Questions For My First Meeting With The Cataract Surgeon
Posted , 6 users are following.
Contemplating cataract surgery for the first time, I happily came across this forum, which I’ve been reading for information about my options and to help me formulate questions for when I meet with the cataract surgeon / ophthalmologist for the first time in mid-August. Many thanks to you all. And many thanks in advance for you consideration. (And because this is my first post, please forgive any formatting issues.)
Below, are the questions I’ve come up with so far. I’d appreciate comments and suggestions for their improvement.
As background, at the time of possible surgeries in mid- and late-October I’ll be nearly 73. As it may affect product availability, I live in Massachusetts. I’m myopic and have worn glasses since third grade, progressives for a long time. FWIW, for the last few years, I’m wearing everyday PALs with Shamir Autograph III lenses; sunglasses with Shamir InTouch lenses; and Shamir Workspace computer glasses.
My most recent prescription, from January 2021, is:
|Eye | Sphere | Cylinder | Axis |Add|Distance VA|
|R |-6.25|-0.75 |180 +2.50|20/20|
|L |-7.50| -1.50 |134 +2.50 | 20/30|
.
In January 2020 and October 2018, my prescription was:
|Eye | Sphere | Cylinder | Axis |Add|Distance VA|
|R |-6.00|-0.50|180|+2.50|20/20|
|L |-6.50 | -1.50| 134 | +2.50 | 20/30|
Moderator comment: I tried to sort formatting of above but unsuccessful so I have added a reply with an image of the table for easier reading.
.
My Questions So Far
Based on today’s examination and comparing it to what the optometrist found in January 2021, do you think it currently makes sense for me to have cataract surgery on one or both eyes?
If it does, and if I want the best possible vision and am willing to wear prescription glasses to achieve this result, what would you recommend and why?
What would my daily life look like?
For what purposes would I need what kind of glasses?
.
To what extent can my need for prescription glasses possibly be eliminated or, at least, reduced?
Are there intermediate steps between the “best possible vision” option and the least dependence on prescription glasses option?
What vision trade-offs and risks are involved in moving from the “best possible vision” option to each successive “reduced dependence” option and between each “reduced dependence” option?
.
What about my astigmatism?
.
Do you recommend laser surgery?
Why (or why not)?
What is its incremental cost?
.
I’ve read about mini-monovision and mixing different IOLs in one’s dominant and non-dominant eyes.
When, if ever, do you think these options might be appropriate?
Do you think either might be appropriate for me?
.
When I made my appointment to see you, your office reserved surgery dates for me two weeks apart in October. I’ve read that it may be desirable to wait six weeks after the first surgery so that you can assess the results and recommend whether to simply replicate the first procedure or chose some alternative. What do you think?
If not already discussed: For the option, or options, under serious consideration based on our conversation, what IOL or IOLs do you recommend for me? Why do you recommend it, or them, and what is its, or their, limitations?
If not already discussed: If cataract surgery is indicated but is not particularly pressing, are there new IOLs you’re aware of that although not currently available will be reasonably soon. (Currently, the Clareon Toric IOL shows on Alcon’s website as “coming soon”.)
If not already discussed: You don’t offer Light Adjustable Lenses. Is this because you’re not satisfied with the product or for business reasons?
0 likes, 11 replies
Emis_Moderator RebDovid
Posted
Guest RebDovid
Edited
Lots of questions there but bottom line is if you're correcting to 20/20 and 20/30 I think surgery is premature. Unless the cataracts are causing other issues beyond visual acuity.
.
When do to the surgery is up to you. It's so low risk and routine these days that surgeon's say it's really up to you / personal decision. But if you're correcting to 20/20 in one eye that's excellent. I would wait. The technology can only get better. The deciding point for most people is when they notice that they no longer feel comfortable / safe driving.
.
Don't do laser. Laser can't correct your vision if the vision issue is INSIDE the eye (i.e. a cataract)
.
