Mono- versus Multifocal

[Occupant]

Hi,
After more than a year of waiting for an Alcon Restor that still isn't available (-8 to -9D), my ophthalmologist called and said, that this year of waiting had at least shown to them that one out of four patients is unhappy with the multifocal lens and whether I would consider a monofocal. Can this be confirmed or does he just want to get it over with? After following this forum for a while, I have to admit, that I too have some concerns. Wouldn't the curvature of the lens in my case be greater than if I weren't so myopic and, therefore, even more sensitive to decentering and tilting?

[Forum-OD-MP]

ha!  yes confired just by the number of postings on this websitr alone.  it certainly fails in some people and causes a lot of problems.  may, many posts on here about this.  read away.

"Wouldn't the curvature of the lens in my case be greater than if I weren't so myopic and, therefore, even more sensitive to decentering and tilting?"

hmm.  more complicated than this.  no, not necessarily.

[Ag-i-doc]

BTW i wasnt laughing at your problem or descision...

its just that there are many, many people here struggling with this and MANY MANY people here who have major problems with multifocal implants.

it is my opinion that 25% number your surgeon threw out there is probably close.  maybe even a little conservative (although i have no studies to back it up or anything, just personal experiences...)

[JodieJ]

Since multifocal lenses are profitable for the surgeons implanting them, I seriously doubt that your doctor just wants to get your surgery "over with."  I think the best way to determine patient success rates is by reading the comments made by cataract surgeons to their peers.  In a recent thread ("ReStor IOL and astigmatism"), I sited an article in the current issue of EyeWorld in which cataract surgeons discuss factors associated with multifocal success.  (The fact that one surgeon wouldn't want multifocals in his own eyes and another currently favors monovision over multifocals suggests that the success rate has been less than stellar.)

There are also interesting comments by Dr. Michael Wong of Princeton in the archives of this site.  Find the thread:  "ReStor Intermediate Vision Woes" (5/14/06) and scroll down to the post by hud (5/15/06).

Multifocals obviously work well for many people.  Does the profile of the successful multifocal patient describe you?  (Having a very experienced surgeon undoubtedly also boosts the chances of success.)

[K-D]

All I can say is that I know at least 5 friends/relatives that have recently had monofocal cataract implants.  All are very happy.  It has been one rough year for me, with a multifocal, halos, focus, etc,  and still adjustments are taking place.  I would think long and hard about the multifocal.

[Occupant]

@Forum OD_RMP: Yes, I have read many of the posts here, but I   wouldn�t call that statistically significant. Human nature being what it is we generally only voice an opinion, when something doesn�t go quite the way we expected. There are certainly some people with good experiences that posted here, but if one only considers those versus the negative opinions,
nobody in their right mind should select a multifocal lens in my opinion. I don�t like 50/50 or even 40/60 chances and hoped that there might be some more reliable data out there, but then may be not.
@JodieJ: Thanks for your post. I wasn�t quite serious with my remark about getting it "over with", but if I were a surgeon and would have to field constant questions about when lenses would finally be available, "does it take so long, because they can�t their act together?"  and "my eyesight isn't getting any better, you know" - I would react that way.

[Occupant]

Thanks, We must have written our responses both at the same time. I didn't see yours until I had mine posted. Yes, I hear you and I am leaning more and more that way.

[JodieJ]

What really bothers me is the repeated advice from experienced surgeons to their peers to limit multifocals to patients who already have impaired contrast sensitivity and poor near and distance vision.  This group reportedly is the happiest with their multifocals, presumably because they have no standard for judging their post-surgery vision, and they're happy with anything that's an improvement over the blur they had with cataracts.  There's just something very cynical about this kind of reasoning.

[K-D]

I guess if you are lucky like Hud, multifocals would be wonderful.  But I can only speak for myself.  For me, it has been a very hard year, trying to adjust to constantly changing vision, depending upon the lighting, and the incredible psychedelic night life, for the first 8 months.
And then, I still have to wear glasses to read.  And it seems that many people with the multifocals do still have to wear glasses, rezoom for reading, restor for computor.
Maybe you would love the multifocal.  But if things do not turn out like expected, it is one very rough ride. One that you need to be  prepared to take.  I was not. Very best wishes to you. Good luck!

