Post LASIK cataract surgery
Posted , 9 users are following.
This is my first post to this board. I found this board after doing a search on cataracts, and have been thoroughly impressed with the knowledge that some of the posters exhibit. I have been diagnosed with a cataract in my right eye. I had LASIK surgery in 2001 on both eyes, and vision had remained 20/20 up until a couple of years ago when it started degrading a little bit. I had glasses prescribed that I wore some of the time but not all time. At that time, I found out that I had a cataract developing in my right eye, by Dr. said it would be a while before we needed to worry about it. Distance vision was still good up until about 6 months ago when I noticed that distance vision in right eye was slowly getting worse. I went back to optometrist, and he said cataract was getting worse. He said he could correct me with glasses to 20/30, but that was the best he could do. I asked about cataract surgery since I wasn't keen on wearing glasses full time, and he referred me to one of the ophthalmologists in his office. This doctor said since I had previous LASIK surgery it would be difficult for him to measure and get the best lens strength, and he made me an appointment with a specialist. My appointment with him is 01/13/21.
Since I have been using reading glasses for the last twenty years after LASIK, i could probably go with a monofocal lens and use readers. I play a lot of golf(retired), and want to be able to see the ball on the ground while hitting it. Right now with my right eye the vision is very blurred looking down at the ball. I do not have a clue as to whether this distance would be good with monofocal lens or whether I would possibly need to go to an EDOF like Symfony, or possible multifocal lens. Right now vision in left eye is still pretty decent, but I do have a cataract starting to develop in it. I also spend quite a bit of time on the computer, but can see the computer without using reading glasses just fine. Only need readers for smaller print and up close reading.
I guess what I am most curious about and concerned about is will I be able to see the golf ball if I go with monofocal lens, or would something else be better. I will discuss this at length with the surgeon before any decision is made. I was just curious as to others that might have had post LASIK cataract surgery and their vision using monofocal lens. Thanks in advance for any info you can provide!
0 likes, 34 replies
RonAKA bricks609
Posted
I have a monofocal lens in my right eye, and am currently using a contact in my left eye which has not been operated on yet. The vision out of the monofocal lens starts to become quite clear at about two feet. I would expect seeing a golf ball which would likely be 5 feet or more away would be a slam dunk. The vision in this eye came out with a residual of 0.0 D Spherical, and -0.75 D Cylinder (astigmatism). The astigmatism may be helping me a bit at the closer distances, but I am sure based on my experience that you will have no trouble seeing a golf ball at your feet.
.
One lens to consider that does give closer vision is the AcrySof IQ Vivity. It is free from the disturbing flare and halos that some other lenses have, and does give some nearer vision. In some enough to read, but not all. One option to get better reading with them is to under correct the vision some in the non dominant eye. The one downside of the Vivity that I am aware of is contrast sensitivity at night. If you are a frequent night driver like a truck driver, it may not be the best option. However, it should not have the halos and flare around headlights that many other MultiFocal or EDOF lenses have. Two monofocals with one slightly under corrected may work very well too. That is something you could try after you have the right eye surgery. Use a contact in the other eye to simulate different degrees of under correction. I am currently doing that with a -1.25 in my non operated left eye.
.
In any case with full distance monofocals in each eye, I would expect no problem with golf, other than reading the fine print on the ball up close. Computer and reading a book would require cheaters, or you can go with progressive eyeglasses that correct any residual distance (they can't assure you get an exact outcome and try to go -0.25 D under), and for reading at the bottom.
.
I recall there are some issues with doing IOLs after Lasik, but they are not coming to me right now. Will post again when and if it does. Perhaps others that have had Lasik will know...
RonAKA bricks609
Posted
OK, it came back to me. One of the choices, which I think is far from the most important one, in lenses is whether or not to go with an aspheric lens or not, and if you go with an aspheric lens whether you try to correct aspheric error to zero or leave it slightly negative. Here is a decision tree on what is suggested. It considers whether or not Lasik surgery has been done, and whether or not it was a myopic or hyperopic correction.
