RXLight Adjustable Lens - I'm not happy, do I have any options?
Posted , 13 users are following.
I have been myopic since 8 years old. Having wonderful near vision is a real gift. Cataracts came along, and I ended up choosing the LAL because the doc was very confident he could get me "functional" near vision, such as using my phone, reading a menu, reading labels...but that I would need reading glasses for novels or tiny print. Of course with a disclaimer that it comes with no guarantee, but his confidence and enthusiasm were convincing. My directive to him was that I wanted to ditch transitions glasses if possible, but that I absolutely did not want to give up functional near vision. I emphasized that it would be a huge adjustment with even functional vision, and I did not want to swap near vision for distance clarity.
If you opt for LALs, be SURE your doc actually listens to you about your wishes, and is willing to take the time to discuss/demonstrate your choices.
It was a tough lesson for me, story not quite done. Eyes were blurry after the surgery as expected. At the followup, I was told I had a "decision" to make at the next appointment, whether to choose close or distant vision. I came to the next appointment with a list of visual goals, and a few questions, expecting he could provide some guidance for the decision. I was told "We don't have time for that". RXSight advertises as a patient you will have the chance to "try" visual options to take the anxiety out of the decision. My "trial" was having my eye test adjusted for clear distance vision on the screen. (20/15, the doc was over the top!) I had no opportunity to see what my vision would be like if I chose the "near" adjustment, although I tried to get clarification. I wasn't given any opportunity to try functional tasks with each option. The doc basically told me to either choose between seeing well up to your arm's length vs seeing the rest of the world out there (basically his words), with the important assurance that there would be up to 2 additional adjustments if needed.
I opted for the distance...but the adjustment did not provide functional near vision. Everything was blurry until at least 8" beyond arm length. Had to grab for cheaters for all reading except headlines, fumble for cheaters to use phone, read a menu, do food prep, check price labels when shopping, put on makeup, etc. My food was blurry without cheaters. It was pretty traumatic to feel so handicapped. Even with cheaters, I had difficulty doing many near tasks. Sick of grabbing for them with every ring of my cell, I discovered wearing them on my nose so they were handy made me dizzy walking in my house.
At the next adjustment appointment, I requested to have a small portion of that near vision restored, since the doc said he would "tweak" my vision with additional adjustments. I wanted simply to regain clarity for near vision to a functional level. "You can't go back," he said. But instead, he said he could offer blended/monovision with just a slight loss of depth perception. I was stunned. Should I stop now, or have them adjusted again? I had questions about this step, because when I came out of the surgery and the first adjustment, I had better distance vision in my non-dominant eye. Plus I wanted to know what my quality of distance vision would be with less depth perception. His "trust me, let me do my work" approach was not as reassuring as the first time. I balked enough that he gave me a contact lens to try in each eye for a couple days, to see what monovision was like, and to decide which eye I wanted adjusted for reading. At this point, I haven't been able to trial yet, so perhaps my concerns are premature. My doc and I apparently are not a good match, and he is now refusing to answer my questions. His last comment to me was, "All I want to hear from you next time is which eye you want for near vision." (If you're wondering, let me assure you that I am not an obnoxious patient. I just like enough information to make an informed decision.)
At this point, I would welcome suggestions for who might be able to answer my questions, since my doctor and I are at an impasse. Now I must choose +1.5 in one eye for monovision, or cut my losses with fantastic distance and no functional near vision. He says monovision can be reversed, but what are the downsides? I would like to know if I go ahead with monovision and don't like it, can transition glasses or bifocal contacts recover my depth perception? Then I would have options if I didn't like the monovision adjustment. Otherwise I'm stuck with terrible close vision and back to glasses, which IMO is worse off than when I was nearsighted.
Takeaways and LAL experiences:
- The LAL needs more light for finer indoor vision, compared to my pre-cataract vision.
- Be sure your doc is willing to counsel you while making a decision, and answer reasonable questions with clear explanations. Be aware that he might overpromise.
- Find out what your doctor does to let you "test" your visual options before adjustments.
