Multifocal IOLs and Halos

[Richard123]

With regard to the multifocal IOLs, such as Restor and Rezoom, I am trying to determine what is meant by the nighttime haloing effect that is reported by some on this forum. Also the accommodating IOL, Crystalens, does it have the same or similar effect?
I have found a website that has simulations of various visual conditions including halos and starbursts. This is the address:
http://www.visionsimulations.com/
A question to those of you who have a multifocal or accommodating IOL and are experiencing night vision problems:
Is the simulation at the above site accurate or are you seeing something other than what is depicted there?
Any information about this would be appreciated.
Thanks
Richard

[Forum-OD-MP]

interesting site.

YES the halos depicted there are approx what most people complaining of "halos" see.  similar, anyway.

all multifocal IOL's can cause halos.  IMO crystallens is no better than restor or rezoom in that regard.

[Richard123]

Thanks. I had been picturing something completely different when I read about the haloing. I was not picturing an amorphous sphere of light as depicted on that site, but a ring of light around the light source, like an angels halo.
Maybe even multiple rings corresponding to the rings of the multifocal IOL.
If this kind of "sphere" haloing is just as common with the crystalens then I guess that would also apply to the regular monofocal lenses?
I wonder about the monofocal ones because I have also been considering monovision using the regular monofocal IOLs (combining far for the dominant eye with middle for the nondominant eye and using reading glasses for near).

[Ag-i-doc]

monofocal lenses are much LESS likely to cause halos b/c of the way their optics are made.  very few monofocal IOL patients complain of halos.

[Richard123]

I am confused then.
I thought the crystalens was just a monofocal that could move, to a limited degree, in response to the cilliary muscle.
I thought that would mean it would have the same glare and halo characteristics as a fixed monofocal.
But are the optics of the lens also different resulting in more glare and halo problems than a monofocal lens?
Thank you very much for your responses, this is helping me a lot.

[K-D]

Hi Richard,

Speaking for myself, and I have astigmatism, I do see the halos shown like those at the website that you have provided.  I do not know if other people see what I do, but I will try to give you a understanding of what I see with the multifocal lens,( at night only.)  If the light source is horizontal, I get the soft halo effect.  However, if the light source is vertical, I get large circles around the light source with spokes in them.  I do not know if people that do not have astigmatism see this as I do.   The circles are more annoying to me than the halos.  However, I have adjusted to them, (for the most part), and am hoping they will decrease when I have my other eye done. I feel that for me, the advantages outweigh the lively night show.  But I do not do much night driving. And everyone is different. And what is right for one person, may not be right for another. And what one person sees at night, may not be what another sees. Some people do not even see any night abberations.  I like being able to see distance, intermediate, and near.  And so for me, I will live with this trade off.  Hope that helps you.  Kathy

[Richard123]

Thank you.  
Which lens do you have and are you going to get the same lens in the other the eye?

[eyecu]

Any lens can produce unwanted visual images. Monofocals would have the least amount as they have one focal point but you can get some edge phenomenon and glare from acrylics more than silicone and the older ones that had a flatter front surface.

Crystallens is a monofocal optic that moves so you will not have as much of the effect except that it is a smaller optic in the 4-5mm range so you can get some edge effect. The problem is that it does not move that much so you can give up the near which is a downside for what you have to go through in the initial stages of implantation.

The others have multiple images. So at night while you are driving and using distance, the near is defocused but will pick up the halo effect. Astigmatism exacerbates this effect so the less you have the better. When both eyes are done, the effect lessens as you have the same system in each eye. You also adapat over time with neuro adaptation so the effect is minimized and you do not notice it as much. Some not at all and others more. Just depends on the person. But I have talked with surgeons and optometrists that have had the Array implanted for over five years and say that it is amazing how it continues to get better.

There are people from all walks of life with different jobs and hobbies that have theses lenses. I also know of some pilots and they are very happy. The pilots I know have the Array and now the ReZoom due to intermediate importance of the instrument panel etc. As you can expect, there are some patients that you would think would not be happy and they end up happy and others that you would think would be dead on and are not as happy.

I truly believe that attitude and personality plays into it and realistic expectations. In the retrospective quality of life studies studies that were done, multifocal patients overall were happier than monofocal patients but that is not to say that monofocal patients are unhappy.