.
.
It could be a bit of a rabbit hole adventure, but here is an article about it. You have to google the phrase as we can't post links here. My thoughts are that there are more important things to consider. For what it is worth I went with an AcrySof Aspheric that in theory leaves you with some negative aspheric error.
.
Role of Asphericity in Choice of IOLs for Cataract Surgery *Aman Khanna,**Rebika Dhiman, *Rajinder Khanna, *Yajuvendra Singh Rathore, *Spriha Arun
.
bricks609 RonAKA
Posted
Ron, thanks for the info! I will confess that all this talk using scientific terms like aspheric error and others goes WAY over this old man's head! I just know two things.
I am trying to learn some of the terminology that those of you who know such terms use, but I think it is daunting task! Since my appointment is two weeks out, I will probably rely on the surgeon for good advice. I trust this particular group of surgeons, as my wife has had pterygium surgery twice there, and my brother had a cornea transplant there, and both had good results. Both different surgeons, but both surgeons were very thorough in explanations of procedures, etc.
Thanks again!
RonAKA bricks609
Posted
Am I correct in assuming you are going in for a consultation only session with the surgeon on 01/13/21? If so, I would suggest trying to get up to speed as possible with the terms and options, but not get too bogged down with the detail until after your meet the surgeon and see what options he/she is offering and recommending.
.
I see in your response to @rwbil that you were significantly myopic prior to Lasik. That flow chart I posted earlier would direct you to an aspheric lens that leaves you with a slightly negative asphericity. In more practical terms it is directing you towards a AcrySof lens instead of a Tecnis. They are the two most popular lens brands in the US.
.
When you meet I would suggest asking about the impact of having prior Lasik treatment for myopia has on the selection of the IOL. It may make the measurement of the cornea to calculate the power for the IOL more difficult. That may be the reason for not correcting asphericity to zero. Zero asphericity causes all the light coming into the eye to focus at one sharp point. If you get the power right the vision is excellent. However less than zero asphericity leaves more room for error as the focus is spread out some rather than a single sharp focus. The Vivity lens for example uses this method to achieve the extended depth of focus effect.
.
Based on what you have said I think your prime options would be:
.
Monofocal lens corrected for distance in your first eye. And then later when you have experience with the first eye, consider whether or not you want another monofocal corrected for difference, or slightly under corrected to give you some better reading. ?The other option would be to opt for a EDOF (extended depth of focus) for the second eye to give you the reading. The Vivity would be a good one to consider. I would discuss these options with the surgeon to see what they think.
.
Hope that helps some
bricks609 RonAKA
Posted
Yes, my appointment on 01/13/21 is the first appointment with this surgeon, so I guess it would be considered a consultation only. I do know from reading that it is more difficult to get the correct lens power after LASIK, but there are different formulas one could use to come up with the best lens power. I know there is concern about the cornea power being measured correctly.
I will certainly ask questions during this visit, and your suggestion of asking what impact having LASIK would have on proper selection of IOL will be one I will be asking! In more reading this afternoon, I feel like the AcrySof might be a better fit than the Tecnis, and I will be addressing that with him also. I am certainly leaning towards having the right eye corrected with a monofocal lens, and if I need correction in the left eye will wear a contact until it gets bad enough to do something about. Since I am on Medicare here in the US, it will only pay for traditional monofocal lens. I could afford spending the extra money for premium lenses, but from what I have been reading, a lot of doctors don't think it is a good idea to go with a multifocal lens in persons who have had LASIK correction, and if I don't have to spend an extra $2000-$3000 that would be OK with me!
Thanks for taking the time to give me some information. If you think of anything else I might need to ask doctor, I would certainly appreciate the suggestions.
RonAKA bricks609
Posted
Yes, I did think of something else that is important. First you should expect that the surgeon may have the measurements of your eye done by a technician before he/she talks to you in the consult. Until these measurements are taken you will not know if you have astigmatism in your cornea that potentially should be corrected by a toric lens instead of a standard one. You really can't go by your eyeglass prescription to predict your need for a toric lens. It is the total of the error in your lens plus the cornea. An IOL only needs to correct for error in the cornea as the surgery eliminates the natural lens. I expected to need a toric lens but after the measurements were taken a toric lens was not appropriate.