It all boils down to quality (monofocal) vs. quantity (multifocal). You can see "more" with a multifocal (wider range of focus without glasses) but the quality will not be as good.
.
If you're used to progressives and like them I might suggest just going with a monofocal… like the Alcon Clareon Toric… when the time comes. With that lens you will have the best possible quality and have to use glasses or progressives for anything within 3 feet of your head. But you milage may vary. Some people get better close up distance than 3 feet / outstretched arm. But your expectation going in should not be better than 3 feet.
RebDovid Guest
Posted
Thank you. I do understand that cataract surgery may be premature. That's why it's my first question for the ophthalmologist / surgeon. I'm seeing him for two connected reasons. First, at least subjectively, my vision has become less clear since January 2021. Second, my health plan won't cover a new eye exam within two years of that exam, but it will cover my seeing an ophthalmologist to determine whether I need cataract surgery. (I also accepted his office's offer of a regular eye exam, which may cost me $30 in addition to my $60 co-pay for the cataract consult.)
Regarding your substantive suggestion, while I'm very open to the idea of continuing to wear glasses, including progressives, to attain the best possible vision, I want to find out and explore my options.
Regarding laser surgery, in case my question as currently formulated isn't clear, I'm not thinking of something like Lasik. Rather, the question goes to the choice between laser- and non-laser cataract surgery. My impression is that laser-assisted cataract surgery may produce a better result in addressing my astigmatism.
Guest RebDovid
Edited
Oh! Sorry for misunderstanding the laser question! Also i clearly missed that his was looking for feedback on your questions for the surgeon, not looking for answers from us.
I looked into the laser question a lot and opinions vary but most of what I've read indicates that there is really no benefit to laser assisted vs. manual. Although with a toric lens it can be good to have a system that projects overlays to help with positioning. I don't think that is what is mean by laser assisted though. Laser assisted means a laser is making the incisions, the opening in the front of the capsular bag, and also helping with removal of the natural lens.
RonAKA RebDovid
Edited
I think you have most of the questions covered. Whether or not you will get fulsome answers to them all will depend on how much time the surgeon is willing to spend with you. The surgeon I had never seemed to allow much time for discussion and I found the whole process rushed. My final two consultations were by phone when he found the time. My point is that you may want to have a short list of questions you really want answered and then some optional ones if he/she gives you the time.
.
If the office is cooperative you may want to do some inquires now to get some information. One example would be asking which lenses are offered by the surgeon. Many will only offer Alcon (AcrySof, Clareon, Vivity, PanOptix) or J&J (Tecnis, Eyhance, Symfony, Synergy), but not both. They seem to get married to a supplier... That will help you narrow down your research on what lenses to consider, or determine if you need to find a different surgeon. The other thing you could ask for is a price list. The surgeon I went to has a one page handout that gives the price of each lens offered. There may also be prices for the extra examinations to determine if you could benefit from a toric lens or not. Then you can talk to your insurance provider and determine what they will pay for and what they will not.
.
If your objective is to get the very best vision then I would suggest there is only one option. That would be an aspheric monofocal lens like the Alcon AcrySof IQ or Clareon, or in the J&J line the Tecnis 1 Aspheric. About 95% of people choose this option with the lens power to get you to full distance vision (20/20) without glasses. If you combine that with progressives you will be able to correct any residual error for distance, plus get reading vision with a +2.5 add as you do now. The other variation is to use the same lenses but be left at -2.5 D myopic. The only difference is what you are going to see with no glasses. In the former you will see distance, but not close. With the latter you will be able to read but not see distance. There are advantages to both, but the large majority choose to see distance without glasses. If you are committed to wearing glasses there is no need to get a toric IOL as the glasses will correct any residual sphere and cylinder.
.
Other options:
.
