Preparing for 2nd Cataract Surgery (Synergy), Need help better understanding the IOL Master Numbers.
Posted , 8 users are following.
Well, finally went in for my cataract eye exam for my 2nd cataract surgery.
When I did my first cataract surgery 4 years ago I had studied up, but after coming to this forum and doing more research I know just how little I knew back then and how little I still know.
They had actual put my records into storage which they are going to dig out. I want to use the old numbers, because my cataract is so bad I worry how accurate the new numbers are. I could not even make out the 20/200 Big Letters.
They pulled out the old IOLMaster, but did both the Laser and Ultrasound measurements. They actual take a pencil like device with a blue light and touch your eye. Not sure how accurate that is when they might indent when pushing it in.
Anyone with knowledge about the difference in readings these 2 methods produce. It seems like the Axial Length AL was different from the 2 methods. Also should the right and left eye AL be close?
The reading for Cyl was .78D. Am I correct in that is the Astigmatism? I hope that do not mean I need a toric IOL.
The readout provides A Cont, which I think are diopter IOL power for various monofocal IOL. They just used the Tecnics Monofocal for my numbers. I guess same manufacture and IOL structure is the same.
From that chart I was a 13.5 to get -0.19D or Plano (I think) or 13.0 to get to .11. Being I am planning on Synergy maybe safer to go with the 13.0.
I am not sure how that 13.0 relates to refractive error as it seems huge to me and very nearsighted.
Not sure how it compares but my contact prescription for that lens was power -4.5.
Any suggestions on what other numbers to read that are important from the readout? There are numbers like K1 and K2 and so forth.
Next topic cost. I was told it was $2300 for the Synergy. I have no idea what that lens should cost. Does that sound about right? It seem a bit unfair that insurance fully pays for a monofocal, yet you must pay full cost for the premium. Seems to me it should be an upgrade only cost of whatever the cost difference is.
Finally he has only implanted 5 people so far the Synergy IOL, but says they all are happy. He advised if close vision is most important go with Synergy and if less Dysphotopsias is most important go with PanOptics. I should that is if one wants a defractive IOL as he is still a fan of monofocals as he was when I had my first surgery.
He was actual a trial doctor for Symfony and was not thrilled with the Symfony saying his experience with that IOL was people got dysphotopsias and did not get good close vision.
0 likes, 27 replies
lucy24197 rwbil
Posted
If you search "Biometry for Intra-Ocular Lens (IOL) Power Calculation Eyewiki" you'll get the American Academy for Ophthalmology's writeup on how the IOL calculations work, including definitions of the variables.
Regarding the 13 number vs refractive error, if I'm understanding things correctly, the 13 refers to the diopter of the IOL itself that will give (in your case) the 0.11 resultant diopter in refraction based on the geometry of your eye.
lucy24197
Posted
Just had my second eye done this morning. I've gone for mini-monovision and my targets are 1.25-1.5 D apart based on the numbers they were talking about during surgery this morning--and I got the same exact lens in each eye. Both are 22D Tecnis ZCB00 IOLs. So assuming the surgeon didn't screw up somewhere with his calculations, the diopter of the IOL doesn't tell you a whole lot with regard to refractive error.
RonAKA lucy24197
Posted
Yes, a lot goes into the mix between an eyeglass prescription and an IOL power. My eyeglass prescription was -2.75 D spherical, -2.75 D cylinder, or moderately myopic with significant astigmatism. Those numbers may of course been really influenced by the presence of the cataract. The IOL used was a non toric 15.5 D. I now test at 0.0 D spherical, 0.75 cylinder. I am thinking a perfect spherical cornea may need a power in the order of 19.0 D. Just a WAG! It seems that both the shape of the cornea and the length of the eye from front to back both influence the power of lens needed. It also seems that as the more myopic you are, the lower the power of IOL needed. Severely myopic seems to require powers into the minus values. Way too complex for me to figure out...
RonAKA rwbil
Posted
On measurement methods about all I know is that my surgeon used two different methods and with one I was -0.4 D Cylinder (astigmatism) and the other method gave 0.0 D. After surgery I measured at -0.75 by the optometrist. I don't recall the numbers for spherical.
