ReStor IOL intermediate vision woes

I am a 50 year old CPA ReStor IOL recipient (right eye 11.5 D, left eye 10.5 D power both w/4.0 add in November 2005).  Previously I was nearsighted with a lot of astigmatism.  With ReStor I have perfect 20/20 distant vision, and can read the smallest print on anything at a comfortable reading distance.  However, the intermediate range vision (from 2 feet out to roughly 25 feet) is unacceptably horrible.  Sitting in an office, everything around me is fuzzy, out of focus.  I can't see the computer screen without leaning in very close; can't read file labels in a desk drawer when sitting in a chair, can't read things on the bullettin board behind my computer on my desk or things on the wall 10 feet away; can't read product labels on the shelves at a grocery store or Wal-Mart; the dash board instruments in the car are fuzzy; etc.  My eye surgeon is recommending replacing the ReStor lens implanted in my (non-dominant) left eye with a ReZoom lens in late June 2006.  As a "stop-gap" remedy I am currently wearing a +1.25 Accuvue soft lens in the left eye, which does capture a good bit of the intermediate range vision while sacrificing a slight bit of distant and near reading vision.  He believes that the ReZoom lens will yield better results than the contact lens, and will solve my problems without waiting > a year for Alcon to release a better intermediate range ReStor lens (currently in bench study).  Should I proceed with his recommendation?  Risks?  Downside?  Wait for Alcon to improve ReStor? Any comments or guidance will be greatly appreciated.  Thank you

[Forum-OD-MP]

sorry.  you need further surgical consult...

[eyecu]

I would go with what the doctor ordered as it could clear up your problems and is becoming a widely used practice. The longer you wait, the harder the exchange could be. There was a post on the results of blended vision on a thread which stated the results from a paper by Rick Milne, MD. It is under one of the ReStor Rezoom threads.

[eyecu]

Read thread from fcsmd under cataract surgery. He has blended vision.

[fcsmd]

Mike- See my case hx regarding the implantation of the Rezoom/Restor combo at http://www.medhelp.org/forums/EyeCare/messages/925.html  It pretty much says it all, probably more than you want to know. I would be happy to help with any other specific questions you may have. I only had to deal with the stress for 1 week about- combo or no combo- unlike the months you have had. If it works out for you as it did for me you will be wandering what took you so long to do it.

[Mustang Mike]

eyecu---why do you say "The longer you wait, the harder the exchange could be."

fcsmd---thanks for the referral to the journal of your experiences.  Not too much info at all.  I have had no problems with halos with the 2 ReStor lenses since day 1.  My only complaint has been the intermediate range vision, which affects everything I do on a daily basis.  IMHO, Alcon should not have released ReStor for marketing until they at least improved if not perfected this deficiency.  I have been ready to go for months now on a solution, but my doctor is taking it slow, hence the 6 month lag between the original surgeries and the planned remedy.  In fact, I am not even on the surgery schedule yet, I have just been told it will likely be near the end of June.

I am brank new to this forum and don't know my way around yet.  Can anyone give me the address to other discussions of the ReStor / ReZoom combo, like fcsmd directed me to his journal?  Thanks.

[Mustang Mike]

Another question:  I read in another thread post that it is recommended to put the ReZoom lens in the dominant eye, with the Restor lens in the other eye.  My eye surgeon is recommending replacing the ReStor lens implanted in my (non-dominant) left eye with a ReZoom lens in late June 2006.

Does it matter which lens is in the dominant eye?

[eyecu]

Many surgeons implant the ReZoom in the dominant eye to give you excellent near and intermediate and the ReStor in the non dominant for reading. Since are a CPA and your job requires it, he might be thinking to give you the best near for what you do most of the time. You also have pupil size issues going on. The Restor is great for reading in bright light but not for distance. The ReZoom is great for distance in bright light and better reading in low light than Restor.  No matter what, you should be better off and happy over what you have going on now and there are many patients with both combinations of dominant and non dominant that are happy.

As far as exhange time, it is always better to do it sooner than later.  The capsular bag that is holding your implant in place, shrink wraps the implant over time. There can be some fibrosis as well. The sooner it can be replaced, you are generally dealing with less fibrosis and it is easier to free up the implant to take it out.