- Ask your doctor if the upcharge for the lens includes time for questions and collaborative decision making about your future permanent vision, or if it only covers the adjustments.
- Be aware that "adjustable" is not an all encompassing term, since I apparently cannot recover any amount of near vision with an adjustment. Only next option is some degree of monovision to recapture near vision, which has drawbacks too.
0 likes, 23 replies
RonAKA donna13579
Edited
Unfortunately, I think your expectations are exceeding what the LAL lens can provide. They can adjust one lens for distance or for close, but not both in the same eye. The method of achieving both distance and close is to do one eye for distance and the other eye for close which is monovision. If I read your post correctly, what they are suggesting is reasonable. Use a +1.5 contact in one eye at a time. This will leave the other eye for distance. Most people can adjust to that amount of differential between the eyes. I don't have LAL lenses but chose monofocal lenses which have given me a 1.4 D differential and I am quite happy with it. Without glasses I can see from about 8" out to the moon. I find the brain switches which eye it uses quite easily. Perhaps some do not. That is the reason to trial it with contacts. I did a trial with contacts after I had my first eye done, so I could choose the power for my second eye.
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So, I would try the +1.5 D contact in one eye for a while and then only in the other eye for a while to see which one you like better for closer vision, or if you like it at all. If you don't like monovision then you may want to go back to simply being myopic in both eyes and then depend on glasses. I would suggest going to -2.5 D if that is your choice. You will read well without glasses, but for sure will need glasses for distance. Most will opt for progressive glasses in this situation so you can see from close to far, but will require wearing glasses.
Guest RonAKA
Posted
Donna can correct me if I'm wrong but I didn't think that was the request / expectation. I interpreted it as… I'd like to dial back the distance vision a little to be slightly more myopic… enough to be a little more functional close up. That said, with a monofocal like the LAL I'm not sure how much near you'd get from a slightly myooic target like -0.5 (for instance). Probably not much and not enough to see you phone. So yes, going with -1.5 for the other eye is probably the way to go, But trial it first. Normally you do the non dominant eye for near. There are simple tests you can do yourself to determine dominance.
judith93585 donna13579
Posted
Thanks so much Donna! I really appreciate your taking the time to share your experience. Extremely valuable information.
MountainCat7 donna13579
Posted
Thank you Donna for sharing your experience. I am currently scheduled to have cataract surgery in 3 weeks. the doctor wants me to chose the Light Adjustable Lens. he is really "preaching" its advanced performance. this includes having the ability to refine the vision post implant to provide all distances...near, intermediate, and distance. these lenses are so new in the United States and particularly in our state. I would be one of the initial groups receiving this lens.
I am concerned, especially after reading your post, that they are "selling" a lens that doesn't live up to the advertised abilities. my understanding is that the lens is completely adjustable post implant. I do not have any advice for you as I am as unsure of what to do as well.
Like you, I have asked a-lot of questions but do not feel that I am an unreasonable patient. After all, it is our vision we are concerned with. And we are paying a premium price for this lens. Perhaps ask if he can make both eyes myopic and go back to wearing glasses for distance. I am worried about losing my near vision as well. enough so, that I am considering having a traditional lens placed in each eye that provides near vision. (which my doctor isn't so happy with).
RonAKA MountainCat7
Edited
My understanding of the LAL is that it is still basically a monofocal lens. Your comment saying " the ability to refine the vision post implant to provide all distances...near, intermediate, and distance" is a bit concerning. I don't believe that can be done within one eye. You have to pick the optimum distance for each eye. For example you would likely pick full distance for the dominant eye, and then a closer distance for reading with the non dominant eye. The perfect distance eye would be plano or 0.0 D. The closer eye would be more like -1.5 D to give you near vision. Then you have a full range of vision with both eyes combined, but not in each individual eye.
