Two Differing Opinions on Multifocal Lens, not sure if I should get a third?

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I went to two different eye surgeons in Orange County, California where I live about my cataracts and got two differing opinions. The first , Dr Tinoosh wanted me to go with J&J ZK BOO in my right, non dominant eye and ZL BOO in my left. Then when I saw Dr Chao, he wanted to put PanOptix in both eyes and pretty much said they were the best and he'd put them in his own and wouldn't even talk about any others.

Do doctors get kickbacks from the companies they use? Not sure if I should go with a 3rd opinion. I'm 65 years old and need glasses for both reading and distance. I wear progressive glasses now. My last Optometry exam was a year ago and reads as follows. Any helpful advice is most welcome.

Sphere Cyl Axis ADD

OD +5.50 -0.75 096 +2.50

OS +4.75 -0.75 137 +2.50

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12 Replies

  • Edited

    The first doctor seems to be recommending the combination of monofocal and multifocal lenses and the second doctor, two multifocal lenses. Have you read the IOL package disclosures, and determined whether those IOLs are suitable for you? What are the credentials of the two doctors you have seen? If not certain about their recommended IOLs, by all means get a third opinion.

  • Edited

    Doctors don't get 'kickbacks', they simply get paid more (by you) if you go with a multifocal lens rather than a standard monofocal. The latter is usually covered by insurance, while the former costs extra.

    If you read many of the posts on this forum you'll see why some people are not happy with their multifocal lenses (although some are), because of the glare, halos, etc. that can result. If you don't mind wearing glasses for certain activities, monofocals are usually a safer (in terms of visual aberrations) bet than multifocals. There are also EDOF (extended depth of field ) lenses, which are, to simplify things a lot, somewhere in between the other two types.

    • Edited

      They may not get kickbacks like car dealers do based on volume of sales, but according to my ophthalmologist preferred surgeons can get their clinic outfitted with all the fancy and expensive instruments needed to measure the eyes by the IOL company. This is worth quite a bit especially to a surgeon early in their career.

    • Edited

      You might be interested in checking out a US government website called Open Payments Data CMS. It seems to track funding that individuals get from private companies in the US. I found it when checking out Dr. Uday Devgan who is one of the rockstar ophthalmologists that is located in LA. I didn't check into all of the years, but he seemed to hit a peak of about $30,000 in payments in 2019, and has gone down to much lower levels in the years since. Most of them seem to be drug reps buying him lunch. Most payments came from Novartis and in 2019 it seems he was on a paid speaking tour for Novartis. Bausch and Lomb and Alcon come in with lower amounts. To my knowledge Novartis does not make IOLs, but they do make the name brand Vigamox and Durezol eye drops that are expensive and commonly prescribed for the cataract surgery recovery period.

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      To Sandy, Dr. Devgan may be someone that would use B+L lenses (based on the lunches they have bought him!). Their enVista lens is one I would consider if doing monovision with a monofocal lens. They can be harder to find than the more commonly available J&J or Alcon lenses.

    • Edited

      Oh yes, I'm well aware that doctors and drug companies, device manufacturers, etc. often have too-cozy relationships. I was simply responding to the idea that an eye surgeon might be getting more money for prescribing a certain type of lens rather than another: they do, but in any particular case that extra money is from what the patient is paying out of pocket for, say, a multifocal rather than a monofocal, even by the same manufacturer.

      There's a reason that multifocals are pushed so hard by certain docs, and while their underlying choice of which multifocal can certainly be influenced by what you describe, the pressure to use one over a monofocal comes down to wanting the patient to pay more out of pocket.

  • Edited

    The first thing you need to understand is that most (not all) surgeons will be locked in to a particular supplier like J&J or Alcon most commonly. When you go to them and ask for another brand, it is kind of like going to a Chev dealer and asking them to sell you a new Ford. So like buying a new car, if you want a particular brand of IOL you need to choose your surgeon carefully. It is more than just choosing a skilled surgeon.

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    Your first doctor offered J&J multifocal lenses which I would suggest are a bit old school now. They are essentially bifocals with a varying degree of near focus add. The ZKB00 has a +2.75 D add and is said to be about equivalent to a +2.0 Add in glasses. The ZLB00 has the next step higher add at +3.25 D and is said to be about equal to a +2.5 D Add in glasses, similar to your progressive prescription. I have not seen any comments about these lenses here, so they are probably not that popular any longer. They are similar to the Alcon Restor lenses which have fallen out of favour too. The newer J&J lenses appear to be the Symfony and Synergy. You will find quite a few comments about them here. If you google this you should find a pdf document on these J&J lenses:

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    The TECNIS® Multifocal 1-Piece IOLs, Models ZKB00, ZLB00 and ZMB00 Patient Information Brochure pdf P980040S049c

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    The PanOptix lenses are newer and are most similar to the J&J Synergy lens, but probably have a bit less near add than the Synergy. PanOptix gets quite mixed reviews here. My surgeon initially said on my first eye the opposite to yours and claimed he would not put them in his eyes. But now he is in bed with Alcon so is singing a different tune. He offered it for the second eye.

