Post-op report - LAL

What power of lens did the surgeon finally use? Post op refraction will not be reasonably accurate until after 3 weeks, and even then it may still change some until you hit 5 weeks post op. Your eye may not become clear until it has healed further.

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When you said your eyes did not work well together, was that with a correction to plano (0.0 D) with a contact? If so, it may be necessary to correct it to -0.25 D including the astigmatism to reduce the differential to 1.50 D.

"Do you have balancing issues with two eyes seeing?"

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No balancing issues. Both of my eyes are now close to plano, so they are in balance and cooperating normally. My only problem is I can't see things clearly close up. It's manageable and hopefully temporary, so I can't complain.

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I'm glad to hear your surgery went well also. You certainly have a big difference to adjust to. Do you plan to get the second eye cataract surgery soon? Hopefully, your first eye settles in a good place, and you can get a good result with both eyes in the future. Good luck with your recovery!

With your IOL now in place and close to plano you may want to use some reading glasses to simulate how my myopia you will like without accommodation. You can do that without using up your light adjustment numbers.

That's a good idea. I have +2.00 and +4.00 D lying around. With the +2 glasses, I can read 3-point type font, and with the +4, I am barely able to read 2-point type, even with good lighting.

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My eye is still fresh off surgery and the vision may change a bit. But if my surgeon is right and I am currently slightly hyperopic, this result tells me that the point of diminishing returns for myopia in my new eye is no greater than -2.00 D. I find that highly encouraging -- I would be pleasantly surprised to be able to read 3-point type, and if I can do that with a refraction of -1.50 or -2.00 D, I think that should leave me with decent intermediate-to-far vision in the near eye - close to what I had for most of the last 30 years with my LASIK monovision.

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Thanks for the tip!

Oops - looks like those glasses I thought were labeled +2 are actually labeled +3. My reading vision really is bad now! I should have known that was too good to be true.

From all of the videos I have watched of folks that have gotten the LAL, reading J7 seems to be common when you're corrected to Plano. I wish I could remember what trilemma could read after her LAL surgery in the distance eye.

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My ophthalmologist told me that I can wear contacts 24 hours after LAL surgery. Phil, do you think this is possible? Then I will not run out of adjustments.

Hi Ron,

Surgeon used 9.0D Envista to target -0.6.

yes my contact lens is fully corrected to distance. i messaged my optimetrist to see if refraction would help with balancing, he said my L eye went through a big change abd needs more days to get used to. He suggests to get the second eye done as soon as possible. Now i can see my R eye has a layer of thin fog but it can still see clearly wt distance. With contact lens in it, using two eyes, i feel like i have a new prescripstion glasses to get used to. Anyone has that experience? How long does it take to get used to?

My second surgery is scheduled in two weeks but i like to postpone it until i get used to the current situation and know what my refraction is on my L eye.

That is an unfortunate miss, but it may turn out to be very good for a near eye. The trick now would be to figure out how to get a much more accurate prediction for the distance eye. On a quick look the EVO formula seems to be the one closest to your outcome but is still way off. I think for sure you want to delay the second eye until you can get an accurate refraction done at 5-6 weeks. Then you need to have a serious talk with your surgeon about how you can get much closer to plano with the second eye. It would seem that if your current refraction in the left eye is correct, you may need something in the order of +8.0 in the right eye. Once you have an accurate refractions for your left eye, your surgeon should be able to make a correction to the formula for the right eye.

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Yes, if your right eye is corrected to plano with a contact then you will have full mini-monovision without glasses and it probably will take a few weeks to get used to it.

"My ophthalmologist told me that I can wear contacts 24 hours after LAL surgery."

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My post-op instructions say contacts are ok any time after surgery in the un-operated eye only. No contact in the LAL eye.

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How would a contact help you not run out of adjustments?

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Now that you mention it, maybe I should try a contact lens in my natural eye. It could make the next three weeks a lot more comfortable while I wait to get my reading vision back in the LAL eye. But I haven't worn contacts in nearly 30 years (hard lenses), so probably I'll just suck it up and go without.

hi Phil,

my second eye surgery supposedly on 1/23, but i am thinking to postpone it until a few months later. i am not sure that's a wise choice because my two eyes are not balancing well.

Are you doing your second eye? does it have a cataract?

Ron,

The mini-monovision is what i am feeling like a new peescription? With sunglasses walking outside, I feel much better but without sunglasses even though cloudy, i feel somewhat disorienting! This is also why i am afraid to do the secobd surgery in two weeks because if the surgeon targets the same and it didnt shift for the sexond eye, I would have the mini-monovision!

I remember you also have a mini-monovision. Were you used to it before surgery? or it took a few weeks to get used to after both surgeries?