[Highsound]

Eyecu,
Read your explanation of what causes nightime halos, but what causes the indoor and dim light secondary ghost image of the primary image that causes everything to be blurry?
Like KD, I am seeing a distinct very bright light ring with inner spokes or something like that around all pinpoint lights like headlights and auras around all other light sources.
Of these aberrations, the ghosting is by far the worst since it's everywhere 24hrs except daytime outdoor when my pupil is small. You can accustom yourself to the halos especially if your other eye doesn't see them and can dominate.

My Doc gave me Pilocarpine Hydrochloride drops to use to try and narrow the pupil size permantely and eliminate all of the above.
It's effect works very well short term due to the pinhole effect. No ghosts or halos and 20/20 chart vision. Do you think it will accomplish his goal?
If it doesn't, at least I'm getting a break for now.

[K-D]

Richard, I have the Rezoom in my left dominate eye.  Yes, I am going to have a Rezoom in my right eye in September.
Just research as much as you can to decide what lens is best for you.
If I could have gotten by with just wearing glasses to read, I would have gone with the traditional lens.  But my intermediate vision is important to me. And I was told that to arms length would not be clear for me with the traditional lens..  So, for me, I would rather have the night halos, and circles, than to lose my intermediate vision.  But some people may get by with just readers.  I did also want to tell you that my halos are not as large as the ones in the website that you supplied.  I have soft halos around a horizonal light source.  It is smaller than the light source and soft.  No problem at all for me.  The circles that I have from vertical light source are much larger than the light source and very thin with spokes in them.  I have come to live with them as for me, it is worth the trade off because I do not do alot of night driving.  Also, I have the circles on anything that reflects, at night,  such as parked cars,  and the reflectors on the roads.  (At night only.) Important to know if you do a lot of night driving.  Then again, you may have none of my night abberations because I have astigmatism. Just research as much as you can about the lenses, and get the very best doctor you can. When I see the circles at night, I just remember the thick coke bottle glasses my mom had to wear after cataract surgery, and it seems to put things in perspective for me.  All in all, I have great vision in my left eye. And have learned to live with the lively night show.  Best of luck to you Richard!

[K-D]

Highsound, I am still hoping that your inside vision will clear up for you. I had no hope of clear inside vision, without laser,  after two months of blurry inside vision.  Now, it continues to improve, going into my fourth month.  Maybe asked for a pair of glasses to wear while your eye heals.  That helped me greatly.  I was not so frustrated when inside. I wore the glasses all the time. Then little, by little, I notice that things were getting better.  Now I never wear glasses, except to read, and then only under certain lighting conditions.  I never even notice when I walk inside from outside.  And for 3 months, it was a dramatic change in vision.  Your eye has been through a lot.  Maybe all it needs is time to heal.  The best of wishes for you Highsound. Kathy

[K-D]

Richard, put in your search, (IOLs New advances.)  Very interesting information about about the lenses.  Guide to Iols by Dr. Slonim should come up.  Hope it help you. K-D

[Richard123]

Thanks, I am just getting started on gathering information on IOLs and this is all helpful.
I have also come across some articles and studies on the internet that compare the advantages and disadvantages of the various lenses.
And also some information about mixing and matching lenses.
Here are some that I have found helpful

http://www.eyeworld.org/ewweeksupplementarticle.php?id=104
http://www.eyeworld.org/ewweeksupplementarticle.php?id=105
http://www.lachmanconsulting.com/EyeQRpt1.pdf
http://www.eyeworld.org/supplements/2006%20AMO_SF%20DAILY%20MAY%20INSERT.pdf
http://www.ascrs.org/Meetings/Annual-Symposium/06am_PhyHandouts/19-103.doc
http://www.crstoday.com/PDF%20Articles/1005/CRST10005_supp.pdf

Related to that last one, the archive at Cataract & Refractive Surgery Today (http://www.crstoday.com) has a lot of information that I am trying to go through.

[Eagle eyes]

Hi,
As I recall on another thread, you had a crystalens exchanged for a ReZoom. I also thought you might have your IOL decentered. If indeed this is the case, this would explain your ghosting day and night. This is different from the normal halos or fuzz as some people describe as associated with ReZoom (and ReSTOR to some extent.) When your Pilocarpine is working and making your pupil smaller, it cuts down on the halos/ghosting from the decentered IOL, I believe.