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This is standard mini-monovision which can be done with monofocal lenses as well. The advantage of the LAL is that it can be adjusted after implantation to refine the outcome in each eye. You could try different amounts of myopia in the close eye to see what you like. Some might like as little as -1.0 D, while others would want -1.5 D. You could try both as well as points between like -1.25 D. With standard monofocal lenses you have to do that experimentation ahead of time with contacts to see what you like, and then depend on the surgeon accurately hitting the targets for refraction. That can be done also, but the LAL will do it with more accuracy and certainty. I suspect surgeons that do LAL like that as it takes the pressure off them to hit the target refraction.
julie66167 MountainCat7
Posted
MountainCat7 - Did you have cataract surgery using the LAL? Will you share the outcome of your IOL choice? I am considering the LAL but have a long list of questions. Especially since, like you, I want to maintain being able to do bookwork and computer work. Thank you.
maura04015 donna13579
Posted
From everything I've read my understanding is the same as RonAKA's, that the LAL lens is a monofocal and achieves good vision at all three distances via monovision. The thing that caught my eye is what I took in the OP to say the doctor said no adjustment could be made for more myopia. If that's true and adjustments can only be made toward better distance vision, I've never seen that said before and would like to know the truth of it. My current idea is that if I have a disappointing refractive surprise with the first lens to pony up for LAL to make sure it can't happen with the second. An emergency Plan B so to speak.
However, it also sounds as if some people are dealing with doctors with a real resistance to those of us who favor good near vision over distance.
jimluck donna13579
Edited
He can definitely make you myopic in both eyes. He is asking which eye to make myopic for monovision. Therefore, both eyes are able to be adjusted to make you myopic. I suggest you be very assertive and instruct him to dial both eyes back to -1.5 or -2.0 or whatever you like for near tasks -- whatever your "cheaters" are giving you now. Then, wear glasses for distance. You know what it is like to be myopic and wear glasses for distance. It's not bad. For near, you just take off your glasses or peer over them. You don't know if you're going to like monovision.
I have minimonovision with contacts. Depth perception is fine and it doesn't give me headaches or dizziness or any other bad symptom. It's just not as sharp as I want. I want the sharpness you get when both eyes are sharp. So, I end up wearing glasses over the contacts -- one pair for computer, another for TV. And I need reading glasses for really tiny print.
LAL can be configured for extended depth of focus by some doctors. They do it by manipulating higher-older spherical aberrations into the lens. Google "Extended depth of focus with induced spherical aberration in light-adjustable intraocular lenses ."
Quote from this article: "Conclusions: Controlled amounts of negative spherical aberration and defocus can be induced in eyes implanted with adjustable intraocular lenses to enhance near vision."
My surgeon has offered to give me extended depth of focus using spherical aberrations if I choose LAL for my left eye. My right eye is not a candidate for LAL (too much astigmatism).
Also Google "Binocularly Extended Depth Of Focus With Induced Spherical Aberration In Light Adjustable Intraocular Lenses"
A third article, "Power Adjustments: Potential of the LAL", discusses 3 methods for handling presbyopia with LALs: (1) mini-monovision (2) creating a near zone in part of the lens, making it a multifocal, and (3) inducing higher-order aberrations to give the LAL extended depth of focus.
My guess is your doctor is not skilled enough to do #2 or #3 or not willing to spend the time to do so.
The Codet Institute in Tijuana, Mexico is a leader in use of the LAL and heavily promotes its ability to address presbyopia with the LAL. A Mexican doctor is cited in the last article I referenced above; I suspect he's from Codet.
trilemma jimluck
Posted
"My right eye is not a candidate for LAL (too much astigmatism)."
How much Cylinder? The maximum number for astigmatism diopters has been increased to 3 diopters I think.
If you get a toric lens to correct for astigmatism, the placement during surgery is critical to get the angle right. That would seem to be a strong advantage to LAL.
trilemma jimluck
Posted
I did Google "Extended depth of focus with induced spherical aberration in light-adjustable intraocular lenses".
Does that say that adding some astigmatism to LALs can be advantageous? And if it says that, it would follow that not correcting for a small amount of astigmatism could be advantageous.
So that would seem to imply that somebody with 1/2 D of astigmatism could be better off with a lens with no astigmatism correction.
Am I understanding, or misinterpreting?