.
I did a fair bit of research into it and you need a very minimum of 0.75 D corneal astigmatism to justify a toric lens. If you are over that or higher, it is probably best to go with a toric IOL. There are other options, but the minimum cylinder correction power is -1.5 D in an IOL, and less than 0.75 D of need would result in making it worse instead of better. If you do need a toric, I would much more strongly recommend an AcrySof lens. They have proven in studies to be more stable (sticky) in the eye and tend to rotate out of position less than the Tecnis lens.
robert80020 bricks609
Posted
In my opinion, the RxSight light adjustable lens is the best monofocal/toric lens available anywhere. Hands down, no contest. It is especially well suited for lasiked eyes. I think it is worth traveling to get it. Remember ; YOU ARE GOING TO LIVE WITH THE RESULTS FOR THE REST OF YOUR LIFE . This is precisely the WRONG time to get concerned about money or time spent.
bricks609 RonAKA
Posted
Had my consultation visit today with surgeon. He said since i had prior LASIK surgery he would only recommend a monofocal lens and not a EDOF or multifocal. This does follow what i have read that a lot surgeons do not recommend EDOF or monofocal lens for prior LASIK patients. He does use the Alcon AcrySof IQ iol. He didn't mention astigmatism, but paperwork stated mild irregular astigmatism from LASIK. There was no mention of Toric lens. They do charge an additional $350 per eye above what Medicare pays due to more testing needed for prior LASIK patients, and he recommends doing left eye at least two weeks after right eye. He said I may not think vision is bad enough to do left eye, but after I see what right eye does, I will notice that left eye is worse than I thought.
Guess my plan is to go ahead and schedule right eye with monofocal iol, then think about the left eye after right eye is done. Thanks for all the very helpful information you have provided!
RonAKA bricks609
Posted
I would suggest waiting 8 weeks after the first eye. That will make sure it is settled down and you will know what you have for vision. It also gives you some time to think about what you want to do with the second eye. I wouldn't think mini-monovision would be contradicted because of Lasik - it is just two monofocal lenses. It could be a worthwhile option to consider if you want to be eyeglass free at least most of the time.
bricks609 RonAKA
Posted
Thanks. I had in the back of my mind to wait at least two months before doing left eye, and will check about minimonovision and see what he recommends.
rwbil bricks609
Posted
If you are also considering premium lens I would see at least 2 Ophthalmologist and make sure they specialize in premium lens, as many Ophthalmologist only implant monofocal lens; probable because Medicare and insurance don’t cover premium lens and the problems associated with the older premium lens.
Are you in the US and if so which state?
OK I will only cover the options in refractive lens, at this time. as that is what you mentioned.
Non Premium Monofocals:
These are the most common Iols implanted. They will have the best contrast and the least issues of any lens (unless you consider close vision an issue). They have been around and tested for a long time. You mentioned concerns about golfing. A Monofocal lens should provide great distance. In general close vision is reading your cell phone or a book, maybe 33cm-40cm. Intermediate is about 2 feet or so. A perfect example might be the dashboard on your car.
I would suggest you research and get the defocus curve for the monofocal you are looking at. I would guess for golf the vision ranges needed would be pretty good with a monofocal.
I also suggest just getting 1 eye done at a time and evaluating the results before getting the other eye done. Mix and Match is always a possibility to obtain the best vision possible.
Premium Monofocals:
LAL – If considering a monofocal I would recommend giving this IOL serious consideration. I have had Top Ophthalmologist highly recommend this lens. Having said that it has been around for a while now, but not as long as the standard monofocal so there is the test of time issue.
What makes this lens great is no matter what equipment Ophthalmologist use they don’t always hit the refractive mark and in a few cases can be way off by more than 1D. And let’s say you decide to do monovision. You want to hit those marks.