[Mustang Mike]

eyecu---what you say makes a lot of sense.  Thank you for your insight and comments.  I will discuss further with my eye surgeon.  I am encouraged by what I have read on this forum about ReZoom, and the combination of that with ReStor.  I was very concerned and regretful over the results with the 2 ReStor lenses, but the use of the soft contact lens (although just a temporary measure), the input from my doctor and the experiences posted here have given me hope and optimism.  I just want to proceed with replacement of the ReStor with the ReZoom lens as soon as we can.  Thanks again.

[fcsmd]

Check these sights to help answer some of your questions

http://www.ophthalmologytimes.com/ophthalmologytimes/article/articleDetail.jsp?id=313908&searchString=henry%20milne

http://www.ascrs.org/Meetings/BPOS/06bpos/2-K.pdf

[EyeDave]

I am always curious why eye care professionals who for the past few years have finally seen the light that aberrations were a bad thing are now saying aberrations aren't so bad after all?  Wavefront Guided and Wavefront Optimized surface ablations have taken over refractive surgery because it is known that aberrations were causing the "glare" and "halo" issues of standard LASIK.  These aberrations led to many patients being miserable following LASIK.  Reducing aberrations improved the quality of vision to the patient and thus happier outcomes.  Now a couple of years after the industry has decided aberrations were a bad thing, multifocal implants which according to the design, splitting of light rays and physician labeling are aberrated lenses.  Now the same manufactures that have convinced physicians and the public that patients do not adapt to aberrations thus the need for custom LASIK are saying out of the other side of their mouths that patients will adapt to the glare and halo issues of the aberrated lens designs. So the question to these two multifocal and excimer laser companies is don't your cataract people talk to your laser refractive people?

[jmbesq]

I am  really confused.  My prescription is very close to Mustang Mike's (right around - 11.00).  But when I met with an eye surgeon recently to discuss my options he told me the ReStore does not come in such a strong prescription and if I went with the ReStore I would need to have a series of additional procedures to get me totally out of my glasses or contacts.  He did not even mention the ReZoom. From what I have read here patients seem to be pretty happy with 2 ReZooms or the Restore/ReZoom combo but my surgeon did not even mention the ReZoom.

[hud]

You should not be shopping for body parts on the net. Would you feel comfortable wearing my Florsheims oxfords just because I like them?
See your doctor, and get another surgeon opinion or 2 before you go forward.
With that said, allow me, a ReSTOR patient, and industry insider, to give you my 2 cents.
1.You and your doctor chose bifocal implants. The ReZoom is a bifocal implant. Near and far, far and near. The ReSTOR was modified from the 3M diffractive design by increasing the ADD to 4 diopters from 3.5. The ReZoom has just a 3.5 diopter ADD. Alcon chose to increase the add to improve the near vision, and to eliminate unwanted visual aberrations. The company that makes ReZoom will introduce the Tecnis diffractive multifocal lens in 2007 at the earliest. This lens has a 4 diopter ADD, just like ReSTOR. Coincidence?
2. You have not helped yourself adapt to the new visual system by using contacts. I can't say you can't go back, and unlearn this vision, but the neural adaptation of the brain helps all these lenses to perform at their peak. I had a muddle in the middle of my vision, but I knew enough to allow this technology to work and now I use my computer and other iintermediate distance tasks without glasses. That fuzzy zone WILL decrease to NOTHING, if you go glass-free for a few weeks. Hold materials in your sweet spot for your best vision-it has changed.
3. Explanting a lens at this point is risky. The chance of vitreous loss and subsequent retinal detachment goes up. Your doctor I'm sure shared this with you. He will have you sign a release. If you choose to have your explant replaced with a ReZoom lens, keep in mind that it is an OFF LABEL procedure that has not been validated in peer-reviewed journals. I would assume that you will have this experiemnt done at NO COST.
4.The evil of "good" is "better". If it ain't broke, don't fix it.
Please see the attached comments from Dr Michael Wong in Princeton:


I’m more than happy to give you my perspective on the ReSTOR lens.  This is just my personal opinion knowing full well that the ophthalmic community at large is still in a wide and open and healthy debate, which is good.  So take this as simply my humble opinion at this point in time but allow me room to change my mind in the future.  Also, know that I’m not paid by any medical company; just paid by my patients, whose best interests I have in mind.   Also, I have not tried the ReZoom or Crystalens, both of which I reject for scientific reasons.