RonAKA trilemma
Edited
Astigmatism does stretch/smear the point of focus and as a result extends the depth of focus, but at a cost in image quality (just like in other EDOF lenses). I have 0.5 to 0.75 D of astigmatism in both eyes which are in a mini-monovision configuration using monofocal IOLs. I am able to see reasonably well down to 18-20" or so in my distance eye, and 8-10" in my near eye. However, I suspect that has come at a cost in visual acuity. In my distance eye I suspect I have 20/15 with astigmatism corrected, and just 20/20 without.
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Would it be reasonable to intentionally induce astigmatism to extend depth of focus? I don't think so. It is much more reasonable to use some form of mini or micro monovision to do it.
jimluck trilemma
Edited
Let's get one thing straight: There is astigmatism and there are higher order aberrations (HOA). They are not the same thing. To get extended depth of focus, doctors manipulate a type of HOA call "spherical aberrations." They do not, to my knowledge, induce astigmatism.
There are three lower-order aberrations: Myopia, hyperopia and astigmatism.
More than 60 different higher-order aberrations have been identified. To quote the website "All About Sight" -- "Higher-order aberrations comprise many varieties of aberrations. Some of them have names such as coma, trefoil and spherical aberration, but many more of them are identified only by mathematical expressions (Zernike polynomials). They make up about 15 percent of the total number of aberrations in an eye.
Order refers to the complexity of the shape of the wavefront emerging through the pupil — the more complex the shape, the higher the order of aberration."
Some HOA are spherical aberrations. These can be manipulated to produce extended depth of focus. See the article "Expanding depth of focus by modifying higher-order aberrations induced by an adaptive optics visual simulator"
As to how this works with the LAL, see the article in Presbyopia Physician "The Light Adjustable Lens: Reshaping the Premium IOL Landscape." Here is a quote from this article:
"A misconception about the LAL is that it’s a simple monofocal lens aimed at precision distance vision. While this is partly true, it’s also highly oversimplified. It is indeed a monofocal lens; however, given its aspheric design, it does allow for an element of extended depth of focus (EDOF). This aids in extending visual range even in a plano targeted eye. Additionally, patients can elect to add negative spherical aberration to their nondominant eye during the light treatments. This adds an additional 0.50D-0.75D of EDOF, providing a solution for presbyopia and reducing the need for reading glasses postoperatively. "
To your question about not correcting astigmatism in order to preserve some natural EDOF, I recently read an article that investigated this. It found worthwhile gains in depth of focus up to 1 diopter of uncorrected astigmatism and no signficant benefit beyond that. I've read other things that put the cutoff lower, at half a diopter. But please bear in mind the distinction between higher order aberrations and astigmatism. Both can create some EDOF. As always, the extended depth of focus comes at a cost imposed by physics -- loss of acuity, loss of contrast sensitivity or something.
bill76991 donna13579
Edited
I had cataract surgery last year with LAL IOLs as my lens choice. I can relate to your sense of being hurried and rushed in the post-op light sessions. By the second or third light session, I could sense that I was teetering on the edge of being labeled picky or a problem patient. I ultimately went with mini-monovision, but the lens that was tweaked more with the light sessions post-op seems to have regressed to the way it was immediately after surgery. For me, monovision is functional to a point, but my brain doesn't totally tune out the non-dominant eye. It's like you can see close-up and far, but both distance choices are filled with noise, ghost images, fuzz, grit, and distortions.
RonAKA bill76991
Posted
"It's like you can see close-up and far, but both distance choices are filled with noise, ghost images, fuzz, grit, and distortions."
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Interesting. I have mini-monovision using 2 standard monofocal lenses and don't see anything like that.
kim68149 bill76991
Posted
bill76991
Is the noise,ghost images, fuzz grit and distortions and better? I am still struggling with the same.
K
judith93585 bill76991
Posted
Hi Bill,
I'm just now recovering from my first cataract surgery with a plan to pursue mini-monovision. Could you share the difference between your eyes in terms of diopters? I'm wondering if limiting the difference to micro-monovision levels (-.5D to -.75D) might eliminate the noise, ghost images, fuzz, grit, and distortions while at the same time increase the range of vision slightly.
Thank you!