But it even gets cooler than that. From what I understand you can adjust the LAL more than once. So you decide on monovision, but not 100% sure how much monovison. So set 1 eye to plano and then try various settings with the 2nd eye to see which one works best for you. I would only consider micro-monovision like 0.5D, but if I had the option to adjust it you could try a different setting and see if you end up with a lack of stereopsis or other problems.
Crystalens Lens – You hardly hear about this lens anymore. This is the only FDA approved accommodating IOL. Many people did not get accommodation or much accommodation, so you were paying premium price for a monofocal lens that did not give the range of vision expected.
But from what I have read Crystalens at distance provides the same level of contrast as a standard monofocal and you are likely to get some accommodation. This lens could be a great mix and max with a PanOptic Trifocal IOL.
IQ Vivity and Tecnis Enhance - The newest hottest IOLs on the block. A refractive IOL that provides some EDOF. I think IQ Vivity is around 1D and Enhance around 0.5D. So not a lot but combined with micro-monovision you should get decent intermediate and maybe a little close up vision.
Now here is the part that is trick. I have read these lenses get DOF by manipulating SA. So IMHO that means contrast sensitivity will not be as good as a standard monofocal. Could the average person notice the difference, I don’t know. But I suggest you get an Ophthalmologist who is an expert with these lens so you can discuss that exact issue. And of course there is the test of time issue.
Now if you are out the US there would be more options for you and I think Enhance is still not approved in US yet.
I will throw in my last 2 cents worth, so take it for what it is worth. No one is going to care about your eyes as much as you do.
With so many options no surgeon can spend the time explaining in details all the options and the Pros and Cons with each IOL. A surgeon might ask a quick question or two about your interest, but no surgeon has the time to evaluate all the activities you do.
IMHO it is best to do your own research so you are familiar with the pros and cons and the different IOLs out there so you can intelligent talk with your surgeon.
Based on your latest comment, I am going to tell you a story I don't think I have ever mentioned here before.
I did a lot of research before I got my left eye done and saw several Opthamalogist. Every Opthamalogist in my area for premium lens, at that time, only did the Restor IOLs. I had researched it to death and I wanted the Tecnis MF +2.75 as all my research showed the material to be better (I won't go into glistening and all the other issues).
I was thinking about travelling quite a distance, but then found an Opthmalogist who has done clinical trails, written papers and was highly recommended in my area. But the most important fact was I had an instance repport with this doctor. He had done many Tecnis Monofocals but also had only done the Restor Premium IOLs. I emailed this doctor back and forth and showed him my research and he agreed to do the Tecnis MF and I would be his first guinea pig. Now in fairness the implantation part was similiar to the other IOLS he did.
After my surgery and he saw how good the results were he switched to the Tecnis MF as his main premium IOL (at that time IMHO it was the best premium IOL out there).
He commented how few patients actual do any research and know specific details about the various IOLs as I did. My point is if I did no research and knew nothing, he would never had known to even recommend the IOL I had implanted, even though he is a TOP Rated Opthamologist.
Many doctors are locked into what they have always done and don't keep up with all the advances out there. I highly recommend spending time researching all the options out there. That is my 2 cents worth and worth the price paid.
bricks609 rwbil
Posted
Rwbil, thanks for all of that info. I will try to answer some of your questions.
I am in the US, in Texas. I am leaning towards monofocal lens implants, especially if I could see the car dash without corrective lens. As I stated earlier, I just want my distance vision to be what it was right after LASIK, which was 20/20. I have been using reading glasses since LASIK 20 years ago, so having to use them after cataract surgery is not that big of a deal to me.
I will only have my right eye done at this time, because my left eye still sees fine, and has just a beginning of a cataract. If vision in left eye starts worsening, I will just wear a contact lens in the left eye until it gets bad enough to do something about it.
Please don't take this next statement the wrong way. I am not trying to come off as a smart a$$. Everyone keeps throwing these numbers out like 1D, -3.5, +2.75, etc., and I have no clue as to what you are talking about, or how to interpret what they mean. I do know that before my LASIK procedure, my vision was about -7.5 to -8 in both eyes, and my glasses were very thick.
