2010 CrystalensHD vs Restor, etc...

[DallasCPA]

Dear Doctor & patients,

I'm very confused & concerned about getting eye surgery... I'm in my early 50's and can no longer wear my GP contact lenses due to dry eyes.  I had great, crisp correction of astigmatism & severe myopia for many years with my GP contacts, then used reading glasses over them throughout my 40's until I could no longer tolerate my dry eyes...

Now, I am wearing progressive glasses for over 2 years, but  many of my activities are limited, including driving because my vision is not crisp & I do not have the peripheral vision that contact lenses provided.  I've become much less active & it is affecting my work ...

I am a CPA & an avid reader, so my vision is crucial.
With my astigmatism, myopia & presbyobia... what type of implants would you recommend?  I've been told I am not a good candidate for laser surgery, and one surgeon suggested CL HD, followed by yag & then lasix if needed (probably needed...)... meaning 6 total surgeries -- 3 in each eye.

This was from a very high-volume "big name" clinic in Dallas, with little input from the doctor himself -- who briefly looked over my chart after a technician spent considerable time examining my eyes.

Should I get a 2nd (and 3rd opinion)?  I'm concerned about "waxy" vision or ending up with worse dry eye problems, making my vision worse than better.  The information seems very confusing & I'd like more objective information, especially concerning astigmatism & eye surgery...

I've seen some eye docs who prefer aspheric implants vs Crystalens HD, and I am also wondering about the details gearing the procedure more to close (reading) vision versus distant vision.  Is all this considered "wavefront" technology?

And last, but not least, what about significant side effects with the newer implants (like waxy vision, glaring & halos?).  

Thanks so much for your time & any guidance you can provide,

Sincerely,
Dallas CPA



This discussion is related to Facing cataract surgery, need feedback, help deciding on lenses.

[JodieJ]

Yes, cancel the surgery!  You need more information before you can make an intelligent decision.

[DallasCPA]

you are so right, after coming to this forum I'm amazed at how little my surgeon discussed with me... I don't think I'm going through with the Crystalens surgery this week though!  Yes, I'm surprised PRK wasn't mentioned...?

[JodieJ]

I agree that your astigmatism and dry eyes are your two biggest issues.  You need to consult surgeons who are knowledgeable about both astigmatism correction and the Crystalens.  (Is your astigmatism regular or irregular?)  If a toric monofocal IOL could eliminate most of it, this might be your best option.  Your outcome with the Crystalens would depend (among other things) on eliminating most of your astigmatism, and I'm thinking that LASIK might be out of the question given your very dry eyes.  (Maybe PRK would be better in your case.)  Getting recommendations from more than one surgeon seems to me to be the best way to proceed.  Come to the consultation with your list of questions.  It might be worth a trip to Austin if that's feasible for you.  Your astigmatism and dry eyes make you less than an ideal candidate for a refractive lens exchange with the Crystalens--and I don't have a good feeling about a surgeon who doesn't even discuss these issues with you.    

[DallasCPA]

Jodie, just wanted to add that my optimitrist said that glasses could never give me the crisp vision that my gas perm lens did because they weren't right on top of my eyes like the contact lenses... Apparently the gas perms sort of "mold" the irregular cornea to a more normal shape?  Even soft lens didn't give me the acuity I enjoyed die +35 years in my gas perks... The 2.5 years I have been out if my gas permeable contacts has definitely led to reduced productivity & independence, which seems premature at only age 52 :-(. That is what makes me anxious to pursue whatever might improve my vision again...

[DallasCPA]

please excuse my typos -- my vision makes typing much more difficult these days!  A terrible affliction vmfor one who loves to read & write, for both work & pleasure!

[DallasCPA]

Than you JodieJ; you are very knowledgable. Yes, I always get all the upgrades when I have my glasses made -- have to, otherwise they are way too heavy to wear.
Do you think the Technis IOLs you have would be a better option for me?  Dr. I mentioned a Dr. Dell down in Austin, who I have researched and appears to be top-notch with astigmatism.  The doc I have consulted in Dallas  was a FDA trials crystalens participant but also works with many other the other multi-vocals & IOLs; my concerns are mostly around the astigmatism & dry-eye issues, since my optometrist has been concerned with the steepness of my cornea-- certainly not keratoconus, but I believe what they call irregular. However, my crystalens consult surgeon didn't seem concerned at all.  There are several LASIK & crystalens dogs here in Dallas & at UTSW who appear to be very successful, but I also am aware that the premium lens bring huge financial & experience incentives.

Thank you once again for sharing your vast knowledge so generously!

[JodieJ]

You're almost certainly in the Crystalens range.  You might have too much astigmatism to be reduced by limbal relaxing incisions, so you'd need some type of laser vision correction post-cataract surgery.

It's important for you to know why your near vision is impaired with glasses, since this might conceivably affect your outcome with IOLs.  (Have you tried single vision reading glasses made with the highest quality lenses?)

Another surgical option for you would be Alcon's aspheric toric IOLs set for distance vision, with glasses for reading/computer worn over.  (This option probably involves less risk of post-surgery problems.)

People with high myopia (like you and me) are at higher risk for retinal detachment, and cataract surgery and YAG both increase that risk a little.  This might be a consideration for you, although your overall risk would still be low.

Please get more opinions before making a decision.  The process of consulting different "experts" will be educational, and it will also help you in selecting a surgeon if you decide to proceed.