[JodieJ]

ReStor comes in powers as low as +10, which would probably work for someone who wore -8D or -9D lenses.  Have you had measurements done to see what power IOL you would need?  Maybe you can get your ReStors now (if you still really want them).

[JodieJ]

Hud, do you still monitor this forum?  I was surprised to learn that ReStor now comes in a clear version WITHOUT the blue-light blocking feature.  I always thought that this type of "retinal protection" was totally worthless (and possibly a marketing ploy), although its potential for harm had yet to be proven in a well-designed study.  Now it seems that Alcon has had second thoughts about the benefits of blue-light blocking (or, as you call it, blue-light "filtration.")  Does this mean that there is experimental evidence of the harmful effects of this feature (i.e., impaired night vision and/or color perception) on the horizon?  Are you still glad to have IOLs with blue-light filtration in your own eyes?  I just wish that the AcrySof IQ had come in a clear version last fall when I got my implants.

[Occupant]

I guess I had that wrong. My eyes were measured and I was told, I needed 8.5D for one and 9.0D for the other eye and ReStor only comes down to 10. This is what you confirmed.

[JodieJ]

I've read that sales of ReStor lenses for '06 were WAY below projections.  This might make it less likely that Alcon would be expanding the power range to less popular sizes any time soon.  (They did introduce a ReStor model recently without the blue-light blocking feature, though.)  And the Tecnis multifocal lens by AMO (sort of an aspheric version of ReStor, but with reportedly better intermediate vision), which had hopes of gaining FDA approval later this year, was dealt a blow by the FDA recently.  Now it's not expected to gain approval till late 2008 (if then).  I believe that ReZoom currently comes in your size, if you're interested.

I really think that multifocal/accommodating IOLs will become excellent products, but perhaps the technology and surgeon experience isn't there yet.  With aspheric monofocal lenses you could have super distance vision in all lighting situations without halos, ghosting or glare.  And you wouldn't have to wait months to adjust to your new vision.  (I was driving the day after surgery.)  If you left one eye a little myopic, you'd probably only need glasses for reading small print.  (Did you know that people wearing glasses are perceived to be more intelligent than people without them?)

[K-D]

Jodie, Evidently that is true. Because before getting the Rezoom implant, I did NOT wear glasses. ;-)

[hud]

Good morning, all.
Just to clarify. Alcon got FDA approval and launched the clear U.V. -only and the "natural" blue-filtering versions of ReSTOR on the same day. Doctors have always had their choice of Restor lenses, but since most lenses implanted today have the added feature of blue-light filtering, that is the way most have gone. Alcon tells me that every new lens model going forward will have this feature, except the phakic lens. This makes sense because the human lens already has the filter in it, so no need to double-filter.
In my opinion, Alcon management grossly over-estimated the market potential for Restor, as this is a new market in the Medicare segment. Surgeons tell me that the biggest deterrant to a qualified patient agreeing to choose Restor over a monofocal is the cost. Incredibly, most surgeons are not well versed in refractive surgery, which this technology requires. Seek out an experienced doctor and ask how many he /she has done, and then reduce by 20%. Maybe in time there will be a price correction. Overall, there has been plenty of experimentation with mixing and matching lens designs, but Restor appears to still lead the pack in hitting performance expectations. It sounds nice that different optics could be a ying and yang for each other, but in reality, it's all hype. Potential patients should do their homework, as clearly, you can't lump all multifocals together.

[K-D]

Hud, I was wanting to ask you a question.  Do you work for  Restor in any capacity?  If so, you need to identify this when you post.  It would make a huge difference to those reading the board and trying to decide what lens to choose for themselves. Not that anything that you post is inaccurate. But people would want to know if bias was influencing your posts. Important to know when trying to decide on a lens implant.  And yes, people can research all they want about a product.  But reading posts from people that actually have the implants and have NO bias, is very imformative also.