Having said that, I believe we are experiencing yet another tectonic shift in the way we will be practicing ophthalmology.  In part because of Lasik, the expectation placed on us by many patients is to improve un-corrected visual acuity.  Cataract surgery is now also refractive surgery and thus, multi-focal IOLs are here to stay and so far, I have chosen, on a scientific basis, to run with the ReSTOR lens.  Of course, you and I think that our greatest role is to improve best-corrected visual acuity, but patient expectation is moving the bar higher and higher, rightly or wrongly.  Therefore, I start every cataract consult clearly defining our mission and that is to “restore the health of the eye,” and that the measure of success is best-corrected vision.  I cannot emphasize this enough…just like Lasik, management of patient expectation is the key to success with the ReSTOR lens.  

I choose the ReSTOR because:
a) it’s on an excellent single piece acrylic platform which will stay centered, with less PCO and less likely to have a late post-operative refractive shift, all important if you’re doing cataract/refractive surgery.  Further, the toric version prove invaluable.
b)  the pupil works in concert with focusing needs.  That is, this lens is distance dominant most of the time and in the dark, but there is more near emphasis as the pupil gets smaller, as what happens when one reads.

To date, I’ve done about 150 ReSTOR lenses, all in true cataract situations.  From my point of view, I would say that 90% of the patients are ecstatic, 5% get a marginal gain, and 5% are not helped and may be slightly worse off.  The key is to stick with true cataract patients.  They cannot distinguish between the wow of the cataract operation and that of the ReSTOR lens.  Thus, I actually have very few unhappy patients and no explants.  However, just because the patient is happy doesn’t mean that I’m happy.  It’s important to me to be able to sort out these 10% of patients in whom this lens does not help that much or may indeed be negative, and so I offer you these suggestions.


I would avoid the ReSTOR lens in patients with:
-unusually high expectations…engineers, type AAA.
-very discrete scotopic visual needs…radiologists, truck drivers, commercial pilots.
-multi-focal corneas…s/p PK, RK, ALK, keratoconus.  It’s probably OK to use over Lasik, CK, although IOL power choice is more difficult.
-non-optically pure corneas…s/p corneal scars, guttata
-abnormal pupils…Adies, traumatic mydriasis, corectopia
-retinal conditions which diminish contrast sensitivity…s/p RD in which the Stiles-Crawford effect is large, large retinal astigmatism, staphyloma, epi-retinal membranes, diabetes prone to CME, vitreo-retinal interface traction, obvious AMD.
I think it’s OK to put it in someone with a few drusen and it seems to bother AMD patients less than ERMs.
I think it’s OK to put it in a glaucoma patient with no Goldman visual field changes.
-minimal pre-op refractive errors in patients with relatively mild cataracts.  The 20/40 minus 2.00 myope with only NS can read better pre-op than post-op.  

I have found that:
-glare is an early issue, but tends to diminish with time.  I tell everyone that the near focus point shows up as a glow around lights at night.  I’d say 20% say that it’s noticeable, 5% appreciable and so far, no one says it’s disabling.  And it gets better with time.  Nationally, only 27 explantations have occurred in the 50,000 inserted to date.  Most have been for power problems, but some for glare.
-they are more sensitive to folds in the posterior capsule, not necessarily PCO.  I have had to do 2 YAGs for posterior capsule striae.
-given that I never promise complete spectacle independence at the outset, the secondary refractive procedure rate is surprisingly low.  I’ve only had to to do one follow-up PRK.
-“binocular summation” is a real thing.  Patients do OK with one eye done, but there’s a real synergy when the second eye is done.  This is the reason why I stick to the same lens style in each eye although I know others are trying a mix and match of multi-focals.
-The optics for distance is adequate, but not fantastic.  Many are 20/20 minus.  However, with both eyes done, patients usually do not ask for distance glasses, even when they are +0.75 with 0.75 cyl.  There’s a murky endpoint to the refraction, a little like the old RK days.  For this reason, I do not believe this is a great refractive lens exchange IOL.  I have not done any RLEs to date and would only consider this for high ametropes, preferably hyperopes.  High myopes with axial lengths >25 mm, age <65 have a 5% RD rate and that’s too high for me to do a RLE.  As I said before, patients with pre-op refractions of plano to minus 2.00 have less a wow on the refractive side and thus the glare and contrast sensitivity issues loom larger.
-it can be used in one eye (other eye a previous monofocal IOL or not-ready-cataract) but with lessened expectations.
-the biggest pearl that I can give you is, at the last post-op visit, do the “-3D test.”  I put a -3.00 diopter lens in front of both eyes and say “this is how you would have seen had you had a conventional IOL.”  This locks in the value of the ReSTOR and prevents buyer’s remorse.