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    The big issue with all multifocal IOLs is that they frequently have optical side effects like flare, halos, and spiderwebs. Some adapt to them and some do not.

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    In the end I was not brave enough to risk the side effects of the multifocal options and went with mini-monovision using monofocal lenses. That involves targeting the distance eye to -0.25 D (usually the dominant one) and the near eye to -1.50 D. The idea is that the brain uses the near eye for close vision and the other eye for distance vision. It works well for me with very minimal side effects. Some surgeons will not offer mini-monovision as there are no big bucks in it for them. Another little secret of the trade is that the term "premium" does not refer to the quality of vision you get, it refers to the price you pay!

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    Hope that helps some,

    • Posted

      Thank you for all your replies. It's very helpful since this is a big decision. I think my first doctor is still old school about his choices because he said he's had less problems with the older IOLs in terms of halos and other issues and he said it would give me the best reading, mid, and long distance vision and thought I would be happiest with them. The second doctor just insisted on the PanOptix and wasn't much concerned with the side affects saying that those would clear up several months later. The first doctor also said he goes back two weeks after surgery and cleans things up with his laser. I have no idea what that means. He said he does it for all his patients. His price was $2900 per eye and the PanOptix doctor was $3500 per eye. I'm in California, so we pay a "premium" no matter what. Unless, of course I go with monofocal lenses. Then it's all covered. Thank you again for all your feedback.

    • Edited

      I am not sure about the doctor's conclusion that the older multifocals being better. The majority of surgeons are abandoning the use of those lenses. There are two possibilities with respect to the statement that he "cleans things up with his laser". One is that he is cutting a hole in the capsule that holds the lens and that will reduce the side effects. That is called a YAG laser process. It can be needed but only in about 15% of cases where there is posterior capsule opacification (PCO), and doing it before it is needed is not responsible. And YAG is sometimes used to pacify the patient that complains about the other optical side effects like flare, glare, halos and spider webs. But YAG will not fix those issues because they originate in the lens itself. And if you ever need a lens exchange it becomes very difficult after a hole is cut in the capsule. The other possibility is that he anticipates missing the power selection and goes back to do a Lasik correction to your cornea to correct for the miss on the lens power selection. That also is not a good prospect. You really want the surgeon to do everything possible to hit the correct power and not leave you with a surprise.

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      If your objective is to be eyeglasses free after surgery, I would not discount the option of doing mini-monovsion. It uses standard monofocal lenses so would be fully covered in your case. The best way of evaluating it is to use contact lenses to simulate what it would be like after surgery. An optometrist and contact lens fitter would be the best to choose contacts to do the simulation. Just say you want to be corrected to plano (0.00 D) in your dominant eye and to -1.50 D in the non-dominant eye. Wearing the contacts will give you a good idea what monovision is like.

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      From what you say, I do not get a good feeling about either of these choices for a surgeon. I would suggest finding another couple that will at least consider mini-monovision and work with you to evaluate if that solution is right for you or not. To be fair it does not work for everyone, but neither do multifocal lenses. It is what is a best fit for you and your priorities. The nice thing with monovision with monofocal lenses is that you always have a plan B which is to use prescription glasses. Prescription glasses do not always work to correct the issues with multifocal lenses. You are kind of stuck with them unless you get them removed, and some do that.

  • Edited

    One other comment. Your eye prescription does not look like there should be any problem with moderate hyperopia, and minimal astigmatism. You won't know for sure until after your eyes are measured, but you probably will not need toric IOLs.

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    Update: I see I misread your prescription and you are currently hyperopic not myopic. Still should not be a problem. It just means you will need an IOL in the higher power range above +20.

  • Edited

    Definitely follow advice of AKA Ron about monofocal lenses. And definitely get a third opinion. Sounds like you are being pushed into premium lenses Find someone else.

  • Edited

    Since you live in Orange county, CA, you are about one hour from Los Angeles, where the Jules Stein Eye Institute is located. It's one of the best eye hospitals in the world. I would go there for a another opinion. Look for a cataract surgeon who is fellow ship trained in Cornea/Anterior Segment surgery. The specialize in cataracts. Also, nearer to you in Laguna Hills, I see the Harvard Eye Institute that has a lot of cataract surgeons, but I know nothing about them. But you need another opinion or two.

  • Edited

    sandy56884 I was on the fence for months to mix my Panoptix with a single vision IOL or EDOF. Oh and regardless of what kickbacks or benefits any Dr gets in the end make the best informed decision for you.

    In the end I got the Panoptix in both eyes and the reason was I decided that I was given 2 equal eyes at birth. I decided that having 2 equal IOLs would provide as close to nature as possible. Sure it cost more but it was worth it thankfully for me both settled at 20/20 near to far. Currently my vision is glasses free from 12 inches to infinity and I am very happy. I have the vision of my very younger days.

    For me the known side effects are so min I actually don’t notice them. I have no issues with contrast, night vision, driving, nothing.

    I wish you the best.

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