Mini-Monovision
In this case the dominant eye (ideally but not essential) is corrected to give full distance vision with a target of -0.25 D. The non dominant eye is targeted to -1.5 D myopia. The original monovision targeted as much as -2.5 D to give better reading, but the trend now is toward less, as the differential of -2.5 between the eyes can be difficult to adjust to, and can leave an intermediate vision gap. If you are considering this option I would highly encourage you to simulate it with contact lenses now while you can still see well with correction. Assuming your right eye is dominant you would simply get a contact to fully correct to 20/20 vision in it. In your left eye instead of full correction you would reduce the sphere correction to -6.0 D instead of -7.5 D, and leave the cylinder the same at -1.50. This will let you determine if you like monovision, and if not, then you can discard that option and focus on the others. I have this option and like it, but some may not.
.
Full Multi Focal
The two main options are the Alcon PanOptix and the J&J Synergy. You should search for threads on them here. These options have compromises like halos, flare, and spider webs around lights at night, and reduced overall vision quality at night. But some like them, and some hate them. In most cases they provide decent vision at all distances, but with the main issues at night. Search for experience with them here. It tends to vary from loving them to hating them.
.
EDOF
There are extended depth of field options that provide distance and intermediate vision but in most cases require reading glasses for closer vision. In descending order of reading ability there is the Symfony, Vivity, and Eyhance options. And although it may be hard to find the older non aspheric monofocals may provide some extra depth of focus at a cost of reduced sharpness at distance.
.
I hope that helps some. On laser for making the incision it is certainly not necessary. The consensus seems to be that it comes down to the skill of the surgeon using each method. Best to go with what the surgeon is practiced and skilled at. And on astigmatism you won't know whether or not you have it until they measure your cornea topography. You should ask for that at the first appointment. Then you will know if you will benefit from a toric or not. In general residual astigmatism less than 0.75 D is not corrected, and over that can be if you want to go without glasses. But if you plan to wear glasses it is not a necessity.
.
On when to do it, that may depend on your current vision. I would not rush into it, and in the near future a better selection of the Clareon line may become available. If you go for mini-monovision it is normal to do the distance dominant eye first. If it gives you the distance vision you want then you do the second eye for closer vision. If you don't get the distance vision, you have the option of doing distance in the non dominant eye to make up for it -- which means abandoning min-monovision. But it remains an option.
RebDovid RonAKA
Posted
Thank you for your detailed comments.
I take your point regarding prioritizing my questions. That, in part, is what I tried to do in my draft. Can anyone say roughly how long the examination part of the appointment should take? Presumably, that's not with the surgeon. Altogether, I've been told to expect the whole thing to take about two hours.
I'll ask which lenses are offered. With my new patient packet, I received brochures about AcrySof IQ PanOptix and Tecnis Toric II lenses.
From what I've read so far, you're correct that my best vision will come from monofocal lenses and progressive glasses. The point of asking further is to find out what trade-offs are involved to reduce my dependence on glasses. The cost in vision may be more than I want to pay. But maybe not.
Min-monovision intrigues me, even though I don't think I fully understand it. I was impressed that another area ophthalmologist's website mentions monovision, including: "Many patients who wear contacts or who have had refractive surgery have monovision and are happy with it. Your surgeon will discuss and demonstrate this option to see if it might work for you." Of course, I'd want to simulate it first with contacts. I'd need something to change, however, from when I was in my twenties and physically uncomfortable trying to wear contacts.
Your comment regarding laser-assisted surgery is particularly helpful. I hadn't appreciated that the surgeon's comfort may be the more important consideration.
RonAKA RebDovid
Posted
The appointment time and procedure will vary depending on how the surgeon has his practice organized. I can relate what I had based on my memory of my first eye done. Most of the time was consumed waiting for either the technician to do measurements or for the surgeon to go over them.
.
A technician did some visual checks first with an autorefractor (hot air balloon or barn on the horizon) to get a rough measure of your correction refraction. They also checked vision while looking through a paddle with holes in it. Why, I don't know?? I think they did the full refraction exam as well (which is better, A or B?). Then they take the measurements on both eyes to determine the length of your eye and the topography (for astigmatism). This may be two separate instruments, but I believe the latest instrument (and probably the best), a Zeiss IOLMaster 700 can do both. You can see the name and model of the machine on the side. I recall they also take photographs of your eye. Ideally these images/readings are entered into their computer system.