From a patient flow point of view, these patients will take a lot more time.  It’s almost like you do a normal cataract consult and then add on a Lasik-type refractive consult.  It makes a mess of your schedule.  Therefore, you need to charge enough to cover your time.  I charge $2,000 per eye.  I pay the ASC $745 per lens.  I do IOL Masters on everyone, as well.  I do not charge for LRI’s.  So far, I’ve stayed under 2.50 diopters of cyl with the LRIs, but don’t really trust them.  The toric ReSTOR will be invaluable when it comes out.  I’ve only done one PRK over ReSTOR and did not charge for it as there were some misunderstandings involved with this particular case, but plan on charging ½ price for future laser vision correction enhancements.

From a marketing point-of-view, I think it’s important to advertise this to patients.  How else will they find out about it?

All-in-all, I’m thrilled with this lens.  It’s way better than the Array, more satisfactory than mono-focal monovision (although this is not bad), better than doing Lasik in one with early lens changes, more stable than the Crystalens (which won’t work with an increasingly stiff posterior capsule), gives better reading than the ReZoom and will be better than the Tecnis multi-focal (which has glare because it isn’t apodized and the gratings go all the way to the periphery).

I hope this information will benefit you, your partners, and most importantly, your patients.  Please do not hesitate to call with any questions.

Yours,
Michael Wong, M.D.

[The Queen]

Dear Mustang Mike,
Intermediate vision is such an important part of everyday life, you should not have to live without it.  You Dont!!! - crystalens is a accommodating lens that provides excellent distance and intermediate vision without compromise of visual quality.  Many of the surgeons are mixing the combination of ReSTOR and crystalens.  Excellent near vision courtesy of the ReSTOR and uncompromised distance and intermediate vision from the crystalens.  Ask your doctor.  Good Luck

[Mustang Mike]

To HUD:  Let me clarify a couple of points in response to your comments.  I am not shopping for body parts on the internet; I am diligently seeking a solution to a very real problem I have encountered with the ReStor implants.  If the doctor could have simulated pre-op my intermediate vision results so that I could see what the result would be, I would have RUN away from these implants.  My individual results are unacceptably poor.  I have rejected contact lenses in the past that gave me this kind of vision difficulty.  However, I incurred the risk and expense of this procedure in order to get out of contacts and eyeglassess.  I am in the middle of this now, so I cannot go back; I need to find the best "permanent" solution to my intermediate vision deficiency.

My surgeries were on 11/8/05 (right) & 11/21/05 (left).  I did not start wearing the +1.25 contact lens in the left eye until 4/10/06, approximately 5 months post-op, because the poor intermediate vision was useless to me.  I could read a building directory (no matter how large the print) from more than about 18 inches distance.  There was NO improvement in my intermediate range vision in 5 months.  I felt that was long enough to wait for improvement, as it was obvious in my case that no improvement was forthcoming.

Your comments about the risk of explanting are very troubling to me, as are the remarks of "eyecu" on this subject, especially the conept of how the capsular bag "shrink waraps the implant over time".  How much time?  Is 7 months (i.e. late June) post-op too later to explant a ReStor lens?

When I asked my eye surgeon on 4/10/06 about the risk of removing the left ReStor, he replied that there was virtually no risk, he's done it numerous times to change the power (although never replacing with a ReZoom, but his national colleagues have done many "combo" implants).  I do not know if he has performed an explant more than 6 months post-op; I will ask him that soon.

