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Cataract surgery- multifocal lens implant in one eye vs monovision
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Cataract surgery- multifocal lens implant in one eye vs monovision

Hi,
I have -9.5 myopia in the right eye because of a fast growing cataract.  My left eye is 20/25, onset of presbyopia.  I had 20/20 vision in both eyes all my life until 3.5 years ago when I started developing the cataract.  I am confused over the choice of a multifocal and monovision IOL.  I have been living with monovision these last 3 years and without glasses for the first year of that.  As the right eye has gotten increasingly myopic, I am using cheaters for the left eye.  My doc wants to set my bad eye for intermediate vision and leave the left eye as is as she says my brain has already adopted to monovision.  I did get a consult with a different surgeon who suggested a multifocal lens.  I have problems with depth perception lately, parking, reversing has become tedious, and halos and glares do not allow me to drive at night except around my immediate neighborhood.
Both docs are not very forthcoming and seem brusque.  I am scheduled to have the monofocal lens surgery this week, 23.50 diopter, Alcon lens SA 6080 (whatever than means).  I called the doctor's office and they were not sure if the right eye was being set to near or intermediate vision.
I would like to have the kind of eyesight I had 3.5 years ago or the kind that some of the people on this forum have achieved even with monofocal lens set to distance.  Should I ask for distance instead of near or intermediate?
Any suggestion/feedback is appreciated, thank you!
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Avatar_m_tn
I replied to that same comment where you posted it on  another thread, but I'll repost it here:

The diopter lens each person needs for a particular distance depends on a number of eye measurements (axial length, chamber depth, corneal curvature, and even ideally a customization factor that is unique to the surgeon due to differences in how they position the lens). So we can't tell from just that lens power what they are adjusting you for.

I'd suggest if possible holding off on surgery until you are sure what lens you want since they strongly recommend against surgery to change a lens later if at all possible. I can understand if your vision is too bad to wait.  If you don't get enough advice here, I'd suggest talking to  other eye surgeons if you can. Some eye surgeon clinics do have free consults if you are considering surgery there if you'd prefer to find a doctor who isn't as "brusque" and answers your questions well. You could check to see if your eye doctor responds to emailed questions, some busy people prefer that.  Many people are used to researching things on their own, but others prefer to find a doctor willing to address their questions.

I don't know the various monofocal lens options in detail since I didn't consider using them, but  I know  they aren't all created equal. For instance here was a blog post from last year talking about issues with the Alcon lenses, though it doesn't specifically mention that model:

http://eyesurgerysingapore.blogspot.com/2013/08/an-overview-of-cataract-surgery-lens.html

Also the lens material that other monofocal lenses use may give better vision, this trade magazine supplement talks about the issue of "chromatic aberration"  and mentions that with better lens materials:

http://eyeworld.org/supplements/EW-December-supplement-2014.pdf
" Cataract surgery with an IOL with an Abbe number greater than that of the natural lens (47) can improve CA, so that our cataract patients could actually experience better vision quality than they did as young adults. "

If your eye doctor can't address the issue of the Abbe of the lens then talk to another. There also   debates among doctors over correcting "spherical aberration", most seem to suggest lenses that correct for it (I hadn't looked into whether that one does or how it compares to others).

Have you tried a multifocal contact lens in your good eye? Some surgeons like this one:
http://www.reviewofophthalmology.com/content/i/1650/c/30426/

recommend that as a way to get a sense of whether you might wish to consider a multifocal IOL. Unfortunately it isn't quite the same, an IOL's optics are different and I assume better, but it may still give a sense of it.

If you don't like a multifocal lens, there are also accommodating lenses like the Crystalens that (if it works for you, it doesn't for everyone) may give you some better intermediate and near vision. If it doesn't work it winds up being like a multifocal.  Check the recent thread from a 35 year old looking for IOL suggestions where I posted about the other options, and in the unlikely chance you were willing to travel abroad for surgery (or aren't in the US)  you can check my thread on the Symfony lens or others regarding trifocal lenses like the Finevision or the AT Lisa trifocal.
8 Comments Post a Comment
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Avatar_m_tn
I replied to that same comment where you posted it on  another thread, but I'll repost it here:

The diopter lens each person needs for a particular distance depends on a number of eye measurements (axial length, chamber depth, corneal curvature, and even ideally a customization factor that is unique to the surgeon due to differences in how they position the lens). So we can't tell from just that lens power what they are adjusting you for.

I'd suggest if possible holding off on surgery until you are sure what lens you want since they strongly recommend against surgery to change a lens later if at all possible. I can understand if your vision is too bad to wait.  If you don't get enough advice here, I'd suggest talking to  other eye surgeons if you can. Some eye surgeon clinics do have free consults if you are considering surgery there if you'd prefer to find a doctor who isn't as "brusque" and answers your questions well. You could check to see if your eye doctor responds to emailed questions, some busy people prefer that.  Many people are used to researching things on their own, but others prefer to find a doctor willing to address their questions.

I don't know the various monofocal lens options in detail since I didn't consider using them, but  I know  they aren't all created equal. For instance here was a blog post from last year talking about issues with the Alcon lenses, though it doesn't specifically mention that model:

http://eyesurgerysingapore.blogspot.com/2013/08/an-overview-of-cataract-surgery-lens.html

Also the lens material that other monofocal lenses use may give better vision, this trade magazine supplement talks about the issue of "chromatic aberration"  and mentions that with better lens materials:

http://eyeworld.org/supplements/EW-December-supplement-2014.pdf
" Cataract surgery with an IOL with an Abbe number greater than that of the natural lens (47) can improve CA, so that our cataract patients could actually experience better vision quality than they did as young adults. "

If your eye doctor can't address the issue of the Abbe of the lens then talk to another. There also   debates among doctors over correcting "spherical aberration", most seem to suggest lenses that correct for it (I hadn't looked into whether that one does or how it compares to others).