[Highsound]

The decenterd IOL was recentered and sutured to the iris 3/6.
Follow up exam by another Doc reported it was perfectly centered but slightly tilted. He said that could be causing the ghosts and halos, but didn't really know for sure.  
If I knew for sure the tilting was causing the problem, I would probably look into another surgery to straighten it even with the risks involved in a 4th surgery. To assume that risk without knowing it will fix it is difficult.
Using Pilocarpine every 4 hrs or so eliminates the aberrations, but they come back even worse when it wears off. Perhaps using it will prevent any possible future visual adjustment, but the short term relief is welcome.  
Like others, I'm searching for answers, so I can get on with my life. I even called the mfg of Rezoom for opinion input, but they turned my inquiry down with "we can't give medical advice" after initially telling me they would look into it.
I am getting the impression that most Drs. and IOL mfgs. are more concerned with patient turnover than patient satisfaction. The lack of honest in-depth pro and con consumer info about such a common surgery is astounding, and results in Drs. making their patient's decisions.
The help you and other professionals who frequent this forum give is an exception to this statement and is greatly appreciated.

[Davidd]

I had crystalens put in both eyes about 3 months ago. Though I had an unusually long post-surgery reaction (8 weeks of extreme light sensitivity and pain), I am happy with the IOLs. I do not have any night time halos or anything else. I only need glasses (1.25) for extended reading with small type. I also have a very slight out of focus effect at long range but not enough to require correction. My intermediate vision and close vision is great. I am a 46 year old male in otherwise good shape and lead a very active sports life, these IOLs are turning out to be a good decision for me so far.

[K-D]

Wonderful news David.  Very happy for you!

[Richard123]

Davidd did you know your nighttime pupil size when you had the crystalens put in? I assume it must be smaller than the 4.5mm optic of the lens if you have no nighttime glare problems.

K-D Related to your descriptions of your nighttime vision with your Rezoom lens, have you been in other darkened situations since you have had the lens put in? I am particularly curious about what people experience in a movie theater or in a restaurant with a darkened atmosphere. Darkened situations other than just being outside and/or driving at night.

[K-D]

Richard, when in a theater, the screen is very clear.  The lights in the theater on the side of the screen, next to an aisle, have circles around them.
In a restaurant, I see circles around candles or lights.  But reading the menu is great in low lightening.  All about trade offs I guess.  Hope I answered your question.

[LLGirl]

You speak of knowing many that have had multifocals implanted and are happy.  YOu specifically mention the Rezoom, but do you also know many satisfied with Restor lenses implanted?  I am having those put in left eye on 7/19, right eye 8/2.  Just wondering - doesn't seem like as many people choose it, or maybe not as many with Restor are having problems, and aren't writing in to these forums?

[eyecu]

My father and uncle have had Array lenses implanted which was the first multifocal lens. They are very happy. The surgeon who did that surgery uses the ReZoom now as his lens of choice so I know more people who have that lens implanted. I am sure there are very many happy ReStor patients as well. But you have to look at the optical system. The ReZoom provides better intermediate vision and clearer distance vision across the board. The Restor offers stronger or more consistent near. But my dad has the Array and can read without glasses and is happy so he is fine with his near. You get the halo effect with both. SO it boils down to what you do and what your work is etc. If the ReStor had worked so well, then blended vision would have never come about in the first place because there would have been no need for it. Obvioulsy patients were not happy. I have a friend whose father in law got the restor and was not happy with his first eye. After about 2 months he had the ReZoom put in the other eye and is very happy as they both work together to give him what he was looking for.More surgeons are now trying the ReZoom and you will start to hear more about it due to that fact. The market has recognized it as well.

[LLGirl]

But i thought that Restor and Rezoom came out into the market about the same time, only about a year ago?

[LLGirl]

Wasn't it march of 2005 that both Restor and Rezoom was approved?