[JodieJ]

Thanks so much for the info about Alcon's position on blue-light filtration.  I'm looking forward to someday reading the research that will give us a definitive answer about the benefits of this feature, or lack thereof.

Hud, I agree with your comment about how few cataract surgeons are skilled doing refractive procedures.  I started out with a list of 30 "top" cataract surgeons, and I could immediately eliminate at least half because they didn't do refractive surgery.  But I suspect that it's not the out-of-pocket expense that's keeping sales of multifocals down.  I've noticed that most of the people posting on this forum about multifocal issues are in their late 40's and 50's (or even younger)--i.e., much younger than the average cataract patient.  (And I don't believe that this is because older people don't surf the net or post on forums.)  I suspect that the desire to be free of glasses is negatively correlated with age.  And the need for a lengthy time period to adjust to a new visual system could be a deal-breaker for many older people, who could easily afford the out-of=pocket fees associated with multifocals.

[hud]

In previous posts I have stated that I am in the investment community with access to all ophthalmic device manufacturers. I attend Wall Street conference calls with them, and I also interview eye surgeons for my business. I have to get feedback from international surgeons as well, as it's a big world, and these companies are global.
If I sound biased toward ReSTOR, over crystal and Rezoom, it is because I am. I am a happy bilateral Restor patient, having come to the implant choice through my business research.
I have very mixed feelings about this forum, as it has the potential of doing more harm than good. If you are in the middle of the amazon or Somalia, this might be a good resource.
I say this because patient opinions are very unscientific, and more anecdotal. But I have chimed in when I feel something needs clarifying.
I think people would be better served by using forums like this to research vacuum cleaners or cars. Otherwise, getting 2-3 doctor opinions is the better way to decide about your own healthcare. Just my opinion.

[Susan12345]

Well, believe me if I had discovered this forum before having my ReStors placed I would have been smart enough never to have them.   True, forums are not a random sample, the people with bad experiences are much more likely to write in, but doctors certainly don't know the whole truth either, especially about something that's new.  I am in my 50's, but choosing multifocals was never about not wanting to wear glasses, it was because I couldn't adjust to bifocals and was sick of constantly switching glasses.  Since my ReStors I'm still constantly switching glasses and now have constant dry eyes, focusing fluttering problems and intolerance to bright lights as well.   Susan12345

[K-D]

Hud, I do not live in the middle of Somalia. And I am guessing that most that post on this board do not either. And I am also guessing that most that post on this board did research before choosing their multifocal implant. However, the harm on this board, in my opinion, is bias from posters that have a financial interest in their posting. I did much research before choosing my surgeon, a year, and much reading about the Rezoom lens, after it was recommended to me.  I had never heard of a multifocal lens before seeing the doctor. However, had I come across this board before my surgery, I do not believe that I would be in my present situation, which has been one rough year, with more to come.  Research is vital.  But hearing comments from posters that have had a multifocal implant is also very helpful, and not just for people that live in Somalia.

[hud]

I am sorry to hear about your problems. One question- did you have cataracts before your surgery? Also, dry eye is not a result of surgery, but a condition that must be managed once you have multifocal implants.

[Occupant]

Amen to that. I guess, if Alcon ReStors would have been available for me, I would have had the surgery by now and would probably be in the same position that you are in. Through this board, I've come to the conclusion to stick with monofocals. Granted, who ever posts here doesn't fall under the heading "Statistically Signicant Sample", but where else are you supposed to get that information. My surgeon certainly didn't tell me about the potential problems or, if he did, minimized them. He only said: "If I were you, I would wait for the multifocals". However, he apparently changed his mind based on what JodieJ said, that market projections for 2006 weren't met for the ReStor and in all likelyhood they wouldn't come out with a lens where the potential market is only a fraction of what they can sell to "normal" people. The only thing that bugs me now is that this surgeon will only do Alcon and not even consider the AMO Tecnis and/or do an evaluation. Does anybody here know, whether the differences between them warrants a second opinion?