I really appreciate all of the information that you gentlemen and ladies are posting. I just wish I could get a better grasp of what in the heck you are talking about!
Thanks again.
rwbil bricks609
Posted
If you live in TX and anywhere near Dr. Shannon Wong, I would definitely at least get an evaluation from him. Let me upfront and honest, I have not researched Dr. Wong and have no idea if he is a clinical trial doctor, which I always recommend or if he is a Castle Conolly Top-rated doctor or has written papers and so forth.
But I watch his youtube videos and he seems very knowledgeable and caring and he has responded to my emails. If you live near him, check out his videos.
I will try and answer your Diopter question and hopefully, others will chime in with better explanations.
Your natural vision could be nearsighted or farsighted, of course, there is astigmatism and other possible issues, but trying to keep it simple. So the IOL will be correcting for that.
I will try to best explain Diopeter with the attached defocus curve. I picked this particular chart because it shows a monofocal against several MFs (including the +2.75 which I have), so I think that makes the concept easier to understand.
Let’s start with the technical definition:
“Defocus curves are created by presenting a series of positive- and negative-powered lenses in front of a patient’s eye and measuring the degree of “defocus” that is induced.
Using 0.50-D increments, the defocus curve measures a patient’s binocular visual acuity often from +1.00 D to -4.00 D. In doing so, the resulting acuity that is measured can be used to simulate what the patient’s visual acuity would be at different distances.”
Ok now let me try to hopefully make sense of that. First, the cool thing about the defocus curve is it lets you compare the visual acuity across different IOLs.
For me, my left eye was set to Plano, which means optimized for 20/20 at distance.
The first thing you have to understand is this is a LogMAR chart. One nice thing is this chart shows the conversion, but I have included another chart that also shows the conversion as a reference.
Let’s look at the Y-Axis labeled VA Acuity. LogMAR value of 0.00 means 20/20 and going in the positive direction a LogMAR value of -0.10 is 20/16. Going in the closer to you direction; LogMAR of 0.30 is 20/40 vision.
Now let’s look at the X-Axis labeled Defocus (D). Typically labeled Diopters of Defocus. You are mostly going to be interested in 0 to -4 D.
This is the critical formula for the defocus curve: focal length: f = 1/D.
So a -2.00 D lens in front of the eyes equates to viewing the chart at 50 cm or 20 inches
With the basic concepts behind us let’s now look at the defocus curves for the ZCB00 monofocal against 3 different Tecnis MF IOLs.
So if you look at the chart you will notice at 0.00 D the patient is getting 20/20 vision at distance for all the IOLs. Now there is an obvious deviation around that which this chart does not show. So basically all IOLs are producing Great Distance Vision (I am ignoring other issues like contrast, night vision, dysphotopsias, etc.).
As you get closer, you will notice the curve goes down, but for the MF the curve pops back up. That is because these MFs have 2 focus points and each MF has a different close-focus point. So let’s look at the chart at 2.5D (40 cm or about 17”). This is typically considered near vision. So with a monofocal you would be getting about 20/63 vision at 17” which is not great, but with my MF I would be getting about 20/25 at 17”.
You mentioned the dashboard. Let’s say your dashboard is about 2 feet or 24” or 60 cm. Assuming I did my math correctly that would be about -1.7 D. So for this particular monofocal you would expect to get about 20/40 vision for the dashboard, where my IOL would be giving me better than 20/25.
Now let’s say you want to eventually do monovision with a monofocal. So the first monofocal is set to Plano and the other monofocal is set more myopic (negative Diopter). You basically would be shifting the curve to the right. So if you set it for -1 D then shift the curve to the right by -1.0D to give you an idea of the Visual Acuity you would be getting from the IOL set to more myopic vision.
Therefore your distance will be less clear in that eye, but gain intermediate and close up vision. Your brain will hopefully do Neuroadoptation and pick the best image. This is the basic concept of MF lens.