I believe that I have been very patient, following doctor's orders and waiting for healing / improvement throughout this ordeal.  But something further must be done.  While I do NOT relish another eye surgery, I relish far less struggling through the rest of my life with such poor intermediate vision, which affects the vast majority of my daily activities.  This situation is "broke", and it definintely needs fixing.

[Mustang Mike]

That should read..."...I could NOT read a building directory from more than 18 inches, no matter how large the print..."

Sorry.

[Mustang Mike]

Oh, and the reason for the delay in the explant procedure---I was first told by my eye surgeon that the maker of ReZoom was going to give them the "conversion factors" to apply to the ReStor measurements / calculations in order to derive the correct ReZoom prescription / lens for me.  

I was later told by his assistant that it is more complicated than that.  They are implanting ReZoom lenses in ( I believe) 30 patients, both eyes (or it may be 30 lenses / 15 patients, not sure), and they need the data and results from those numerous procedures in order to accurately ascertain my ReZoom prescription. They won't get to that point until mid-June, hence the plan to schedule me for late June (around 6/27/06).

Does this sound right to you tecnhical folks?  Knowledgable comments are always welcome.

Also, the explant will be done at no charge to me.

[hud]

Thanks for the details. I am concerned about your intermediate vision also. It should be there by now. There is considerable diificulty in removing any implant this far out, especially ReSTOR.  If there is a complication, the surgeon can implant anopther Restor or Rezoom in the sulcus (in front of the capsule) for an acceptable  result. You are going to give up something with any exchange.
The 30 lenses your surgeon is refering to are the monofocal precursors to the ReZoom lens that the Rezoom manufacturer requires of all doctors to fine-tune their calculations before venturing into multifocals. It is not Rezoom lenses.
Best of luck.

[Mustang Mike]

HUD:  Thanks for your comments and concern.  Much appreciated.

RE your last comment:  "The 30 lenses your surgeon is refering to are the monofocal precursors to the ReZoom lens that the Rezoom manufacturer requires of all doctors to fine-tune their calculations before venturing into multifocals. It is not Rezoom lenses."

You are saying that he is completing implants of mono-focal lenses in his batch of 30, but these are not ReZoom lenses.  He is proposing in fact to implant a ReZoom lens in me though, correct?  Please clarify.  Thanks.

[The Queen]

Dear Mustang Mike,

I believe it is too late to have the ReSTOR implants removed.  

Of interest, the physician labelling for the ReSTOR, under intermediate vision cites " At at distance of 70cm (30"), the percentage of eyes achieving 20/20 or better uncorrected visions and 20/25 or better uncorrected distance corrected vision was significantly worse for the ReSTOR IOL as compared to the monofocal control.

Go to the FDA website and retrive the DFU (directions for use).  You will find some very interesting information.

[The Queen]

Beware of the ReZoom lens.  It is the Array lens in an acrylic material.  The Array did not catch on, and many docs explanted as many as they implanted.  Its just a matter of time before the same problems start to emerge with the ReZOOM.

[Mustang Mike]

Well, I have to do something, soon.  Wearing a +1.25 contact lens over left eye ReStor is unacceptable to me, for several reasons.  The ReStor alone is unacceptably deficient in the intermediate vision range.  In my opinion, this product should have never been released with this deficiency---Alcon should have continued their R&D to improve if not "perfect" the intermediate range vision before going to market with it.

I'm stuck in the middle and cannot go back.

So, what do I do, beyond praying a lot?

[K-D]