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If the 0.78 D cylinder was of the cornea then that is on the margin for needing a toric lens. Alcon has some articles that suggest a toric should be considered at 0.70 D or more. That does not make total sense to me as the minimum toric correction is 1.5 D. It seems to me that a cornea with 0.7 D would be over corrected with a toric power of 1.5 D and would leave you with just as much astigmatism but reversed in angle. And that assumes the lens is placed at the perfect angle. That is not always achieved. I think if I was in the <1.0 cylinder range I would pass on the toric. Skilled surgeons apparently can make the incision for the lens removal and insertion in a location that can reduce the existing astigmatism, or unfortunately if there is none, or minimal, actually induce some from the wound healing. It is something to discuss with the surgeon.
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I do not fully understand the powers of the IOLs, and about all I can say is that my eye was in the -2.0 range before surgery and I got a 15.5 D power IOL. If you have a perfect cornea I am guessing that a power of about 18 is required?? Not sure. The IOL has to provide the power of a perfect natural lens plus any correction for the cornea error. I will have to read that link provided by @lucy24197 and see if I can get my head around it.
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$2300 sounds like a reasonable price for a state of the art lens like the Synergy. It does seem unfair that your insurance makes you pay the full cost, and not the differential. I believe in Canada you only pay the differential. At least that is the way with a toric. You pay the differential between the basic lens and the toric, not the full cost.
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Hope that helps some,
lucy24197 rwbil
Posted
My target was -0.5D. The IOL is 22D (it's a Tecnis ZCB00 monofocal), and 1 week out my vision is measuring between -0.5 and -0.25D.
I had a slight (< 0.5) astigmatism before the surgery, now I don't have any. This was somewhat expected due to the direction of the astigmatism. From what I've read, the surgery relaxes the cornea to change the astigmatism up to about 0.5. If the astigmatism is against the rule (side to side) the surgery can reduce the astigmatism. If it's with the rule (up and down) it will probably increase. Google "Astigmatic effect from phaco incision placement" by Uvay Devgan. My distance eye was against the rule and seems to have improved. My near eye is with the rule (again, a small astigmatism--just getting a plain, non-toric lens) and will probably get a little worse, but that might give me an extra little boost for reading so I'm not unhappy about it.
As far as prices go. the eye center doing my eye has a price breakdown that uses ridiculous names: "standard", "astigmatism management", "distance vision plus", and "Multifocal Vision". The way I read their breakdown, standard is a monofocal with no astigmatism correction. Astigmatism management is monofocal/toric, with free lasik within 1 year if needed--an additional $1750/eye. Distance Vision Plus is EDOF, with free lasik if needed, for an extra $3250/eye, and Multifocal is...multifocal, with free lasik, also $3250 extra/eye.
Night-Hawk lucy24197
Edited
Before my cataract surgery, I got 3 different doctor/clinic opinions and price estimates for a tecnis toric IOL (I had almost 3D cylinder astigmatism in my right eye).
The price varied widely between them - the eye center that included "free" lasik had much higher price, so its like paying extra for insurance in case you need it afterwards.
I ended up chosing an eye surgeon at my local clinic I go to regularly that didn't charge that extra higher price. He achieved very close to the target (plano) but a little residual astigmatism so I ended up with 20/25 or so without eyeglasses in that eye. The price for the tecnis toric IOL there was $1333 out of pocket cost, the other surgery fees were mostly paid by my insurance leaving me under $400 to pay for that.
After 3 years vision got cloudy in the eye because of PCO, so I got the YAG procedure about 4 months ago and that gave me clear good vision once again and its still good now.
rwbil
Posted
First, looking at those numbers I guess $2300 is a bargain for a dime sized piece of plastic.
2nd I never worried about astigmatism before and might not need to worry now. The only thing I know is less than 1 is considered mild and it means you cornea is more football shaped.
From the IOL master it is .78D @ 20 degrees. Is that side to side or up and down? Or how does one tell if side to side or up and down.
If I think of an Axis with 0 degrees facing right and 90 facing North. I guess it would be more side to side than up and down. But I have no idea if what I just stated means anything in regards to astigmatism.
soks rwbil
Posted
Get 13D. your distance will be fantastic,
why not get PanOptix?
rwbil soks
Posted
Yes, maybe I will get 20/15.
I have thought about the PanOptics and even the Symfony Plus, which I still don’t think is commercially available and hard to get any information on it.
I really cannot keep procrastinating as my vision in my right eye is not even 20/200, so I have to make a decision on the limited information I have.
I have talked to several doctors, but the Synergy is still new and most have not had a lot of Real-World patient experience. My doctor has only done 5. I did ask Dr. Wong who said he did a 100 Synergy Implants, “if he had to pick an IOL for his 2nd eye, which one would he get” and he said Synergy. He also said most his patients have been happy with Synergy, some less happy and a few not happy. But I already have a MF and aware of the tradeoffs.
