Pupil size and lens choice

Presumably soks would agree, at least to some extent. He is relatively young, and young people have larger pupils. His Symfony was replaced with a trifocal PanOptix, which he reported was much better for him.

My situation is different - older, with smaller pupils. Perhaps this means the Symfony would work better for me than it did for soks. I understand that my smaller pupils could reduce visible issues around the edge of the lens, since I may never see the edge of the lens.

What I don't understand is why my doctor advises against the trifocal lens for my small pupils.

Perhaps the surgeon is recommending against the multifocal lens as they are generally not recommended for those who have had prior refractive surgery.

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I don't understand why the PanOptix would be better than the Symfony. The refractive index of the PanOptix lens is slightly higher than the J&J Symfony. It is usually thought that a thinner lens due to the higher refraction index may sit further back from the pupil and increase the chance of light reflections off the edge of the lens.

"Perhaps the surgeon is recommending against the multifocal lens as they are generally not recommended for those who have had prior refractive surgery."

No, that wasn't it. He specifically said they are bad for people like himself and me who have smaller pupils. I will inquire further at the next opportunity.

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"I don't understand why the PanOptix would be better than the Symfony."

I don't know either, but it does seem to be soks' experience so far - he reported that he much prefers the PanOptix. Perhaps due to youth and large pupils, perhaps due to some other individual factor.

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A few other bits of advice from my ophthalmologist:

• The Tecnis line of lenses (J&J) work particularly well in people who have had prior LASIK - fit better with the re-shaped cornea or something, in his experience.
• He's willing to do the Light Adjustable Lens, despite my small pupils - presumably they can dilate to a sufficiently large size to enable the light treatment to succeed.
• He does not recommend monovision with standard lenses. He's fine with monovision, but figures if the extra depth of field is available at low risk via a premium lens like the Symfony OptiBlue, why not take it? (assuming money is no object) There's little downside, he says, just better distance vision in your near-vision eye.
• He does not worry much about preliminary measurement and refraction formulas. He uses ultrasound-based calculations to get a ballpark lens power selection, and then relies on the ORA (Optiwave Refractive Analysis) technology to nail the final decision during surgery. His experience is that this works well and only 3% of patients require subsequent adjustment.

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  I appreciated the doctor's willingness to discuss the details with me. He mentioned that most patients are happy to just let the doctor select the right lens, and I'm sure that is true. His personal experience as a patient is also compelling - he got the Symfony for his own eye, and is happy with it.

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  My main concern with the Symfony is will I get enough reading vision to make me happy? I have always had excellent near vision, and Symfony is designed for just ok near vision. The doctor recommends no more than a -.25 or -.50 D myopia target for the Symfony - will that be enough myopia for me?

I am not sure why he would think the J&J lenses would be better for post refractive surgery patients. For a monofocal I would think the J&J Tecnis 1 would be a poor choice. It corrects spherical aberration to zero and is not tolerant of less than perfect eyes, and perfect position in the eye. On the other hand the B+L enVista is aspheric correction neutral and is more tolerant of less than perfect corneas, and position in the eye. That would be my choice for a monofocal in a Lasik eye.

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Based on my experience I see no need for anything more than a monofocal lens to do mini-monovision with 1.50 D of anisometropia. However if you are pushing it more than that, there can be some benefit to an EDOF lens.

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I believe J&J claim an extension of 1.0 D for the Symfony over the monofocal, so to get good reading vision this would suggest a target of -0.5 D to get a total of -1.50 D. But, from what I can see of the defocus curve it suggests this is a bifocal lens along with some EDOF. So you risk the side effects of those technologies.

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Besides @soks there used to be a lady from eastern Canada, @Sue.An2 that had the Symfony and used to check in here now and then, from what I can recall. Don't recall a post for some time, but you could try a PM.

The doctor recommends no more than a -.25 or -.50 D myopia target for the Symfony - will that be enough myopia for me?

I have no experience with Symfony, but from what you and Ron are saying (i.e. that -.5D with that lens is roughly equivalent to -1.5D), I would say that isn't enough myopia for close, sustained reading. It's probably fine if you want to, say, read a menu, and certainly to work on a computer, but not for an evening settled in with a book. So it all depends on what you want your myopia for, so to speak.

Thanks for your perspective, Bookwoman. That is exactly my concern. I think I would be happier with something like -2.25 D in my reading eye. I would have no problem with the weaker distance vision in the one eye, and the large difference between the near eye and the far eye.

Thanks, RonAKA. Looking at old posts, Sue.an2 seemed to be happy with her two Symfony lenses - she reported good acuity from near to far, and only a minor halo "circle" effect around lights in the dark.

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I appreciate the advice of my very experienced and capable surgeon, but I still feel there is a solid case for me going with simple monofocal lenses and monovision.

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I am also tempted by the Synergy lens - it's part of the Tecnis line my doc recommends for patients with prior LASIK, and is designed for good reading vision. From what specs I can find, Synergy almost sounds like a more advanced version of Symfony - I read somewhere that Synergy also is really a bifocal design with EDOF applied to the nearer focal point to cover the range from near to intermediate.