Mustang,

I can so relate to your horrible anxiety, as probably everyone that has posted a concern on this board can relate to also.
I know the hours and hours that you must have read to research on your choice of lens and doctor.  And then, to have unexpected results, is just so upsetting, that it affects your every thought.
I posted on this board in Feb.  I was so upset because of unexpected problems that I was also having  after my surgery.  The best advise that anyone can give to you is to get to the best doctor possible!  I was so fortunate, as I have a wonderful doctor in my area, that is ranked a Top Doc, (not to imply that you have to be so ranked to be an excellent surgeon.)  And even then, when I was initially disappointed with the results, and so anxious,  I had confidence that he could correct my concerns.  In the mean time, my original problem completely changed, and my initial blurred distant vision is now unbelievely perfect!  It is so clear, crisp, and beautiful! I have never seen this clear before, and I never wore glasses.  I was so concerned that the lens power was incorrect initally, because of blurred distance vision. But the calulation was "right on", and just had to settle where it was suppose to. But even now, almost 3 months post op,  my vision  continues to improve. Presently without glasses, my daytime outside vision is spectacular! My intermmediate vision is excellent without glasses.  Reading without glasses is good in certain lighting and blurr in other lighting. Reading seems better with less lightening.  No big problem for me though.  I do notice that when inside, my perfect outside vision changes.  Depending on the lightening, it is either perfect, or somewhat blurry past a certain point and so I was wearing glasses inside when evening came.  But since I am not wearing my glasses inside anymore , I notice that, even 3 months out, that is also improving.  I do have night time outside halos and circles around lights. And sometime glare inside, under bright light.  But even that is less of a problem for me, as I guess the brain does adapt. The night time halos freaked me out at first, but not everyone has them. Get the best doctor possible.  That is the most important advise you can receive.  And like me, maybe the unexpected will happen when you are not even expecting it. And just maybe you may not need an exchange.  But if you do, check and check and check to make sure you have the best doc possible for the exchange. Best of luck!
  p.s.  I presently have one Rezoom in my dominate eye.

[Jenta]

I was glad to hear someone say something good about Crystalens.  I have Crystalens in both eyes.  I have great vision at all distances.  There was an accomodation period where I was concerned, and a learning period for reading, but the final outcome has been excellent.  

My only problem now is floaters which drive me crazy.

[hud]

Every ReZoom and or Restor credentialed surgeon must be certified first by having experience with the monofocal precursors. It sounds like your doc is preparing for you, and maybe other potential Rezoom patients, and cannot offer it yet until he clears the hurdles set by the company.
I also wonder if he has addressed any residual astigmatism, as ReSTOR's "High Definition" design is very sensitive to astigmatism. The contact you wear addresses the "spherical equivalent" meaning roughly, the combination of power and astigmatism. If you have what is called irregular astigmatism, that cannot be treated with current technology, but may not be as much of a negative factor with the lower tech ReZoom. Currently there have been over 50,000 ReSTORs implanted in the US, and is still the premium lens of choice. The problem is that nothing is perfect, even the lens God gave you needed improvement. If your surgeon is strictly a cataract surgeon, and not refractive also, you need another opinion from a refractive specialist.

[Mustang Mike]

My eye surgeon is the best in the area in which I live.  He particpated in the clinical trials and studies for the ReStor lens.  He has vast experience in Lasik and cataract implant procedures.  

I have the best.  Now what??

[IOLMaster]

Dear Mustang Mike:

You might want to consider a low power piggyback lens to induce myopia. This would pull the distance vision in on one eye and should improve your intermediate vision. It's similar to modified monovision, but you get the benefit of keeping you stereo vision and depth perception. Plus, this allows you to keep the same optical system in both eyes.

[IOLguy]

You may want to consider an accommodating or focusing lens for your other eye. The manufacturers of ReSTOR may not reccomend this approach but you will likely get the intermediate vision that you need. The ReZoom is a multifocal lens that is designed to provide primarily distance and near vision after cataract surgery. Approximatley 17% of the light that is focused through the lens is dedicated to intermediate vision. It sounds like this may not be enough for you. The accommodating IOL, the crystalens, is designed to provide clear vision independent of the distance because it focuses or accommodates. It's the best bet at getting good distance, intermediate, and near vision in the eye that needs surgery.

[fcsmd]

In regards to what now?
I see that your thread has been quite active with posters giving you a variety of advice, encouragement & information, which was the same thing I went thru during my deliberations.What I found to be the most helpful in the end was 1. To pick a realistic goal ( no glasses or contacts) & stick to it 2. Take good notes on all you have seen, heard or read & then take them your surgeon & get his take on all of it 3. If both of you are still on the same page make a plan to make it happen. In the end it will come down to only the 2 of you.
Now for additional concerns- if I were in your shoes, I would be focused more on the explant/implant procedure than on the type of combo you should get.(since your surgeon only offers the reZoomn) Other than sooner is better than later, good info is sorely lacking on this thread. Why don't you open another thread askling for specific info or experiences relating to explanting of the Restor lens?  It would give you more to talk about with your doc.