.
Next I had dilation drops and a slit lamp exam by the surgeon. This is to visually see the cataract development and look for any other eye issues you may have. In my case the surgeon reviewed the readings with me, and in the case of the cornea topography he showed me the images. At this point you should ask if the astigmatism is regular or irregular. Regular astigmatism is bow tie or hourglass shaped. Irregular astigmatism is when the two halves are not in the same axis. You can find images on line of irregular astigmatism compared to regular and it would be best to familiarize yourself with what they look like, so you can see for yourself what you have. You should also ask at this point how much astigmatism there is. Less than 0.75 D cylinder in the cornea is not usually corrected with a toric lens.
.
At this point the surgeon will make a recommendation on whether or not you should go ahead with one eye, or both and then you get set up for an appointment. And depending on how much time they allow you could have a discussion on the pros and cons of the various lens options. My surgeon short changed me in this aspect. So it is best to be prepared by learning as much as you can about each lens, and also on the pros and cons of mini-monovison.
.
If the plan is to simulate monovison while waiting for your surgery date then you should see an optical supply outlet to get contacts. I go to a private optometrist to get my eyeglass prescriptions but use Costco to get my glasses and contact lenses. I got my first contacts about 1975 or so. They were never that comfortable. More recently I got some J&J Acuvue Moist contacts and somewhat tolerated them, but found them almost impossible to put in my eye because they were so thin and flexible they would always stick to my finger. After trying about 6 or 7 different ones to simulate monovison I settled on the Costco Kirkland Daily lenses. They were much much easier to handle than the Acuvue Moist and were more comfortable than any contact I have used before. I could wear them 16 hours a day. They are actually CooperVision MyDay lenses. The other two lenses that were not quite as good were the Alcon Dailies Total 1. They have a newer version that I have not tried which are Precision 1. The other is the J&J Acuvue Oasis 1-Day. The point is to try a few lenses to see what you like. Costco is good at giving free samples. You just take your current eyeglass prescription and they will pick the right power. You will have to tell them you want an under correction of -1.5 D in your non dominant eye though to simulate monovision. All contacts are not all the same. For me the Kirkland ones were the best and also the least expensive.
.
From the list of lenses you got, it sounds like your surgeon does both Alcon and J&J. I would ask about the Clareon lens availability. It is optically the same as the AcrySof IQ Aspheric, but is made of a newer improved material.
.
Some info on the Clareon can be found by googling this:
"Comparison of Visual Outcomes and Patient Satisfaction Following Cataract Surgery with Two Monofocal Intraocular Lenses: Clareon® vs AcrySof® IQ Monofocal Smita Agarwal, Erin Thornell"
.
I have an AcrySof IQ in my distance eye, and a Clareon in my under corrected near eye. Since they are not both set for distance I really can't make any apples to apples comparison in visual quality. The Clareon lens should have longer term durability (if I live long enough to test that!). It also seems to have higher resistance to PCO which is a common problem with IOLs.
.
Hope that helps some,
RebDovid RonAKA
Posted
Thanks again.
.
I'll ask my brother-in-law, who's had one eye done by this surgeon several years ago (the other hasn't been done (yet)), if he recalls the examination process.
.
I've started reading up on different lenses, both here, where I've found your posts particularly illuminating, and by searching the web. Clareon does seem the best likely available option, at least if all I need, or choose, is a non-premium monofocal lens.
.