Hopefully, I did not confuse you even more. LAL!
bricks609 rwbil
Posted
I am a good 5 hour drive from Dr. Wong. I have watched his youtube videos and he certainly sounds like he knows what he is talking about, but he is a little far away for me to consider.
Regarding the other information you provided, I am clear as mud on it! But thanks for trying to get me headed in the right direction. Will continue to do as much research as I can before my consultation visit with the surgeon.
Thanks again!
RonAKA rwbil
Posted
The defocus curves are very useful but kind of hard to relate to reality. As near as I can figure a defocus diopter of 0.65 would be about 5 feet or the distance of a golf ball from the eye. All options displayed on the graph would give equal vision of the ball on the tee. Trying to read the fine print on the ball (made in China!) is a different matter!
RonAKA bricks609
Posted
@rwbil posted the title of a very good video by Dr. Wong, but I can't seem to find it. His explanation of the theory of IOL issues is very good, but it is mainly focused on Multifocal and EDOF lens types. I would note that he seems to have a distinct pro Tecnis and anti AcrySof bias. It is an issue you need to be prepared for when you go for your consult. The surgeon you go to will quite likely will have a bias for Tecnic or Acrysof. There can be some financial behind the scenes reasons for it. About all I can suggest is that you ask them to explain why they would recommend one brand over the other. The main issues that I know of are:
.
AcrySof use a yellow tinted IOL to filter out some blue light. They do it for two reasons. One is that the natural lens does the same filtering and the lens most accurately matches the color rendition of the natural lens. The other reason is that blue light tends to get more impacted by chromatic aberration especially in low light. AcrySof claim vision at night is better with it. On the other hand the clear Tecnis lens transmits more total light, so it can result in a brighter, but less natural color effect, especially in daylight.
.
The AcrySof material is claimed to be more susceptible to "glistenings" which are tiny little voids in the lens due to manufacturing defects that fill with water over time. As best as I can determine they were an issue in the earlier versions of the lens but seldom were an actual impact on vision. My surgeon says he has seen it, but never to the extent it impacted vision. The Tecnis material is less susceptible to it though. AcrySof claims they have solved the quality control issues...
.
There are some pretty solid studies which have found that the AcrySoft material is more "sticky" and tends to stay put in the eye. This is especially important for toric lenses. You do not want them to rotate out of position even a few degrees. Some statistics I have seen indicate that the AcrySoft toric is favoured about 2 to 1 over the Tecnis toric.
.
There are also some studies which show that the AcrySoft material is less susceptible to PCO. PCO is a fairly common adverse outcome of IOL's that develops over time. The capsule that the IOL is inserted into tends to cloud up kind of like a cataract and cause cloudy vision. It can be "corrected" by a YAG laser process but that is essentially blowing a hole in the capsule, which can have further down the road impacts.
.
Hope that helps some,
rwbil RonAKA
Posted
The research I did on lens material was years ago when I had my left eye done. At that time I was choosing between the Restor and Tecnis MFs. I looked at issues like glistening and the Abbe Numbers.
I read so many article, but one I remember was from Dr. Chang In EyeWorld titled, "IOL Optics and Quality of Vision".
Having said that the material was an element, but certainly not the deciding factor.
I have not done any research into actual material design of the new IQ Vivity, the PanOptix or the Tecnis Synergy or Symfony Plus. So I am sure things have changed and like you said glistening has not turned out to be a big issue.
For me my personal bias is Tecnis because I have a Tecnis IOL and from articles I read say it is best to stay with the same manufacturer for mix and match.
But for anyone else, I would just say there is a material difference so you might do some research into any pros and cons of the different materials being used, but again I don't think there is that much of a difference in material that it should be the deciding factor.
rwbil RonAKA
Posted
Agree. At 5' vision with a standard monofocal should be very good as long as they hit plano, which is why I say if you want a monofocal and can afford it look into the LAL.
It is when you start to get down to 3' and closer vision quality starts to drop off dramatically.