I simulated it with contacts before surgery and I really did not take that long to get used to it. I would strongly suggest postponing your second eye surgery until you get a final accurate refraction at 5-6 weeks. That will also let you get used to monovision.

Ron,

I also didn't think -1.75 can be that difficult to get used too. Today is my 5th day, maybe i am too anxious! I have an optometrist appointment in 5 weeks so hopefully my eye is stabilized enough to get a final refraction.

Hello Sam - I have no plans yet for surgery on my second eye. Vision is still good, but the doctors do see an early stage (1+) cataract. They tell me progression is highly unpredictable, so I might need surgery on the second eye in a few weeks, or in a few years. For now, my preference is to hang on to my natural eye for as long as I can.

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Sounds like you have a tougher decision to make. A few months with eyes out of balance sounds unpleasant, but it might not be so bad. Until last week, my eyes were about 8 diopters apart. I used no corrective lenses, and the difference really didn't bother me. But the difference is much more sudden for you. Good luck with your decision and results.

In 5 weeks the eye should be fully healed. Also keep in mind that your refraction may change over that time. I recall that @judith93585 moved from -2.0 D to -1.50 D as the eye healed.

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What kind of contacts are you using? If they are not too expensive or even free trial versions, you could ask to be corrected to -0.25 or -0.50 D instead of plano. That would give you a little less differential to get used to. A -0.25 or so would be more in the range of where you want to be with the distance eye, so may be a better simulation for now.

My catarats are preventing me from wearing contacts to trial mini-monovision. The ophthalmologist is suggesting pre-trying mini-monovision with contacts in my eyes that will no longer have cataracts after LALs are implanted. I will have surgery in both eyes - 1 week apart. If I can't tolerate mini-monovision with contacts, I can choose LAL adjustments for near/intermediate mini-monovision or micro-monovision and wear glasses for distance. If I can't tolerate any monovision, I will choose near for both eyes. I may try contacts again before the LAL adjustment for near/intermediate.

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BUT - I am going to get a second opinion from another ophthalmologist about the contacts so soon after cataract surgery. I am concerned about infection?

I see. I would have the same concern about infection, though perhaps with the antibiotic eyedrops they give you, that may not be a significant risk. I would also wonder about a contact interfering with the healing of the cataract incision at the cornea. This seems like the kind of thing any opthalmologist would be very clear and careful about, but it's always ok to get a second opinion when you have any doubts.

Ron,

Have you had first eye done when you were simulwting fir mini monovision?

a full mini monovision is it about 2 diopters difference? or is it called monovision?

Ron,

My optometrist said to give it a few days, so i will check with him again later this week. luckily i am using the trial sample of contact lenses so hopefully he has a lower power for me to try on.

However, if i can't get used to -1.75 difference, what if my second surgery left me with -1.75? i am concerned!

its good to know Judith shifted a little more towards distance. Do you know if she also missed her distance target?

From Eyeworld (.org):

"What is the maximum difference between eyes with Monovision?

Ophthalmic surgeons distinguish between two types of monovision. Conventional monovision is set for less than or equal to –1.50 D, or somewhere between –1.0 and –2.0 D. Mini-monovision allows a maximum of –0.75 D anisometropia, or between –0.25 and –0.75 D."

Hi Jo,

Wow from that article, at -1.75 difference, i am fully monovision and not "mini-monovision". I have never been in either situation before, that could be why i am feeling disorienting.

does anyone know if after my second surgery, i ended up with a difference of -1.5 and can't get used to the difference, can i use contact lens to fix the problem?

I tried monovision at various times. Once was much before I got cataracts and was just to get rid of glasses by using contacts. I really don't remember which was my close eye or distance eye and what the difference was. The contact lens fitter decided for me.

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I tried it again before my first cataract surgery when I was on the wait list. And I tried it after my first cataract surgery but before my second eye. In these trials I was targeting a differential of 1.25 D. But I increased that to 1.5 D after trying reading glasses with my first IOL eye. That was my final target.

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The definitions of monovision are not set in stone. I would describe -0.75 to -1.0 D as micro-monovision, -1.25 to -1.75 D as mini-monovision, and -2.0 to 3.0 D as full monovision.

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I would give the -1.75 D some time to get used to. And remember you should target at least -0.25 D and possibly -0.50 D in the distance eye if necessary which will reduce the differential. I recall that @judith93585 targeted -1.0 D in the "distance" eye. Don't recall she has updated what she got with an accurate refraction.

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For now you may want to ask the optometrist for different power lenses to leave your distance eye at -0.25 D or -0.50 D. That will also let you know if you are ok with less than plano for distance vision.

I can't say that I would agree with those classifications of monovison. They are off to the low side.