[Mustang Mike]

fcsmd---Sound advice.  This afternoon before reading your latest comments, I printed out this entire thread and highlighted the points I want to discuss with my surgeon.

Your last idea is a good one, to start a new thread specifically on explanting the ReStor (after 7 months).  Let's see what that yields.  

Thanks to all for your input.  I do have more info to discuss with my surgeon.

[Mustang Mike]

fcsmd---The forum has reached its limit of questions for the day.  I will try to post the new thread, focusing on ReStor explant after 7 months, tomorrow after they open it up for questions again.  Thanks for re-setting my compass.  :)

[JodieJ]

Am I the only one who actually read the comments by Dr. Michael Wong (posted by hud on 5/15/06), which are apparently addressed to other surgeons who are considering adding the ReStor IOL to their own practice.  His remarks strike me as being so cynical as to be totally outrageous!  Dr. Wong describes the distance optics for ReStor as being "adequate but not fantastic."  (And we all know about Restor's intermediate optics.)  Consequently, he suggests that surgeons reserve the use of ReStor to "true cataract patients (who) cannot distinguish between the wow of the cataract operation and that of the Restor lens."  At the last post-op visit with a ReStor patient, he actually advocates placing a -3.00 diopter lens in front of both of the patient's eyes and telling them that this is how they would see with a conventional IOL!!  Apparently, he believes that this degree of deception is necessary "to prevent buyer remorse."

Hud, I thought that you worked for the makers of ReStor.  After reading Dr. Wong's remarks,  I'd turn and run (fast) if anyone ever suggested implanting a ReStor lens in my eye!  And I can't believe that others wouldn't do the same.

[eyecu]

I would agree that 6-7 months out could be difficult for IOL removal but eyes react differently and I would let the surgeon be the judge. If he is good and it sounds like he is, I doubt he is going to go in and try to take the lens out if it is fibrosed and he sees trouble. We don't have the chart and we are not looking throught the slit lamp.

As far as blended vision or the ReZoom ReStor Crystalens combo, it is not selling body parts. In a EyeQ Report from an independent consulting group that reports on Eye meetings:

After one year of real world clinical experience, the reality has not lived up up to the initial hype. Alcon is still expressing strong oppostion to mix/match strategies involving the ReStor, arguments which surgeons are increasingly viewing as commercial rather than clinical.

If bilateral worked so well, why would surgeons even have started trying mixing in the first place.

They also reference a Frank Bucci,MD who talked of his data on 55 bilateral ReStor patients and 39 ReStor/ReZoom combo patients. His findings were that there was no statistically significant difference between the groups in bilateral near vision: J.100 for the ReStor and J1.07 for the mixed. Unilaterally the ReStor delivered mean near vision of J1.25 verus J1.56 for ReZoom.

There was statistcally significant difference in the bilateral intermediate vision with the ReStor group acheiving and average of J.381 versus J2.39 for the mixed group. Unilaterally, ReStor delivered mean near vision of J4.42 versus J3.03 for ReZoom.

These findings are consistent with data presented in February at the World Cornea Congress in Brazil.

The combination is leading to higher levlels of spectacle independence and patient satisfaction.

ReStor delivers the strongest near vision for close up reading. But it is not without compromise with a key drawback being intermediate vision (computer) and glare/halo and loss of contrast as with all multifocals. Some bilateral ReStor patients use a +1 D or +1.25D reading glasses to adjust their distance vision to computer distance, while others us 1D spectacle correction to extend their near vision to reach a computer screen.

It goes back to the DFU in the lableing of the lenses and physics.

The bottom line is that you listen and learn. You move forward with all the hype and than find out what is real and adjust. But the bottom line is do what is best for the patient and their lifestyle. At least there are three good choices out there and more on the way. There will be happy patients with all combinations but the cream will rise to the top.

By the way, the ReZoom is not the Array. And the Array has the longest track record of any multifocal IOL. The ReZoom is already a second generation IOL which has been adjusted and improved from the first generation. It also picked up market share in the first quarter in the US at the expense of the others which can be noted in the stock and industry reports.