There is also one other doctor in my area that has an impressive medical history and does clinical trials who I am trying to get a call back from to ask if he has more Real-World patients results with Synergy.
So why Synergy. Well 2 main reasons.
First, I have the Tecnis MF in left eye and overall happy with it. I had researched it before and thought the material was better than Alcon and I have not had any issues like PCO, but that could just be I got lucky so far.
Second, my biggest concern is not halos, unless the Synergy is a lot worse than my current MF, but just how dark the IOL is in low light. And the only study comparing those 2 IOLs at this time that I know of is the clinical trials. And looking at those clinical trials Synergy does much better in dim light. All the diffractive IOLs split the light, so just trying to see which one does it the least and has best MTF.
My expectation is that Synergy will have worse dysphotopisais than PanOptics, but perform better in dim light and provide better close vision.
But now a question of you as I know you go to the Top Rated Vance Thompson Vision place. Have you talked to them to see how many Synergy IOLs they have implanted and what are they saying about their patient’s results in comparison to PanOptics.
soks rwbil
Posted
Wong selecting synergy for his 2nd eye is some endorsement.
i dont expect synergy to be darker than your MF. my symfony is a tad big 20% darker than natural eye. can be a problem only at night.
i havent gone to Vance Thomson but they had the synergy trial in my city. maybe i should do a consulting appointmwnt with them.
but it appears from forum that synergy has more complaints. if u r happy with tecnis MF then Synergy should make you very happy.
when do you plan to get the surgery. i am trying to see if i can hang on till 2022.
rwbil soks
Posted
I am a procrastinator, but I already cannot see anything out my right eye and I don’t see another advanced IOL coming out and being approved anytime soon. So for my needs, that leaves the PanOptics or Synergy.
Ideally looking for a doctor in my area or within a reasonable drive that has implanted lots of people with the Tecnis MF and is now doing mix and match with both PanOptics and Synergy and seeing what their patients Real-World Experience is. Sadly that is not an easy task.
If Vance Thomson participation in the Synergy trials you have a potential gold mine of information there.
I know you have had problems with your Symfony, but I don’t remember off the top of head what they were. Is it a PCO issue or is there something fundamental to the Symfony design that you are concerned about. Synergy, best I can tell is basically Symfony (with some improvements like violet filters) combined with a close add.
rwbil soks
Posted
I might have to wait, as finally got a hold of the only other top rated doctor in my area and they have done all of 2 Synergy IOLs. I want to know the Real World Experience of patients. Depressing!!!!!
catherine67046 rwbil
Edited
That cost seems in range. I'm in MI and paid $2,425 for Synergy lens. Disappointing results- somehow I've gone from being -5.00 in the eye to being +1.00. I cancelled 2nd surgery and now wear contacts in both eyes and reading glasses.
rwbil catherine67046
Posted
Are you saying they missed the refractive mark by +1.0 hyperolic. I think hyperolic side is harder to correct for. What is the plan for correction?
catherine67046 rwbil
Posted
I feel woefully ignorant compared to everyone on this forum. I'm not even sure what you're asking so I don't want to waste your time. The lens is +11.5D, but I don't know about refractive mark.
I'm going to an ophthalmologist for a 2nd opinion and to discuss options. Then I'll return to the first surgeon. I thought I did my research and made it clear what I needed from my vision, but that didn't happen. I'm trying to get answers.
I did find a fascinating video from Dr. Wong about a patient unhappy with Synergy and her experience is very similar to what I'm going through. Dr. Wong took out the Synergy lens and replaced it with a Vivity. The title is: How to Manage the Unhappy Patient with a Synergy Lens. Thanks for your patience.
rwbil catherine67046
Edited
There are just so many possible issues and eye conditions. IMHO defractive IOLs should only be used on patients with perfect eye conditions other than cataracts.
I am not sure if your issue is just a refractive mark issue or more serious. The lens power does tell much, except that is the lens power needed to shoot for the target, plano or whatever, you were shooting for.Let us know how it goes.
RonAKA catherine67046
Edited
Have you gotten an eyeglass prescription for your eye since the surgery has healed (6 weeks or more after surgery)? That is the most telling number. It will indicate how much spherical and cylinder (astigmatism) you have. If the prescription is for +1.0 D indicating your have been left far sighted, then yes the surgeon overshot the correction. The normal target is to be slightly near sighted at -0.25 D ideally.
catherine67046 RonAKA
Posted
I opted for contact lenses for time being. I waiting on replacement so don't have the container with the prescription info.