[K-D]

Really, my reason for posting on this board is not to encourage or discourage anyone from any lens implant.  It is just that I was soooooo unprepared for all my unexpected difficulties with the multifocal, and I just want people to know that if they choose the multifocal route, there may be many anxious and disappointing moments.  Maybe not. But I just wanted people to know of the possible severe  aberrations, and focus problems. They were certainly not stressed to me.  I was told that the clear vision is immediate and a small number of people experience some halos that diminish is a short time.  For me, the focus is still a problem when inside.  And I sure wish I would have been told that huge circles could be around anything that reflected.  It was such a shock for me to see hugh circles on peoples glasses, watches, clip boards, reflectors on the street, parked car paint. And driving at night was impossible, due to rings around entire cars and circles around every single light on the street. It was so frightening and unexpected to me. And I just want other people to be aware that the aberrations can be great. And there are other risks such as focus,and ghosting problems.  But as I said, maybe the majority of people love the multifocals and have had no problems.  After 8 months of no hope, my halos started to decrease greatly. Inside focusing still blurry . I guess this would be better than not being able to see to arms length, as I was told would be the result of a monofocal.  But 5 friends/relatives have had monofocal cataract lens implants since my surgery and I am shocked at their results. One friend can read without glasses and sees in the distance,( not monovision) and asked what I meant by halos. My cousin is driving without glasses. So,that is still my delema. If I truly could not focus till arms length, then I would still have risked the multifocal. But I have friends/relaives` that disbute  this. `So, I am still unable to encourage or discourage anyone on any lens. In the end, it seems to depend on a person's eye, the surgeon's ability, and a little bit of luck. � Best wishes to you!

[JodieJ]

I became a regular reader of this forum last winter, when I was recovering from retinal surgery (vitrectomy to remove a layer of scar tissue), and it was a certainty that I would be developing a cataract in my surgical eye.  I was initially intrigued with the multifocal/accomodating IOLs, which promised to give me something "special" that I didn't have pre-cataract surgery.  It was around this time that several people with preexisting retinal/corneal problems posted on this forum, all reporting their disastrous results with multifocal implants.  It may have been anecdotal evidence, but I decided that it wasn't worth the risk of implanting a multifocal lens in an eye with a less than perfect retina.  And it made no difference that one of the surgeons I consulted thought I was the "perfect candidate" for bilateral ReStors.

Occupant, my first choice was the Tecnis aspheric IOL.  (Have you checked out the patient information video on www.tecnisiol.com?)  But I couldn't find a surgeon here in Chicago who would implant it; they all seemed to use Alcon lenses exclusively.  I tried very hard to unearth published research comparing the Tecnis vs. AcrySof IQ, and I couldn't find a single study.  There seems to be little (actually, almost no) independent research in the field of cataract/IOL.  The professional journals are filled with articles written by paid consultants of the major corporate players (Alcon and AMO), promoting their sponsor's products.  The Tecnis lens corrects slightly more spherical aberration than the AcrySof IQ, but I seriously doubt that this makes any meaningful difference in vision, for better or worse.  The AcrySof IQ has a blue-light filtration feature for "retinal protection";  I found no evidence that this was either helpful or harmful.  So I decided to go with the AcrySof IQ because I had confidence in the surgeon's skills, and that's what he used.

[aimee37]

I'm sorry to read about the troubles associated with the multifocals.  As a recipient of a Rezoom in my dominant eye and a Restor in my non-dominant eye, I must say I have never been happier.  My vision is perfect at ALL distances.  Night time flairs are decreasing, but I had them anyway with contacts so they don't bother me that and my sight at night otherwise is EXCELLENT.  I do not wear glasses.  Yes, light must be present in abundance to read, however, I see perfectly when it is.  The fear established here, I feel, is unfounded in many cases.  To expect absolute perfection is to expect too much, but given time to adjust, with the combination of Restor and Rezoom, I have forgotten I had the procedure at all.  Please research carefully, and don't pass up a wonderful opportunity by taking a little risk, finding a good doctor, and asking for the combination.  They absolutely compliment each other in every way.  Hope for the best for each of you.. I am very very very happy.

