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Cataracts and astigmatism of 1 diopter in each eye - is Toric IOL warranted?
I am a 56 year old female. I had great vision and only needed reading glasses till last year. Last year my vision became blurry for distance and funnily I can see really well upclose and don't need reading glasses. When I went to the ophthalmologist she indicated that I had cataracts in both eyes. On further examination she indicated I also had astigmatism of 1 diopter in each eye. The options for IOLs are toric/multifocals, toric monofocals or plain monofocals. I have done quite a lot of reading on multifocals and it suggests that multifocals come with a lot of issues. Therefore the other 2 options are toric monofocals or plain monofocals.
Given the mild astigmatism I have I was wondering if the toric monofocals would even be noticeably better than the plain monofocals.
Here are some of my eye exam results:
Eye Measurement
Eyeglass:
OD -2.00 +1.00 x 082
Add: +2.25
DCC NCC
20/60 -2

OS -2.75 +0.75 x 081
Add: +2.25
DCC NCC
20/60 -1
Manifest Refraction
Eye Measurement
OD -1.75
Add: +2.50
DCC NCC
20/40 -1 J4

OS -2.75
Add: +2.50
DCC NCC
20/40 -2 J4

Thankyou for your input
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177275 tn?1511758844
This question is posed and answered in greater detail in my blog on important factors to consider before cataract surgery. This is a link to this authors posting:  http://www.medhelp.org/user_journals/show/841991
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The fact that you say you "only needed reading glasses till last year" calls into question whether part or all of the astigmatism is from the cataract, especially if the catarct seems to have   impacted your prescription to make you myopic. Its possible  you did have the astigmatism before and it just wasn't causing enough issues to bother correcting it. Did you have prescription readers before, did they have a correction for astigmatism?

If the cataract is inducing the astigmatism, then it may be you don't actually need a toric IOL or other astigmatism correction since the astigmatism goes away when the natural lens is removed. When my cataract first appeared in one  eye at age 49 it went from -0.75D to -4D of astigmatism within 3.5 months, while a corneal scan, rounding to nearest 0.25D showed only 0.25D of  astigmatism. That reduced a bit over time  before surgery (with the eye getting far more myopic instead). The more precise reading at the preop visit the week of surgery showed only -0.17 of astigmatism in that eye, and I got a spherical IOL and postop all my  refractions have shown 0D of astigmatism for that eye.  

Even if the cataract isn't shifting the astigmatism, the prescription doesn't tell how much corneal astigmatism you have. The refraction is the result of the entire eye acting as a lens, and there can be astigmatism on the cornea but also in the natural lens itself. Unless a cataract is impacting it,  lenticular astigmatism is usually fairly small, but it could be in either direction so it might counterbalance corneal astigmatism, or add to it.

If they did a corneal scan that might give a clue how much astigmatism you have, though sometimes they won't be measuring "total astigmatism" until he preop visit since many corneal scans used for other purposes only measure anterior corneal astigmatism, the surface of the eye. Surgeons used to assume posterior corneal astigmatism was small enough to ignore, but they figured out  unexpected levels of postop astigmatism were due to posterior corneal astigmatism that wasn't being measured. Not all equipment measures it still, so ideally you'd have a doctor with up to date equipment to be sure they are measuring posterior corneal astigmatism as well.

If your prescription astigmatism of 1D and 0.75D were your actual corneal astigmatism, those are in the range where it depends on the surgeon how they'd prefer to correct it. Some prefer to  correct  low levels of astigmatism   via surgical incisions which cause the eye to reshape (often LRIs, Limbal Relaxing Incisions), which can be less predictable, while others prefer toric IOLs. It may partly depend on if they are using a laser to make more precise incisions which they prefer.  

Low levels of astigmatism can extended depth of focus a bit, which can be useful with a monofocal, but as it grows the blur outweighs the benefit.  With premium IOLs they tend to want <= 0.5D of astigmatism postop. (although my first eye has 0D cylinder, my 2nd eye was at -0.5D initially postop, but last check -0.25D).