Yes, for sure you can use contacts or eyeglasses to correct vision after cataract surgery. Personally I would consider that a "plan B" as I don't particularly like glasses or contacts. But, you certainly do not paint yourself into a corner, and the alternatives are worse. Both eyes targeted to near means eyeglasses for sure. Same with both eyes for distance.

I emailed my optometrist again to state my refraction after surgery. I forgot to state my refraction at post op and he probably think that i have distance vision.

not sure how long i will get used to the -1.75 difference. my vision is quite odd especially if I switch from looking at a far distance to computer or vice versa. I am afraid i will have this difference after my second surgery as my surgeon can't really predict the outcome! Can surgeon do a better job at not missing target so much?

Ophthalmologists would tend to be conservative in the case of IOLs. Easy enough to change contact lens prescriptions, not so with implants. They want to avoid patient complaints about anisometropia. I doubt any of them would promote monovision as the means for patients to become eyeglass-free, but instead to wear glasses in situations as needed.

Once you have an accurate refraction done at the 5+ week mark your surgeon needs to compare the refractive outcome to the predicted outcome. A responsible surgeon will try their best to determine what went wrong and make adjustments to the formula used and the target to not repeat the miss. After you get the refraction outcome I would request a consult with the surgeon to show them the outcome. At that point ask to see the IOL Calculation sheet to confirm what the target was, and ask how a more accurate result will be achieved with the second eye.

My surgeon told me that he has done as much as -3.0 D for monovision at the request of the patient. That would be full monovision for sure.

Would the surgeon know why target is missed? I mean based on his experiences, would he be able to tell me?

If one eye is missed, is it likely the second eye might miss too?

also does anybody know if one eye is shifted to the myopic side, woukd the second eye likely to shift to the sane myopic side? I sm afraid the second eye would shift to the hyperopic side, then how to correct thecteo eyes to work together?

This is a difficult situation and depending on the attitude of the surgeon needs to be approached with care. Doctors can have big egos and they could become quite uncooperative if you confront them with an accusation of making a big mistake. I think I would approach it from the perspective that you can live with the outcome by switching which eye will be the near eye, but you want to be much closer to plano with the second eye. A responsible surgeon should identify what possibly went wrong and how they can avoid it in the second eye. It could be the lens position in the eye is off. If that is the case then they need to be more careful in locating the lens in the second eye. Your lower power lens should be less sensitive to lens position though, and the enVista lens is less sensitive to position as well, so I would discount that as a probable reason. You could ask your optometrist if they see anything wrong with the position in the eye to get their perspective. If nothing is suspected wrong with the lens position then the standard practice is to manually adjust the selected power based on the outcome of the first eye. Some surgeons keep records on what their pattern of "miss" has been with each type of lens. They use that to adjust the A- Constant in the formula to get more accurate results. They also could go back and find out if a different formula would have given better results. I have looked at your numbers and there is not an obvious formula which would have worked better. The Barrett and EVO predicted the outcome would be about -0.6 D which I understand was your expectation, but instead it was -1.75 D. That is a miss of just over 1.0 D.

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One method used is to use the best formula based on the first eye outcome and correct it manually by adjusting the target by one half the amount of the miss. Google the article listed below and look at the text just below figure 2, and it explains it. With that technique you would target an outcome of +0.5 D which is half the error on the first eye. From your measurements that would mean selecting a power of +8.0 D instead of +9.0 D for your right eye. You obviously would want the surgeon to validate this as it is a very significant adjustment away from what the formulas are predicting.

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Another thing they could do is remeasure both eyes to see if there was possibly an error in measurement. In any case those are my thoughts. Google this for the article. And last don't come to any conclusions until you have an accurate refraction done at 5+ weeks and the results are converted to a spherical equivalent. I recall another poster here that was disturbed by how much of a miss there was, but once the spherical equivalent was calculated which corrects for astigmatism the error really was not that large at all.

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Review of Ophthalmology PUBLISHED 10 SEPTEMBER 2021 Responding to Refractive Surprises

I had the appointment with the 4th ophthalmologist this afternoon. It was a bust.

He did not have time to answer my questions - so select my questions carefully. He did have time to educate me about how the eye works and cataracts. He thinks my expectations are too high. Targeting for -2.25 with light adjustments - might not be able to get that .25 diopter. I told him my goal was near/intermediate using single focus glasses for distance. We did talk about targeting the LAL -2.0 in both my eyes and adjusting from there. I asked about the LAL+ and he said there would be halos. I asked if there is EDoF in the 1st light adjustment and he said he does not need to put it in. The conversation was disjointed. This practice charges a lot for the LAL.

This practice has a Lenstar 900 and a Pentacam and the exam was very thorough.

I wish I had paid attention for other office visits - I was not reading this forum then.