[DallasCPA]

Many thanks for your comments.  My right eye is ---  -7.250 sphere, +3.250 cylinder 90 axis;
Left eye is-7.00 sphere +3.00 cylinder 84 axis.
Both eyes have 2.00 reading (progressive).

I'm not sure where this falls in the range of correctability & what the best treatment option would be for me... I appreciate any and all input, as this is a steep learning curve for me, but I do not want to make a mistake.

Thanks again!

[JodieJ]

One other major point:  It's quite possible that the Crystalens HD is not available in a power sufficient to correct your high myopia.  (Many very high myopes would require a power outside the Crystalens range.)  This can only be determined with certainty after eye measurements are taken, but a surgeon would have a pretty good idea about this after your eyes have been examined.

In summary (and from a non-professional perspective), you have three possible obstacles to a good Crystalens outcome:  high myopia (which may be too much for the available IOL powers to correct), severe astigmatism, and very dry eyes.  A pre-operative assessment by a technician and a brief look by the surgeon would absolutely not be enough to satisfy me.  (In your place, I'd flee that office.)  This is elective surgery and your vision affects your livelihood, so please proceed with caution.

[JodieJ]

There's no foolproof method for finding a surgeon.  You definitely want someone who is board-certified and VERY experienced with the Crystalens.  Special skills in performing limbal relaxing incisions would be a definite plus.  (How much astigmatism do you have?)  LRIs are less reliable than LASIK or PRK for reducing astigmatism, but at least they can be done at the time of surgery.  (Who wants to wait 2-3 months post-surgery to have an additional procedure?  What do you do during the interim?  How might LASIK/PRK affect your dry eyes?)  Dr. Oyakawa (who has special expertise with the Crystalens HD) has stated elsewhere that this IOL performs best with .5 diopters of astigmatism or less.

Here are a couple of other issues you might want to ask about.  Why are your near and overall vision impaired when you wear progressive glasses, and how (if at all) might this affect your outcome with the Crystalens?  (Would trifocal glasses work better for you?  Are your dry eyes a factor in your impaired vision?)  Younger (i.e., under age 60) patients tend to have larger pupils, and in some cases this has resulted in major problems with glare and halos.  (Are your pupils very large?)

You might want to get more than one opinion about all of the above before proceeding.  (I certainly would.)  Consulting more than one Crystalens "expert" is also a good way to gather information about which surgeon you want.  (If a doctor doesn't have time to address your concerns before surgery, it's doubtful that s/he'll have much time to address problems and concerns after surgery.)  

Even in the best case scenario, most (all?) of the Crystalens HD recipients posting here still need glasses for prolonged reading or seeing small print.  I'd expect to see big improvements in near vision associated with the next few models of the Crystalens, and perhaps even the ability to correct astigmatism.  There are also newer accommodating IOLs under development, which will be available in the USA in the not-so-distant future.

[DallasCPA]

Thank you so much for your reply; I appreciate your knowledgable & generous information!
  
Yes, my optometrist ordered several types of contacts for me, but when even he could not remove the soft lenses from my eye -- they just stuck to my eyeballs & it was very painful.

Yes, I know the premium IOLs will be pricey, but without them my livlihood is in jeopardydue to my poor vision.  However, I'm just not sure how to identify the best surgeon for my situation & do not want to gamble with my eyesight or that much money!

I'm OK with continuing to wear glasses if my overall vision & peripheral vision could be improved, as I'm very clumsy in all things with just my progressive glasses which only provide very crude correction for me currently... I read by holding  material just inches from my eyes, taking off progressives which don't correct well enough to read (I've had 3 different perscriptions in 2 years working both with optometrist & opthamologist).

So, is the technology of the crystalens HD state of the art, or are further improvements in the pipeline ?
We have many, many cataract surgeons in the DFW area, but my particular situation seems a bit more complex & from some of the results I've read about, the outcome appears questionable.  None of my family members have had cataracts, so I'm nor sure I'd insurance will ever cover the procedure -- I'd just love to have another 10 or 15 years of productivity and working, raising my teens, etc.  It's negatively impacted all areas of my life more than one would ever expect...

Thank you once again for your thoughtful and informed input.  Your reply & guidance is very much appreciated with such an important decision.

  

[JodieJ]

Here a few nonprofessional thoughts.  Have you tried toric contacts?  Contrary to popular belief, they can sometimes provide vision which is as good as what you got from RGP contacts.  (I also had to switch out of RGPs in my late 40's, but I could still read the 20/15 line with my soft toric contacts--and they were SO much more comfortable.)  Lens rotation can be a problem with some (but hopefully not all) brands.  Your best bet would probably be to consult an optometrist who specializes in fitting contacts on people with dry eyes.

It seems that the best results with the Crystalens are obtained by surgeons who are very skilled and experienced with this IOL.  Your astigmatism would have to be addressed, so you'd also want your surgeon to be very skilled at performing limbal relaxing incisions.  (Hopefully, your astigmatism isn't severe and your pupils aren't terribly large.)  Since your eyes are already dry, it would be good to avoid LASIK.  Most of the Crystalens HD recipients posting here do seem to need glasses for prolonged reading and seeing small print.  Waxy vision is sometimes a problem with ReStor (not Crystalens).  Because you don't have cataracts, your new vision might cost about as much as a new subcompact car.  It's certain that there will be better products available in the future if you can wait (perhaps even an accommodating IOL which corrects astigmatism).

[Ray T Oyakawa, MD]

This is your third post.  See the answer to your first post.

Dr. O.