[hud]

Rezoom has been virtually available for years as the Array lens. The Array was the silicone version with more refractive optic devoted to near vision than its acrylic replacement, Rezoom. This has helped with reducing the unwanted imaging of Array, but its a trade-off. There are halos with both ReSTOR and Rezoom, but they are definately more persistent with Rezoom as it has just a 3.5 diopter-add, which is harder for the brain to defocus. The company that makes Rezoom is trying to get out a 4 diopter-add diffractive optic multifocal (Tecnis) to match the performance of the 4 diopter add diffractive Restor. The blended vision thing is a curiousity for most surgeons now, and will not become mainstream until one technology (refractive, diffractive, or accomodative) can do it all with consistency. Please don't make your decision from any anecdote. Your eyes are like your fingerprints, you and your surgeon should decide how to treat them.

[LLGirl]

I think i am going to stick with Restor.   Hud, you have the near vision up to about 15 inches, and the distance... the intermediate, like washing dishes, etc., is it just a little fuzzy or ??  Not enough to bother you though?

[LouCat]

Hello group....I have a comment.   I had one eye RESTOR on
6-21-06.   So far no clear vision and the starburst & halos are
so severe, I absolutely could not drive at night.  Have done it
  on familiar streets...4 X.     I  am concerned as my other
  eye is 20/400....legally blind, and I am wondering if I could
  count on Healing with time.  I can be happy to wait 6 months
  if I-DO-GET-BETTER.     Comment for the subject.

[Eagle eyes]

ReZoom has not been available for years, only since last year, one month after ReSTOR. ReZoom is different than Array. The Array was silicone and is discontinued. Both ReZoom is and Array was a refractive optical IOL. More near vision is devoted for smaller pupils with ReZoom than Array. Less near vision is devoted to larger pupils with ReZoom than Array and more to distance to give less halos with ReZoom than Array.

Yes to huds point--> There are halos with both ReSTOR and Rezoom. However, the halos have nothing to do with the add power in the lens. It has to do with the continous optical system of a refractive optic.It is not harder for the brain to defocus a ReZoom vs ReSTOR halo. It depends on other factors and yes, comparitively speaking our patients that have ReSTOR in one eye and ReZoom in the other eye do notice a difference in the halo. They also notice sustainable differences in how each eye functions independently of the other. That is exactly why more and more patietns are getting the mixing of these premium IOLs or blended vision.

AMO is making a 4 diopter add diffractive optic "Tecnis multifocal". It has been in the works before ReSTOR was approved. It has already been available in Europe for a year.

Alcon, the maker of ReSTOR is making a +2.50 add ReSTOR because fewer docs are using ReSTOR now as the intermediate vision is a problem which was first noticed last year, and then the waxy distance vision issue came up. Over the past 4 months or so this waxy distance vision has been the catalyst to make the blended vision phenomenon accelerate. At first, Alcon said that only the AMO doctors were doing this. Now as Alcon investigators and loyalists have stepped upm uch to Alcon's shock and said this is the real deal, Alcon is making it's own changes. Alcon is planning to offer blended vision with their current ReSTOR and the new ReSTOR. It is a bifocal system so that is why there is a "start and stop" in the visual system. The near vision is fantastic. The intermediate vision slows down or stops. The distance varies from patient to patient. This means there is validity to blended vision.

The continuous vision of the refractive true multifocal optic ReZoom provides the near (not as strong as ReSTOR), better intermediate than ReSTOR, and excellent distance vision because of the refractive distance dominant center.

The blended vision thing is a curiousity for the surgeons that have not tried it, but more and more have and once they do, they see the success.  

I agree folks, do not make your decisions on these anecdotes, but experience is a great teacher for us all. Keep a diary of your tasks, activities, and your desires then have your surgeon check your pupil size in bright and dim light, as well as a thorough eye exam and together the two of you make your choices of ALL viable options.

Since hud says he is a financial guy and not an Alcon employee then he may not know that some of my colleagues (other employees of eye surgeons) that teach courses for both AMO and Alcon are being flown into Alcon headquarters to have a week long meeting on blended vision this month. Mixing and matching IOLs as well as the explanation of the new ReSTOR with lower add coming out.

This is why it is best to go to someone in your area that keeps up with the latest info because it changes constantly. All of these IOLs work well if you know which one is the best fit for you.

[hud]

great info- who are these surgeons going to consult with Alcon, that I may speak with them? I do appreciate the heads-up.