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The details get pretty confusing for a layman like me. I will keep working on it...

One thing to keep in mind is that surgeons tend to form "partnerships" with specific manufacturers. My surgeon even insinuated that manufacturers reward surgeons by outfitting their clinics with all the latest instruments, which are very expensive. This makes it hard for a patient that is seeing only one ophthalmologist to shop and compare lenses from various manufacturers. In other words to shop for lenses you may be forced to shop for surgeons! My surgeon offered me Alcon or J&J for my first eye, but that is not the norm for private clinics. That is why it is harder to find the B+L enVista. They only have about 6% of the market.

Yes, I have seen that with my HMO - they contract mainly for the Clareon lens. But this guy is independent, well-established and eminent in the field. He advertises many lenses and brands with success stories, and seems perfectly willing to use any lens that will benefit the patient. At the appropriate price, of course. He advertises several B&L lenses, including the enVista.

Symfony is an older technology. why do you want rings and NO full range of vision?

i got Symfony 5 years ago and sue an got them 6 years ago. better lenses are available now.

you may want to go with clareon vivity if you believe the smaller pupils will give you larger range. vivity will give you as much or more range than symfony and no concentric rings.

your surgeon may he too close to JnJ products.

good luck to you.

sorry that was meat for philo09 .

Symfony is an older technology. why do you want rings and NO full range of vision?

i got Symfony 5 years ago and sue an got them 6 years ago. better lenses are available now.

you may want to go with clareon vivity if you believe the smaller pupils will give you larger range. vivity will give you as much or more range than symfony and no concentric rings.

your surgeon may he too close to JnJ products.

good luck to you.

wearing +0.5 or +0.75 glasses on Symfony gave negligible to no improvement for near.

buyer beware with Symfony.

Thanks, soks. Are you saying that with Symfony, it is impossible to read fine print, even with eyeglasses? Or at least that it was impossible for you?

i could read fine print with +2.5 reader on symfony. but the video quality and picture quality on phone was nit sharp.

but the point is symfony has rings. if u r ok with rings why not go with trifocal? otherwise go with vivity. even eyhance may be better with small pupil but vivity will have larger range.

ring edof is a failed technology in my opinion (symfony and lara). noone wants to come out and say it. leading doctors are not using synergy. i have met all the youtube doctors and they dont use it at all.

Thanks, soks. I am still a neophyte - I do not expect to have my first IOL placed til sometime next year. I am not familiar with the physical structures in these lenses. Are rings something that should be avoided? Is the vision extension that the rings produce insufficient to justify a risk or disadvantage?

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Reading vision is most important to me for my first cataract eye, and I am willing to sacrifice distance vision - my good eye still has 20/25 distance vision. I am concerned that Symfony may not do a great job with reading vision - it does not seem to be designed for that, more designed for intermediate to far, it seems. However, I have seen two highly-regarded cataract surgeons receive Symfony and report that their reading vision is quite good. One left -0.50 D of myopia in his Symfony eye and read J1+ shortly after his surgery. That might work for me.

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What looks best to me right now is either the Synergy lens or a monofocal (the LAL light adjustable lens or the Clareon monofocal lens) set for -2.00 to -2.25 D in a monovision configuration. But my surgeon really likes the Symfony OptiBlue for me - some of his reasons are listed above. So I'm considering that, too. However, doctors have a well-earned reputation for not always listening very well to their patients, and I 've noticed some are strongly biased in favor of distance vision, regardless of my preference. I want to be careful of that and make the decision that is right for me, not for the doctor.

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I did look at a few comparisons of Vivity with Symfony. From my quick review of the published research, Symfony provides significantly better near-vision, via a greater depth of focus than Vivity is capable of. The old Symfony had significantly more visual side-effects, but the newer OptiBlue version seems to have brought them down much closer to similar frequency as the Vivity's side effects.

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I don't yet see a solution that gives me confidence. My fourth opinion is scheduled for next week, 😃 I appreciate your input.

1. the rings will create a spiderweb of light around light sources at night. street lights. light bulbs etc. niw that effect is fine if the tradeoff is great near vision. this is the tradeoff i made with panoptix.

2. "I did look at a few comparisons of Vivity with Symfony. From my quick review of the published research, Symfony provides significantly better near-vision, via a greater depth of focus than Vivity is capable of." - Vivity has no ring so your artifacts will be much less than symfony. also the defocus curves do not support the research.

3. "The old Symfony had significantly more visual side-effects, but the newer OptiBlue version seems to have brought them down much closer to similar frequency as the Vivity's side effects." - this again is a marketing ploy. the yellow filter will not do anything for the light artifacts. you could get yellow version of pretty much any lens. the vivity would be available in both clear and yellow. eyhance is probably available in only clear and the symfony and the synery in only yellow.

4. i am coming from 5 years of symfony hell and truly think that it is old technology. good luck for whatever u decide to do and realize your cure.

"...the defocus curves do not support the research."