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In terms of "it suggests that multifocals come with a lot of issues. ". The vast majority of people are happy with multifocals, the issue is merely that a minority of people have problems so that needs to be taken into account. In my case having a cataract at an atypically young age, I decided the high odds of having more useful vision for what might be a few more decades  (at your age you have almost 30 years more expected) made it it worth the tiny risk I'd need a lens exchange for a monofocal (with the very slight risk that adds).

It partly depends on how much you value not needing to wear correction. I was extremely nearsighted and needed contacts/glasses for everything before surgery. I figured if I were going to need surgery anyway, it'd be nice to not need correction the rest of my life, e.g to never need to worry about not having it during an emergency or accident, etc.

It also depends on how much you like monovision. Usually when people have cataracts that are ready for surgery their vision is too reduced to be able to get an accurate test of options, otherwise a contact lens test of contact lenses in monovision, or multifocal contacts, would provide at least some clues about preferences (even if they aren't the same as IOLs would be).  I liked monofocal contacts and didn't notice any loss of depth perception, but when I switched to multifocal contacts I'd seen the world get subtly more 3D than it had been. I also figured planning for the future that some studies showed a slight risk of falls in the elderly for those with monovision corrections or those wearing progressive glasses or bifocal glasses. Even now I figure when jogging/hiking on rocky trails its likely useful to have crisper vision with both eyes.

I went with the Symfony, which is an extended depth of focus lens rather than a multifocal. Some surgeons confuse it with  a multifocal since it also provides more near then a monofocal, and uses diffractive rings, but it uses diffractive optics differently and so it has a low incidence of night vision artifacts. The risk seems to be comparable to monofocals, but not as low as the best monofocals like the Tecnis control it was studied against. e.g. see:

http://www.healio.com/ophthalmology/refractive-surgery/news/print/ocular-surgery-news/%7B02f433be-622c-4611-94b5-77900b429e20%7D/high-rates-of-spectacle-independence-patient-satisfaction-seen-with-symfony-iol
"High rates of spectacle independence, patient satisfaction seen with Symfony IOL"

and here is a recent publication that asked what some surgeons would use if they needed cataract surgery:

http://www.ophthalmologymanagement.com/issues/2017/march-2017/when-the-surgeon-must-choose

In my case I was planning to go outside the US to get a trifocal that wasn't approved here, and then the Symfony was approved in Europe a couple of years before it was available here  and I  figured it was a better fit for my needs. I had both eyes done in the Czech Republic for less than I'd have spent for my deductible if I'd gotten it done here, including travel (and technically one eye wouldn't have been covered since its cataract wasn't yet advanced enough, it was clear lens exchange).

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I should have noted that > 480,000 people/year have premium IOLs, so only a tiny fraction of them having problems leads to the complaints being visible online since most people  only post when they have problems so its easy to get a skewed view of the prevalence of issues from the net. That said, again its important to be prepared that issue might arise so there is need to be prepared for  a very tiny chance of need for a lens exchange.Everyones risk preference is different, and the importance they attach to being spectacle free.
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Thanks so much for the information that you have shared on your experience!!

The eye exam results are from my pre-op - so I am assuming the data is that of 'total astigmatism.

I have not given my eye doctor the go-ahead on the surgery since I am still researching the various options on lenses.

The symphony lens option seems very interesting to me. Do you know of any eye doctors in Houston, San Antonio or even Canada that have experience with these kind of lenses?

What was the total cost of your surgery for both eyes?
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If you haven't given go ahead for surgery, then I'm uncertain that whatever exam you had was the actual pre-op exam which is usually done the week of surgery (though it can be done within some weeks of surgery in theory, usually its done that week).

The results seemed to be from a refraction and your prescription rather than from some sort of eye scan.  Since not all surgeons even have the equipment to measure the total corneal astigmatism, including posterior astigmatism, you can't assume it is total corneal astigmatism unless you've confirmed it.

I had a special deal on my treatment since I was the first one to get the Symfony there (which I wasn't concerned about since it was physically the same to implant as the other widely used Tecnis lenses, and this surgeon was very experienced), but in general in the Czech Republic, a common medical tourism destination for those from the UK (less so from the US) it ranges from $1200-$2000  per eye or so last I heard, depending on options like lens choice and whether to use laser cataract surgery (which I didn't see a need for).