[LLGirl]

HI everyone,  got Retor implanted in my left eye two days ago, and am having really good luck.  Yesterday at my doctor appt, with my other eye covered, i had 20/20 on distance, and J1 for the near - 1 day post op.  I was so amazed that i could actually read all of the lines on both charts!  I used to really struggle to read to about the middle lines with my contacts in!  I was wearing a contact in my right eye, but it was hard to see well iwth both eyes competing, so at my appt the doctor told me to not wear a contact in my right eye, and let my new eye get used to being the one i see more with for the next week.  The surgery for my ohter eye is 8/2, so it won't be long to wait.  I can see distance to drive or watch TV perfectly with just the REstor eye.  REading is a bit harder, since i am nearsighted and my fuzzy eye messes me up a little, but if i close my fuzzy eye, i can see well with the REstor eye for near.  Computer is a bit fuzzy, but not as bad as i expected.  The near vision with Retor was not as close as i was worried it might be - it is at a comfprtable, normal reading distance, for me anyway (since i was previosuly near sighted).   I can't believe how well i am seeing already, after two days (i did not have any astigmatism to correct), and i am very excited to get the 2nd eye finished so that i can see really well with no glssses!

[Don B]

Hi to all...first post after reading this great forum for a while. Want to give back what little info i have at this time for the benifit of all. Had rezoom in left eye 7/20 and first post op yesterday. My vision before surgery was not bad,20/70 distance, could see pretty go distsnce but couldn't read without progressives. But cateract in left eye was getting worse and it was time or so i thought. I am a male,70, in excellent health. The doctor i used does all three types but said he gets best result with Rezoom and recommended it only based on past experience not what was best for me  I researched the benifits of all types as best i could and went along with his recommendation(fat,dumb and hoping for the best). i did give Restor a good look though and probably would have gone with it but for the Doc's recommendation. We did discuss what I expected which was to see computer screen with no glasses and hopefully read a magazine too, wanted no glasses.
I see distance and intermedite very good, I can read computer screen at 24 in very well. I can't read mag or paper at normal distance. I see halos at night only so far and not so bad. i see a shadow at outer corner of eye...like an arc which i thought was outer edge of lens but he says its reflection and not outer edge. Its not bad and i can get used to it. Viewing has not changed at all since surgery. Distance now at 20/30 and close  about the same. He says viewing close will probably get better when other eye is done 8/2...we will see. So far the worst is that I need readers to read...I was hoping to not need them. I guess I am fortunate as compared to others who have had trouble . No complaints and will use Rezoom in other eye. Hope this helps someone.

[JodieJ]

Congratulations on your fantastic results with your first ReStor lens!  And I'm sure it will get even better after your second implant.  It's nice to know that the right patient (healthy eyes, no astigmatism) and a skilled surgeon can produce such good vision with multifocals.  After reading this forum for awhile, it seems like many (most?) of the worst results are from patients who weren't good candidates for multifocals at the onset (and perhaps surgeons still on the learning curve.)

[K-D]

Hi Don,

Seems like the bottom line is that for people that want reading over computor, Restor is the choice.  And Computor( intermediate) over reading, Rezoom seems to be the one. And then there is the Crystalens, which has advantages also. That is why it is so important for the doctor to listen to the patient's priorities.  There are tradeoffs with IOL presently.  In the future, I am sure there will not be.  Still how fortunate that we have the choices that we do.  It sure beats the old coke bottle glasses that people had to wear in the past.

[songez]

does anyone have any experience with the new Tecnis Multifocal IOL? I read for many hours per day and therefore would love to have near vision to eliminate the need for glasses. My understanding is that this IOL reduces the glare and halo problems of earlier multifocal lenses. In additional, given my failure with monovision with contacts, I am not a candidate for different monofocus in each eye. Thanks.

[JodieJ]

The Tecnis multifocal is not expected to get FDA approval until late '07 or early '08.  It's supposed to provide excellent distance and near vision, but maybe less than excellent intermediate vision.  From what I've read, contrast sensitivity/night vision is supposed to be better than with other multifocals, but glare/halos may still be a problem.

If you're interested in this lens, you can find out more by using any of the search engines.