I'm going to see a different doctor today to see what he says. My understanding from my optometrist is that a far sighted overshot is much more difficult to deal with.
I realize none of you are doctors but am a little curious- how likely do you think it is that I'll be told the 2nd eye surgery will make things better? My LE is my dominant eye and I had the Synergy put in my RE. I also don't know if there is a better lens option to balance the eyes. I need near vision.
RonAKA catherine67046
Edited
If the surgeon has left you at +1.0 D that is a difficult situation. Yes, you can correct it with a contact lens but I suspect you did not pay for a Synergy lens to be stuck with wearing a contact for the rest of your life. If they had gone the other way and left you at -1.0 D you could potentially leave it that way and use it as the reading eye, and try again for full distance with the other eye.
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I believe there is something called a piggyback lens which can be used to correct the error more permanently than a contact lens. And there is the lens exchange where the lens is removed and the correct power lens is put in place. This is kind of a last resort as exchanging a lens is much more difficult than putting one in for the first time. Typically this is done by a surgeon that specializes in lens exchange.
catherine67046 RonAKA
Posted
Appointment was very interesting, but final result was wait. Overcorrection with Synergy lens is +.75 which doc said is not what they like to see, but everything else looks very well done. Cloudiness/blurring may be due to scar tissue- which can be removed. You're correct, they can do lens replacement, but it's a last resort.
The other suggestion he had was PRK. I don't fully understand what he meant but I know it has to do with refraction. He kept asking if it was haloes that were the problem, but it's not. It's that I have reduced clarity, acuity at anything less than arm's length.
He also said that the difference between my eyes is great enough that my brain is having trouble adapting. This might be relieved by having the LE done. He was not pushing at all and he did make it clear it could be a different lens not the Synergy. My sense is that's why he wants to wait, he wants to have a better picture of what exactly I need from my vision.
Sorry this was so long. I have another appointment in November. Until then it's contact lenses in both eye and reading glasses and you're right--not what I expected after paying over $3K.
RonAKA catherine67046
Edited
PRK is an alternative to standard Lasik surgery. No experience, but as I understand it with standard Lasik they peel back the outer layer do the laser surgery, and then place the flap back. With PRK they remove the outer layer and do the laser surgery. The layer is left removed and a contact is used to cover the eye until it heals. The healing time is longer with PRK.
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+0.75 is not a huge miss, and it should not be having the impact on your distance vision as much as close vision. The doctor is correct is waiting until the eye settles down before making a decision on the second eye.
rwbil catherine67046
Posted
Typically they try to shoot for Plano or -.25 myopic to avoid overshooting the other direction, which is more of a problem. With Synergy it should be a bit less critical with a slight + overshoot due to the near add providing such good close vision.
+.75 is a bit, but I would not think dramatic, maybe giving you 20/15 distance. Surprised to hear a .75D difference is too great, as I can assure you my eyes are way more than that apart as I cannot even see 20/200 out of my right eye.
From what I read from your post the good news is it sounds like your issue is solely a refractive miss and not other eye conditions.
My advice is wait until you are fully healed before making decisions and evaluate your vision at that time.
As mentioned there are options to correct the refractive error and a lens exchange as a last resort.
mary27273 catherine67046
Posted
Hi Catherine. Thank you for sharing your experience. I too have about -5 myopic. Surgery next month. How soon were you able to wear contacts after surgery? How is your vision corrected with contacts. In your particular case were contacts able to simulate ok vision near distant and intermediate. Sending much Blessings you way
catherine67046 mary27273
Posted
I believe you can wear them within days, but I was told it was better to let brain adapt so didn't start until almost a month later. Not a good idea in my case because it was too difficult. My vision is all right, but I have scar tissue from the surgery so that causes blurring- I need to have it removed. I'm meeting with the doctor on the 19th to decide on next steps for my left eye.
mary27273 catherine67046
Posted
In your case the scar tissue created the difficulty and blurring with contacts on operated eye? Sending good thoughts your way for future
catherine67046 mary27273
Posted
The scar tissue is part of the problem, but the doctor also over-corrected my vision in that eye so I am now +1 farsighted. Very difficult to fix and deal with as it leaves me without a focal point. I could have PRK surgery on my cornea to correct the refractive error and hopefully get better near vision or I could pay even more money and get a different lens. Neither option is appealing.
I hope all goes well with your surgery!