Regarding getting contact lenses to simulate mini-monovision, unless my vision has deteriorated "enough" since January 2021 I expect the surgeon to say I'm not yet ready for cataract surgery. If it has deteriorated, however, shouldn't I be asking the surgeon for a new prescription and do contacts require something more than the exam conducted for eyeglasses? Or can Costco simply use a print-out of a new eyeglasses prescription? (As you may gather, I don't wear contacts. I tried once 40-45 years ago with, as I recall, something called a "gas permeable lens"; it was too uncomfortable; I think I was told I had something referred to as "tight eyelid".)
Also, is the suggested -1.5D under-correction to simulate monovision or mini-monovision? From what little I've read, the latter seems like a safer option to try.
Finally, how long do you suggest trying contacts-simulated mini-monovision? My appointment is August 19. In case we decide on surgery, the surgeon's office has reserved two dates in mid- and late-October. (I understand that if I'm having both eyes done now, I should talk to the surgeon about holding off on the second eye for about six weeks so he can assess the results of the first surgery.)
RonAKA RebDovid
Posted
One thing to keep in mind is that there is really no premium monofocal lens other than an aspheric lens is slightly better than a spherical lens. I suspect virtually nobody gets a spherical lens any longer. And the hard lenses vs soft foldable lens have disappeared other than in some third world countries. The aspheric lens came on the market 10-15 years ago or so. Some public healthcare systems may try to get someone to take a spherical lens. I recall one person in Canada a short time ago was required to pay a $80 fee to get an aspheric lens vs a spherical one. And also be careful of the term "premium". It does not mean the lens has a higher quality or offer more visual acuity. It really means that the lens has a premium price for some extra features that in most cases reduce visual acuity. The PanOptix for example offers mid and close vision for a premium price, but it comes with optical side effects that reduce visual acuity, especially at night. Even toric lenses are sometimes called premium lenses, and of course come with a premium price.
.
Whether or not you are ready for cataract surgery is something to discuss with the surgeon. 20/30 is on the borderline, and of course 20/20 is not an immediate problem. But, there can be issues with one eye done and not the other eye due to the difference in power correction and where the correction is located. Your correction is up there, so the surgeon may recommend both eyes be done reasonably close together. If that is the case I would suggest doing the dominant one first for distance and then the second 6 weeks later.
.
You should use the most recent eyeglass prescription to get contacts. In lower correction powers the contact power is the same as eyeglasses. In higher powers like yours there is some adjustment made. I recall CooperVision has a calculator on line where you can enter your eyeglass prescription and it will give you the correct contact power. A competent eyeglass prescriber should be able to do it as well. Just remember when simulation monovision to get a reduction of -1.50 D in your non-dominant eye.
.
The gas permeable contacts are the hard type. The newer soft contacts as I suggested above should be comfortable almost immediately with no break-in time.
.
A -1.50 D is based on research I have done on line for the latest recommendations for mini-monovison. It is a compromise. Some call -0.75 to -1.0 micro-monovision, but that would not be enough for me based on contacts I have tried. Full monovision as I think I mentioned earlier is much more in the over -2.0 D range. I was naturally in that range after my first eye was done, and I did not like it at all.
.
You only need to wear contacts long enough to determine if you like it or not. One thing to keep in mind is that you should stop wearing them 2 weeks before your eye measurements are taken. They can change the shape of your eye somewhat and you will get the most accurate readings if you have not worn the contacts for 2 weeks before.
daniel46601 RebDovid
Edited
Regarding the recommendation to not to laser, I would have a conversation. Talk about how the outcomes are similar and take the approach of 'why' do laser. I wouldn't want to push the surgeon into doing something he doesn't feel comfortable doing. Yes he may want to drive up costs and return....or he just may like laser better. Particularly with respect to your circumstances.
Guest daniel46601
Edited
100% agree on this aspect. I was just talking about outcomes. I believe most trials have not found much consistent benefit in terms of outcomes. So it's more about personal choice or what the surgeon prefers. Basically if the surgeon prefers manual then I'm ok with that. I personally wouldn't seek out laser-assisted for it's own sake. Apparently it can be great for correcting astigmatism with very precise relaxing cuts though. So there can be some concrete benefits.