[hud]

The Tecnis multifocal will not be availble in the US for a year or two. You could go to Europe to have it now, or have a ReSTOR implant today.
I say this because the Tecnis multifocal is built on the same 1st generation diffractive optic that 3m developed in the 1980's. The 3M design was a full-optic diffractive surface with 3.5D add. The 3M studies showed a 59% spectacle-freedom rate. Alcon bought 3M VisionCare for this technology, and refined it by apodizing the diffractive component, and limiting the diffractive portion to the center of the optic and bumping the add to 4D. The latter two modifications has improved the specatacle-freedom result to 90%, while reducing the unwanted visual aberrations. Alcon patented these changes, and then released the rights to full-optic diffractive implants. Pfizer/Pharmacia acquired that technology to get in the game, and then Pfizer dumped Pharmacia's eye business to AMO. They are stuck with this old technology as they are far along the FDA approval path. The only modifications that Tecnis made to the 3M design is they bumped the add to 4D (like ReSTOR), and made the optic aspheric (which will give a small incremental benefit with large pupils).

[songez]

Hud, Thanks for taking the time and explaining so much. However, due to my ignorance, there is something that I don't understand. You say, "They are stuck with this old technology as they are far along the FDA approval path." To whom are you referring? And, is this "old technology" the Restor lens? Thanks.

[hud]

I'm sorry. I get a train of thought going, and it misses the station. Alcon makes the Restor lens. Advanced Medical Optics (AMO) makes the Rezoom and Tecnis brands. I meant to say that AMO is stuck with the old technology of full-optic diffraction since they are into the final stages of the FDA studies of the Tecnis Multifocal. It will have a 4 diopter add like ReSTOR, but it is not apodized, and the diffractive rings go all the way to the edge of the optic, just like the 3M design from the 1980's. Alcon's Restor design is much more refined with nanotechnology applied to the apodized diffractive rings, and they are limited to only the central half of the optic. These refinements have minimized the unwanted visual effects seen with full optic diffractives.
Also, when you pick up something to see close, everyone, young and old, has a pupillary constriction response. Restor is physiologic in this way , giving near and far focus in medium to small pupil scenarios. But when the pupil enlarges, a gradual blending of the focal points occurs, shifting a higher proportion of light energy to the distance focus. This helps as you bump around your bedroom at night. I hope that helps.

[songez]

Hud,
You are the best. I will go with the Restor lens and let you know how it works. Only one last thing, for now, I probably have large pupils (trouble with sunlight since my teens). Would this in anyway be a counterindication for the Restor lens?
Thanks,
s.

[hud]

Not that I know of. Typically patients with large pupils report early edge glare with all types of implants, so you might expect some of that with whichever lens you and your doctor choose.I'm not sure what you mean by trouble with sunlight, but if you're like me, you've always been more comfortable wearing sunglasses in bright sun for comfort.

[LuvMK]

I have ReZoom implants in both eyes.  3 weeks out on the left and 2 weeks out on the right.  My far vision is very good but my near vision is not very good at all.  I've been told that the near vision will come in with time, that it can take anywhere from 6-12 weeks for the brain to reprogram itself and get to the best vision.  Just curious if any others with Rezoom can share their experience with the healing time and how soon their near vision was good.

[votglo]

Hi Kathy!
After reading this thread, the description of your halos is exactly the same as what
I am seeing.....it' good to know that is more common w/astigmatism......I think that using
a contact in my right eye helps this condition and also acceptance of the "trade offs"
w/Rezooms vs. other multi-focals.
Did your Dr. talk about trying to correct the astigmatism?  I dont remember how
severe mine is.....I think alot......the same question I asked in another thread is
about the suture that is still in my eye......that must be related to astigmatism....
did you have a suture?

[K-D]

Hi Votglo,
I really do not know why you have a suture. I am sure someone with opthamology knowledge will answer that for you. I know that before the procedure that they genereally  do now, sutures were always used.  My parents had sutures.  I did not have a suture.  But I am sure there was a reason why the doc thought it would be best in your case.  Each eye is different.  I believe I could have laser to try and reduce the halos but I just do not want to take the change of changing the clear vision that I now have.  Trade offs is the word.  I still have slight edge reflection of the implant that seems to be getting less.  And I have slight glare which is removed by moving my head.  That also seems to be decreasing. (All in dark only) .  But as for the halos, well guess that is the price I have to pay for wanting to put on my mascara without glasses.  ;-)