[aimee37]

Congratulations on your wonderful outcome with a ReZoom/ReStor combination!  It's refreshing to read a success story.  I'm curious about what your vision was like before surgery (cataracts? nearsighted? farsighted? astigmatism?)  How long did it talk you to adjust to your multifocals?

[aimee37]

Hi, I had farsightedness with reading issues like most of us.  Due to asthma medication and genetics, I had  mature cataracts in my right eye and a small one in my left at the age of 59. Contacts were not working and actually created most of the astigmatism that was also a part of the ongoing problem.  My doctor at the Buckley Institute in Colorado Springs mentioned the possibility of combining the REZOOM and the RESTOR.  After much research I said definitely and was his first patient to try the combination. 10 days following second surgery, beautiful vision.  Reading came in quickly.. dry eyes are my only residual effect at this time. My doctor does multifocal implants almost exclusively.  

[aimee37]

Like k0k0 I also had rezoom dominant eye/restor non dominant and was farsighted with presbyopia. Wore bifocals for many years. I'm 56. No astigmatism or other issues. Although I have ghosting issue with the rezoom eye, my vision is excellent near, intermediate, and still good distance although not 20/20. The rezoom gives me best near and intermediate, the restor best distance. I'm 20/20 near and overall 20/25, 20/40 rezoom and 20/30 restor. Rezoom eye vision may still improve as ghosting diminishes. Although distance isn't perfect it's fine for all tasks including driving, even with the ghosting issue which is finally beginning to very slowly improve. I am convinced that if I had received bilateral restors I'd be in reading glasses and if I'd received bilateral rezooms my distance would have been poor enough to require specs for driving, and as an aside, I can't imagine both eyes ghosting the way the one has. I would have had difficulty driving at all.  My doc did say when he was evaluating me to decide which way to go (he does both bilateral restors and rezooms as well as combo)that farsighted candidates seemed to do better with multifocals. I guess what I am saying is that unless a doc has experience with both lenses, using them bilaterally and mixed and matched, I'm not sure that they are in a position to recommend best solution. I would stay away from anyone pushing either just Restor or just Rezoom. I am convinced the combo has been the key to eliminating the need for glasses in my case. I could get some improvement on distance with specs but not enough to make it worthwhile and I'm still only 15 weeks post op and distance may yet improve a bit more. At least my doc looked at three possible scenarios and evaluated on that basis, ie bilateral rezoom, bilaterial restor or combo. The first twelve weeks were no piece of cake but most of the weird aberations and the flickering have gone and I just have the ghosting to deal with. Even with the ghosting problems, at least I can function well without glasses which seems to be the exception, at least based on postings here.  

[aimee37]

My current plan is to get the Tecnis monofocal Z003 in my left non-dominant eye. Appartently it is a dense cataract that needs to come out, and it is causing problems especially with driving. 20/60 vision that can't get better than that with a new prescription. My right eye has a cataract also, but not too bad (20/30) with glasses. The plan is to go <.50 in the left eye to theoretically give me some intermediate vision. The right eye will be plano. The doctor calls this approach "blended vision." I am 60 with no idea why I have these cataracts.

About correcting corneal spherical abberation with the aspheric lenses? I understand how that works with contrast sensitivity and shooting for that, but... there has been no testing or measures to determine what my current status is with corneal abberations. It seems weird to me to be correcting/reducing something without a clear sense of what is being corrected. It just seems like too much winging it about the corneal abberations that is apparently the whole purpose of the lens. I asked about testing for that, and the reply was that an ORB scan wass done only if there is a significant stigmatism.

I wonder if I am the only patient worried about the newness of these asheric lenses. A medical school professor friend told me yesterday that I should get a lens that has been used for 10-15 years and that would rule out these aspheric lenes that I gather were invented a few years ago.

This boar is great. This whole decision process is the worst...easier to select a car or a husband!

[Neenah54]

A related discussion, glaucoma was started.