Real life experiences of patients on this board speak for themselves. Blended vision is here to stay and will not go away. And technology will move forward to help us try to regain our youth. The bottom line it to make the patient happy and if they are not, then try to get to the bottom of what is going on and correct it if possible.

[Eagle eyes]

I totally agree with eyecu on this one. Also, both Alcon and AMO require a surgeon to do standard IOLs first to get the best outcomes before gaining access to the ReSTOR/ReZoom respectively. I believe Alcon has now raised their requirements from 30 cases to 60 cases in some areas of the country. AMO requires 25-30. This is not just AMO as hud states.

Mustang Mike --- 7 mos out is not necessarily too late, assuming upon exam your surgeon feels like he can do it based upon what he is seeing. We aren't seeing it, he is.

Intermediate vision does not appear or come in after months of not being there. There is no intermediate correction in the ReSTOR optic -plain and simple. The ReZoom is not a bifocal. ReZoom does have near, intermediate and distance correction in the optic - plain and simple. Yes, ReSTOR gives closer near but most people don't like holding things just beyond their nose to see it.

You hang in there , MM.....

[Mustang Mike]

Thank you and the other folks for some very supporting, encouraging and helpful comments.  You are giving me the info I need to discuss with my surgeon.  He never once indicated that 8 months out would be a problem, not even when rejecting (as impractical) the option of waiting for Alcon to release the improved ReStor lens in 9-12 months (or more).  I cannot believe that when I ask him about risk of vitreous, fibrosis or other problems if we wait(ed) too long to explant, that he will slap his forehead and say "Oh wow, I never thought of that."  My surgeon is too good, reputable, and renowned to make a bonehead mistake like that.  Like you have said, HE is looking at the chart and at my eye, so he and I will have to decide if this is feasible or not.  Trust me though, if he hesitates or even hiccups when I ask about the timeline, I will walk away from explanting.  Only if he is certain of his succuss will I proceed with explant.  Thanks.

[Eagle eyes]

I suggest you find a surgeon that does ReZoom if you want to be less dependent or spectacle free. ReSTOR stops at +10
ReZoom stops at +6 (on the low end)

What city are you?

[hud]

eagle-what city are you in?

[IOLMaster]

Check your facts, the ReSTOR isn't a bifocal. Just check the defocus curve.

[Eagle eyes]

I am reading the package insert of the ReSTOR and quote:

"In bright lighting conditions with a constricted pupil, the apodized diffractive pattern of the Acrysof ReSTOR lens sends light waves simultaneously to both near and distance focal points. As lighting dims and the pupil dilates, the Acrysof ReSTOR lens send a greater amount of energy to distance to improve vision quality while maintaining near energy, and minimized visual disturbances."

I see the depth of focus, but I don't see where light is going to intermediate within the optic.

[IOLMaster]

You know it's funny, I had a patient who had recently been bilaterally implanted with ReSTOR lenses,call me from the Virgin Islands and he was telling me how great it was to read on the beach without glasses. I guess that might be a problem for a patient with ReZoom. Am I right Eagle Eyes ? Since 0% of the light is used at near in bright light....

[Eagle eyes]

It most likely depends on pupil size and refractive error. There is an OD, MD in Indianapolis - Kevin Waltz...he has Array lenses in both of his eyes since 1998. He is 20/15 in each eye and J1+ at near. J1 at intermediate. He has commented at various major meetings that he enjoys reading by the pool and can read the smallest of print, as stated above at J1+. He states that he gets a pinhole effect. To achieve the pinhole effect, it helps if the refractive outcome is slightly minus.

To your point, the ReZoom like the Array is distance dominant, so for some patients they may not read well with small pupils in bright light, particularly if the refraction is plano to slightly plus.

When a person has small pupils and is outdoors alot, this is the biggest advantage of mixing ReSTOR with ReZoom. Bright light ReSTOR reads well, as you have stated. Dim light, ReZoom reads better.

[hud]

Kevin Waltz is a paid consultant for Advanced Medical Optics, the maker of Array and Rezoom. He is virtually an employee, as is Eagle Eyes, of the company that they tout. Dr Waltz is one of the 42% of Array/Rezoom patients that achieved spectacle freedom in the FDA clinical study. The other 58% keep readers in their pocket. Keep this in mind when reading posts with "advise".