I will be frank and suggest you are wasting your money using LAL to target near vision in the -2.25 range. Like @Bookwoman has with one at -2.0 and -2.5, pretty much anything in that zone is fine for either eye. Just go with a standard monofocal targeting -2.25 D and if you get more then target less with the second eye or vice versa.

Even if you use adjustments to try -2.5 and -1.25 for reading and computer? Wouldn't that work? Isn't that near/intermediate mini monovision? I appreciate your honesty.

Your appointment sounds kind of similar to my last pre-op exam. The office was already 90 minutes behind schedule, and though I felt entitled to the exam I paid for, it is hard to ask all the right questions when the doctor is trying to rush you. I ended up making him come out of the operating room to speak with me just before I went in for my surgery to answer my final question about target refraction and adjustment plan. 😃

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My doc also said I would get halos from LAL+, though recently someone here (trilemma, I think) linked a talk by a Dr. Slade who said he had done over 100 LAL+ eyes, with zero dysphotopsias. Not sure what to make of that. My guy also said that LAL+ was not recommended for me because of my old LASIK. No problem, I really did not want the LAL+ anyway.

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Interesting that your doc said EDOF is optional in the first adjustment. That was one of my remaining questions. Still not sure how best to manage the adjustments, but right now I am feeling like the modest EDOF that LAL can offer is worth taking.

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Like you, I am considering significant myopia for my one eye - maybe -2.00 D. I suspect that RonAKA is right, and LAL may be overkill for a target like that. But I decided I'd rather spend the money now than run the risk of kicking myself for the next 25 years every time I reach for my reading glasses!

The thing is that if you want both computer vision and small print vision you will cover all bases by doing -2.5 and -1.50 D. It does not have to be that exact. With standard mini-monovision you cover both near and intermediate with one power - typically -1.50 D. It is pretty hard to miss with one eye at -1.50 and the other in the -2.25 to -2.50 D range.

Accuracy is much more critical when you want to cover near and intermediate with just one eye.

I have it in mind that one eye will cover far, one will cover near, and the two together will cover intermediate. Not sure it will work out that way, but I can see how accuracy would be critical as I'm trying to cover a good range of near without leaving too much of a gap at intermediate distance.

Yes, that is the trick. Increasing the myopia in the near eye will weaken the combined eye intermediate vision. But, you have been there before and may be ok with it.

My refraction of -1.75 was obtained from the balloon looking instrument, is this number the spherical equivalence?

What about the predicted outcome of -0.6D? Is -0.6D a spherical equivalence or my glasses prescription (if target is hit)?

I seriously don't know how to discuss my second eye target with my surgeon because i don't want him to think that I am doubting him. Any suggestions?

The instrument with the balloon image is called an autorefractor. Normally it gives both a sphere diopter and cylinder diopter. It is possible they just told you the sphere, or it may calculate the spherical equivalent. One would have to see the print out from it to be sure. The predicted outcome is very likely to be a spherical equivalent and a number calculated by the IOL formula. They are not in even 0.25 D steps, but just what the computer generates.

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In rough terms the predicted outcome was -0.6 D and the actual outcome was just over 1.0 D more than that at -1.75 D. That is a bad miss. It is kind of hard to candy coat that and tell the surgeon he did a good job! Not sure the best way to deal with the surgeon but I would NOT suggest telling him that it was a really bad miss. The first thing you would want to do is wait until you get an accurate refraction with a phoropter, which is the instrument that you look through to read the letters off the eye chart and pick which image is better. If you are still in the -1.75 D range then I think you just have to say that was not what you were expecting and then ask what may have caused it to be different. To get some backup you should also ask the optometrist when you get the eye test what they think may have gone wrong.

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But if nothing can be identified that accounts for the miss then about all you can do is ask the surgeon to make an adjustment, so you can be closer to plano with your second eye to get good distance vision. In that one article I posted one surgeon says he determines how much the miss was and then corrects for half of that. In your case the target was -0.6 D and the outcome was -1.75 D, so a miss of over 1.0 D. This would suggest you would target +0.50 D or so with the second eye. With a full miss of 1.0 D again then you would end up at -0.50 D. If the miss is only half of that the second time then you would be right around zero which would be good. But this is not something you should tell the surgeon to do. They really should go through this process and come up with a correction to be applied to the second eye.

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Out of curiosity I used your right eye measurements with the EVO formula which was the most accurate of the ones I tried, and came up with this calculation for a target of +0.5 D. The power required came out at +8.0 D. I will insert the output from the calculator. But, again this is not something you should tell the surgeon to do. They need to figure it out and come up with the best target for the second eye. You need to tell them that you want good distance vision and need to come much closer to plano this time.

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