Have you tried a multifocal contact lens in your good eye? Some surgeons like this one:
http://www.reviewofophthalmology.com/content/i/1650/c/30426/

recommend that as a way to get a sense of whether you might wish to consider a multifocal IOL. Unfortunately it isn't quite the same, an IOL's optics are different and I assume better, but it may still give a sense of it.

If you don't like a multifocal lens, there are also accommodating lenses like the Crystalens that (if it works for you, it doesn't for everyone) may give you some better intermediate and near vision. If it doesn't work it winds up being like a multifocal.  Check the recent thread from a 35 year old looking for IOL suggestions where I posted about the other options, and in the unlikely chance you were willing to travel abroad for surgery (or aren't in the US)  you can check my thread on the Symfony lens or others regarding trifocal lenses like the Finevision or the AT Lisa trifocal.
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Avatar_n_tn
Thank you so much for the detailed response, truly appreciate it.  I will look at the articles you have mentioned and yes, I think putting off surgery until I can at least find out what I am actually getting is a great idea. I live in the U.S and the doctor I met with for the multifocal did talk about the accommodating lens but said that his father had gotten the accommodating lens and that it hadn't worked as well for near vision.  That doc actually suggested that if I wasn't sure about the multifocal to go for distance vision in both eyes and have a piggy back (?) lens in one eye for presbyopia correction.  
Also, can I as a patient request a particular brand/lens?  The doctor's office that I have scheduled surgery with says she only uses Alcon Single Vision Lens.
Thank you again.
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Avatar_m_tn
It is true that the accommodating lens might not work for near vision.. but a monofocal set for distance definitely wouldn't. The Crystalens is often done with some amount of monovision. The issue is basically that it is at least a better bet than a monofocal since there is  a chance it may work, but to be prepared that it won't. I preferred the idea of a multifocal or the extended depth of focus lens that I wound up with.

It seems like its simpler  just to have one lens in each eye rather than complicating things with a piggyback lens on one.

re: "request a particular brand/lens"

It may be that the doctor has good reasons for his choice,  but there is a risk he doesn't. Unfortunately not all doctors keep up with all the options, some doctors just find something that works "good enough" and stick with  it. Most patients don't educate themselves enough to know the difference so they don't need to. It may be that his choice of lens is good, but it seems to make sense to be sure before making an important choice like that.

I'd suggest researching the options and talking to  the doctor about things like the Abbe number and risk of glistenings and whether other brands might be better.   (or emailing perhaps to provide links and give him time to check on things).  Presumably the doctor should have good answers to justify his choice of lens. If another lens seems better and he wasn't aware of it, presumably he will consider it. If he doesn't provide reasonable responses to questions, or make a different choice if something else seems better,  you can go to a better doctor who will.

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Avatar_n_tn
Do you have an accommodating lens implant?  Does that work well? or do you have the multifocal?  The other doc suggested using the Tecnis multifocal with limbal relaxing incisions to correct the very mild astigmatism in that eye.
I read the articles you directed me to, thank you, and the offices of one of the doctors mentioned in the articles is fairly close to where I live so will try to see if I can get a consult.  
Thanks again.  
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Avatar_m_tn
I have neither, as a thread I started explains I have the Symfony lens, which is a new category of "extended depth of focus" lenses. The Symfony isn't available in the US yet, I had to go to Europe last month to get it. Among US based multifocal lenses it does sound like the Tecnis is the best to look at, and I gather they either have just released, or are about to, a version with a lower power add which makes it better for intermediate vision (e.g. computer and social distance) even if slightly less good for nearer tasks.

It does sound like among monofocals the Tecnis brand might also be the one to look for, though I'm curious about the new Hoya monofocal that has a bit of "extended depth of focus" I posted about in the thread for the 35 year old woman looking for lens options. It doesn't have as much depth of focus or other features as the Symfony, but is likely at least better than a monofocal.

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Avatar_n_tn
I read up on the Symfony, looks like the FDA is looking into approving it in the near future.  I did take your advice and wrote to the doctor and was pleasantly surprised that she called me within the hour before office hours and talked to me at length about the procedure and her choice of lens for me which was very reassuring.  Thank you for the suggestion.  
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Avatar_m_tn
re: "Symfony, looks like the FDA is looking into approving it in the near future. "

Unfortunately the FDA's idea of "near future" isn't the same as other people's, a decent publication said:

http://ophthalmologytimes.modernmedicine.com/ophthalmologytimes/news/us-surgeons-anticipate-new-iols?page=0,1
" The FDA Phase 3 study is already underway so that if all goes well, the Symfony IOL might be available in the US by late 2016 or early 2017 "

However it is possible that is optimistic given past examples where there were claims that something might be coming soon and it either took much longer, or never was approved. The FDA tends to be far too conservative since they figure they are more likely to be attacked if there is ever a problem with a product than for a product not being available. In addition they get pressure form companies with existing products that don't like competition from new ones.

Once a product is on the market, then it seems to be easier to get different minor variants approved, like different add powers, so predictions regarding the approval of variant products and minor updates seem to be more reliable.  Then again there are are other Tecnis lenses on the market here, even if they are different designs, so it is possible they have the political clout to get it approved in a decent amount of time.
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Avatar_n_tn
Going with monofocal.  Doc said she will set it for intermediate vision with a 1.5 add on. Hoping it is the right choice.  Thanks for all your help.
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