All the defocus curves I see strongly support the conclusion that Symfony delivers better near vision acuity than Vivity. I'm looking at a study done by researchers from Seoul on 63 eyes in 2021. The defocus curve shows substantial superiority of Symfony from about -2.0 D to -4.0 D and presumably beyond.

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Where do you see opposite results?

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Thanks for the good wishes, and I'm glad your hell is finally over! I am hoping to get educated enough to make good decisions and avoid problems like that. Of course, it is often better to be lucky than good...

after 5 years i have 0 stamina to argue or debate anyone here. my parting thoughts to help your educated good decision:

1. rings vs no rings for similar range of vision. seems like an easy decision?
2. you need close to 0.1 logmar at -2.5 to -3 for superior near.
3. if interested pm me and i will tell you what different doctors told me about each iol.

soks out!!

I think what soks is talking about when he says "rings" is that the lens is a multifocal (MF) type. The rings are shaped for slightly different powers and bring the focus of the light to different points. They effectively split the light coming into the eye to different focal points. An extended depth of focus (EDOF) lens on the other hand stretches the focus point giving more depth of focus at a cost of lower sharpness of the image.

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My understanding of the Symfony is that it is a combination of a bifocal MF and EDOF lens. One of the downsides of a bifocal MF is that there is a peak in distant visual acuity and another peak from the multifocal setpoint, and a potential dip in vision between those two points. Using both EDOF which effectively stretches the focal point, with a bifocal MF lens is supposed to overcome that limitation.

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A pure EDOF like the Vivity just stretches the focus point and pays for it in some loss of overall visual clarity and contrast sensitivity. You can identify what technology a lens is using by looking at the defocus curve. An EDOF will have a smooth drop off of vision as you get closer and closer, but at a lower slope than a monofocal. On the other hand a MF lens will drop and then have rise again to a second lower peak for a bifocal type, and two more peaks for a trifocal like the PanOptix or Synergy.

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On the blue light filter about the only optical effect besides correcting to a more natural colour balance is to reduce chromatic aberration. Most IOLs have a higher index of refraction than the natural lens, and the higher index bends the different wavelengths of light at slightly different angles. This creates chromatic aberration. The worst of it is closer to the blue light end of the spectrum and reducing that part will reduce the aberration. I think the OptiBlue is just J&J coming to the realization that their lenses could benefit from a blue light filter too. Alcon has been the primary adopter of it.

thanks, RonAKA, that helps. I don't see why a bifocal lens needs more than one ring, to divide the lens surface into two regions, one for far and one for near. But clearly there must be a reason...

i believe the blue/violet light filter is not the only improvement in the OptiBlue edition - they also smoothed the corners of those rings. based on your comment, the smoothing may be why the new OptiBlue shows far fewer complaints for glare and starbursts than the older model.

with all the tradeoffs involved in premium lenses, i am definitely seeing the wisdom in your advice to consider standard lenses with monovision. i just currently lean toward maxi monovision, rather than mini.

if only i could be confident of accurate refraction, i would be all in. but i have two surgeons warning they could be way off and would just leave me with glasses. the LAL Is intriguing, but I'm seeing disconcerting reports of lens changes long after lock in, producing vision that can't be fully corrected by glasses.

so now I'm thinking about a monovision lens set conservatively for myopia of -2.5 D, with lasik correction if needed. and maybe ORA.

There are different strategies for getting the MF effect. The eyeglass bifocal/trifocal comparison is only loosely the same. With glasses you manually choose to look through the bottom of the lens or the top. With IOLs you cannot choose to look through the top or bottom of the lens. The whole image is presented to the retina and the brain. I suspect the concentric band method is similar to MF contacts. There is also simple astigmatism where your optics are segmented into 4 pieces. Two opposite slices give further distance vision while the other two give nearer vision. One MF IOL actually has the near vision in the bottom of the IOL like a bifocal, or an extreme case of irregular astigmatism. The brain seems to make some sense of it, but it does not seem ideal...

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There is nothing wrong with full monovision providing you are ok with that much differential, or go myopic in both eyes, and resolve to get good distance vision with glasses. You also have to be prepared for a dip in visual acuity at intermediate distances. There may be some strategies with a mix and match lens to minimize that dip. You could go with a Rayner RayOne EMV (enhanced monovision) lens in the near eye. It is quite unique in that it stretches visual acuity to the plus side of the peak. This has zero value in the distance eye, but it could help fill the gap if used in the near eye with the peak acuity at -2.0 to -2.5 D. A Vivity could be used in the distance eye to stretch the visual acuity down to fill the intermediate gap to some degree. But, you may be hard pressed to find a surgeon willing to do that, and you may have to use two different surgeons.

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I still think I would find a surgeon that will do the enVista. Get measurements done with two different instruments, and possibly use ORA. Target distance first, and then based on where it ends up, push the near eye as far as you think you can for near vision. The enVista is a more tolerant lens to a less than perfect eye and is more likely to have fewer optical side effects.

Thanks, RonAKA. I will look into the enVista. I'm not understanding tolerance for imperfect eyes, exactly, but it sounds like a good thing, and no doubt my post-LASIK eyes are imperfect. Your advice, suggestions, and patience are much appreciated.