is quite below my right eye's cylinder of 2.75D+ so it would require additional corneal LRI surgery to reduce astigmatism enough to make it worthwhile, but he said LRI's often can lose much of the cylinder correction after a couple years.  So that doesn't sound like an appealing option for my right eye.  For the left eye its a possibly, but again that would be mixing IOL types which the doctor didn't like the idea of.

I will probably continue with my plan for my right eye of going for the simpler monofocal toric which has larger cylinder models readily available, so no corneal surgery should be needed with that.  The doctor does both Tecnic and Alcon and doesn't care which you select, I prefer Tecnis since it appears to have better contrast sensitivity and no blue filter or glistenings.

Since my left eye probably won't need cataract surgery for several more years unless I pay for it all out of pocket earlier, I will probably use an RGP contact lens in that eye set for intermediate distance, if the right eye is corrected for good distance.  I did that successfully for several years before with RGP contacts in both eyes before the cataract in the right eye started having effect.

I'll still hold out hope I might be able to get a Symfony Toric in the left eye in future down the road, if the right eye is done successfully. May have to find some other surgeon more willing to mix IOL types, thats tough to find!

I think that your plan is good.

You may find that once you have the monofocal lens for distance in the right eye, there will be many surgeons who will be more than happy to install the Symfony lens or the Trulign lens in the left eye later (since at that point they will have more of a financial motivation to do so).

Speaking for myself, my surgeon did not express a single concern about my getting a Symfony lens in the right eye after having had a monofocal lens in the left eye for the llast 18 years. I am also not aware of any potential issue involved in doing so.

My wife got a Crystalens (the non-toric version of Trulign) for her left eye about 2 years back, but was rather disappinted in the narrow range of the focus adjustment it provided. The surgeon was suggesting the same Crystalens for the 2nd eye also, but when we told the surgeon that my wife preferred to have the monofocal lens for the right eye just for reading, there was no counter-argument from the surgeon. Again, there has been no issue due to using 2 different types of lenses.

So you seem to get more of a range of focus with your Symfony eye compared to your wife's Crystalens eye?

Does Symfony typically provide more than the 1D acommodating focus range of Crystalens/Trulign IOLs?

That consulation I had yesterday was different than the first, since this was at the clinic associated with a university so all the top eye surgeons there are also professors.  I had to get thru layers of techs and his student residents first before the eye surgeon came in.  He would send in one of his students apparently to look at my eyes and then outside the door I could hear him quizzing them on what they saw and their diagnosis.  Then when he came in with 2 of his students, he would show them a technique and then they would each look at both my eyes to do what he did to see the difference in my eyes, one with the much denser cataract than the other eye.  They spent so much extra time between them with the slit lamp my eyes felt like a flash bulb had gone off and I had after images of the lights for quite a while after! You kinda feel like a guinea pig for the students there. I wonder if the actual surgery there would be the same with his students watching/assisting?

Since these eye surgeons are not usually cataract patients themselves, I'm not sure if their opinions on mixing IOL types is better than actual patients who have done it and got a successful result.

Seems to me, its not much different than say monovision, mixing a near focus eye with a distance focus eye.  In fact mixing a Symfony as an intermediate focus eye with a monofocal distance eye to me is just a superior form of monovision. I think it would work OK especially if the two eyes have IOLs from the same manufacturer so the other features are about the same. Compared to say mixing an Alcon monofocal with its unique blue filter with a Tecnis (no blue filter and sharper) in the other eye.

Same with mixing a Crystalens/Trulign with a monofocal IOL in the other eye. 

Symfony provides good vision over about 1.5 D. Thus, a Symfony lens with the best focus at 0D willl provide good vision down to about -1.5D.

You seem to be very knowledgeable about mixing a Symfony lens with monofocal.  I've had a Symfony lens in my right (non-dominant) eye since Aug 9.  I immediately had halos and starbursts and although they have subsided a little bit (tolerable at night when using my left eye with my old glasses with the right lens taken out) but I don't have much hope that at three months it get much better.  I like my vision with the right eye.  Can see pretty well at most distances although I think contrast might be compromised a little bit as well.   Can read on the computer but not always on my iphone - depends on lighting a bit.  I have no idea what the doctor set my vision for with this lens.  Originally, I was going to have both eyes done with symphony.  If I had that done, I think night vision could be very difficult.  So, this tuesday I am scheduled to have a Monofocal for distance put in my left (dominant) eye. I think you've had yours set for near.  It's a pretty difficult decision for me.  Do you have any input?  

Am glad that you have a good distance vision and reasonable intermediate distance vision with the Symfony lens in the right eye, but have night vision issues due to the halos (or multiple concentric circles) and the starburst issues. Thus, your experience with the Symfony lens is similar to mine.

I am very happy with combining my Symfony lens in the right eye with a monofocal lens (set to end up with about -2.25D prescription for reading). That will be a good option for anyone who has used or tried monovision in the past. If you have not tried monovision in the past, it may be better to not use this option.

The best option for you may be to try a monofocal lens set to achieve the best distance vision in the left eye. Since your left eye is the dominant eye, you should have much better night vision with that combination of monofocal in the left eye and the existing Symfony lens in the right eye. Of course, your close-up reading vision will not be any better than now.

If the left monofocal lens vision target is met, then some time in the future, you will have the choice of trying a contact lens (or glasses) of -1.0D power in the right eye (with nothing in the left eye), which should help you with better night vision as well as provide you the capability of reading well at 16 inches and beyond.

 

In the first sentence in my message above, I meant to use the words "...but am sorry that you have night vision issues..." instead of "...but have night vision issues..."

My apologies!

I had my right eye cataract surgery about 10 days ago with a Tecnis monofocal toric and am getting right around 20/20 for distance vision already in that eye. The target for that eye was -0.25D and it appears to achieved very close to that somewhere between 0D and -0.25D I estimate.

Testing with various reading glasses powers I've found with the right eye I require +1.25D or +1.50D to get comfortable distance and good focus on my smartphone.  I only require +0.75D or +1.00D for my computer screen distance for good focus with that eye.

So in the future, for my left eye I'm considering a Symfony toric IOL and hopefully it could acheive effectively near a 1.50 focus range to get the good smartphone focus even if that eye is targeted similar as my right eye for -0.25D, though I could target it slightly more like -0.50D and I would probably still get great distance vision in that eye since it gets 20/15-20/12 now at best eyeglasses correction.

It is great that you had a successful cataract surgery in the right eye and that the monofocal toric lens is providing you very good distance vision.

There are always some compromises, but my suggestion is to aim for the -0.75D to -1.0D prescription range for the Symfony lens in the left eye. If you achieve that, you will have good vision over all distances as well as good night vision (ending up with the Symfony lens at -0.5D will probably not be as good for reading books etc as one likes to have and will not really provide significant comparative advantage at any distance)

I appreciate your reply.  I thought you might have the closest experience to me except that I have not tried monovision before so that made me a little nervous.  Surgery on my left eye is scheduled for this coming tuesday so there's no time to try that unless I postpone the surgery.  

My husband just had his eyes done by the same doctor and he chose monovision with monofocals - one for distance and one for near and he's happy with that but has just ordered glasses for reading and computer just to make things easier for long tern use.  I originally went with the Symfony to get away from glasses altogether.  Although my reading is ok and using the computer is good, I can't read small writing on labels and I think I would still need reading glasses on occasion anyway. Do you think there is any possibility by getting the monofocal for distance, my vision could be worse and compromise the good (not great) reading I have now?   My doctor seems to think this would be a great compromise for me. I also figured there would be less negative effects of monovision because the vision in the right eye is pretty seamless.  

My doctor also checked my Symfony eye and says that I will need the YAG procedure done at some point.  I've had the halos/starbursts since the beginning but do you think that would improve after having the YAG procedure?

My other option is to postpone surgery and see if the night vision improves at all in the next few months but from what I've read it doesn't really change, you just get use to it.  I am getting use to it but if I could be just as happy with the monofocal, then it seems like it would be best take that option so the halos/starbursts would be somewhat minimized.  

If you have not had experience with monovision before, it is probably not a good idea to try it with IOL at this time.

As I stated earlier, based on my understanding of your situation, in my view, the best option for you is to get a monofocal lens set to achieve the best distance vision in the left eye. Since your left eye is the dominant eye, you should have much better night vision with that combination of monofocal in the left eye and the existing Symfony lens in the right eye.

With that combination, your near vision will probably not be much better (and will definitely not be any worse) than it is right now with the right eye only.  So, if you are reasonably happy with that now, you will be fine with the monofocal lens in the left eye.

I just noticed that I made an error in the sign of the suggested prescription for reading in my post above. It should have stated that, "If the left monofocal lens vision target is met, then some time in the future, you will have the choice of trying a contact lens (or glasses) of +1.0D power in the right eye (with nothing in the left eye), which should help you with better night vision as well as provide you the capability of reading well at 16 inches and beyond.

If you have some PCO,  removing it with YAG laser  in the future may help a little with the glare or starbursts, but will have no impact on the multiple circles or halos around lights at night. However, if your distance vision is fine right now, it may not be necessary to do anything about the PCO any way.

I think that your best choice from the vision perspective is to have a monovision IOL set for distance in the left eye. As an additional benefit, It also saves you money.

Thanks so much for taking the time to send me your thoughts on this.  I really appreciate it and feel much better after this discussion with you. 

You are welcome.

I send you my best wishes for a smooth cataract surgery on Tuesday.