I don't think Canada is any cheaper, Mexico might be. At the time I had to get my surgery the Symfony wasn't yet approved in those places so I didn't seriously consider them. I also wanted to make sure I could decide at the last minute between a trifocal and the Symfony, which was a close call for me (none of the trifocals are approved here yet, but I saw recently that some are finally in clinical trials for approval). The Symfony was new enough there was less data out there about it, so I guess I keep checking on more recent studies to confirm I made the right choice, and they all seem to back that up, though a trifocal would have been a good bet also.

I didn't explore surgeons in the US since I had to go elsewhere.  I did happen to be in touch with someone who moved to Texas who was considering the Symfony and I did  recall seeing a surgeon in Austin who has been quoted on the Symfony, a Dr. Steven Dell, who is also the chielf medical editor for the trade publication Cataract and Refractive Surgery today. I don't know if that is close enough, I'm sure there are good surgeons in whichever city is closest.

Here are some articles that turn up in a quick search that mention Dr. Dell and the Symfony:

https://www.eyeworld.org/download/file/fid/25

http://crstoday.com/articles/2015-sep/whats-new-in-presbyopia-correcting-iols/

https://www.eyeworld.org/article-ascrs-members-weigh-in-on-presbyopia--correcting-iols-for-cataract-patients

http://ophthalmologytimes.modernmedicine.com/ophthalmologytimes/news/extended-depth-focus-iols-expand-surgical-options?page=0,2
"Studies that asked patients with early-generation IOLs if they would pick the same IOL type again, 92% said “yes,” compared with 97% who have more modern IOLs, said Steven J. Dell, MD, medical director, Dell Laser Consultants, Austin, TX. The same percentage of people (97%) said they would choose to have the Symfony again, which Dr. Dell thought was an interesting comparison."

In February there was a supplement issue on the Symfony:

http://crstoday.com/articles/2017-feb/supplement-2/


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Yes it was pre-op exam - because I was going to get the surgery done the following week. However it had to be cancelled because the lenses she was recommending were not available (I am glad!). At this point something didn't seem quite right and I started researching all options ( I should have done that earlier!)

At the pre-op my eye doctor indicated verbally that I had corneal astigmatism of 1 diopter in each eye. She still has not given me the results electronically or on paper. Her office indicated that they will give me the results next week.

Thank you for taking the time to answer my questions. Currently she indicates that the standard surgery with the standard lenses is going to cost me $5000 per eye (my deductible is $10,000). I would then have to pay extra for premium lenses.

She had not even suggested Symfony - the only one I heard from her were the Restor ones.

Please provide any input that I should consider when choosing my lens and the surgeon.

Thanks once again!
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177275 tn?1511758844
I just posted on the IOL blog. Those prices are out of sight. In Kansas City surgical fee, IOL (monofocal), anesthesia, and surgicenter fee comes to about $1733
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Thanks so much Dr Hagan!! I did read the blog just now - it is so incredibly informative!
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177275 tn?1511758844
excellent
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That price is very low. Prices seem to very drastically by region from what I'd seen before. I don't have a link offhand showing that well, but out of curiosity, here is one source that seems credible for national averages:

http://www.allaboutvision.com/conditions/cataract-surgery-cost.htm
"In 2015, the average cost of cataract surgery with a standard IOL performed in the United States for someone without Medicare or private health insurance was $3,542 per eye. ...
For example, if you want a presbyopia-correcting IOL to reduce your need for reading glasses after surgery, the average added premium for this type of intraocular lens in 2015 was $2,178 per eye.

In 2015, the average premium for a toric IOL was $1,310 per eye....
In 2015, the average premium for LRI for astigmatism correction was $584 per eye...

In 2015, the average premium for laser arcuate incisions for astigmatism correction was $1,136 per eye."

Though this source cites a 2011 figure of $5096 for what I'm guessing is just monofocal surgery (or average of all surgeries, and most are monofocal):


http://www.sciencedirect.com/science/article/pii/S0187451914000778

Another source  claims:

http://health.costhelper.com/cataract-surgery.html
"For patients not covered by health insurance, cataract surgery typically costs $5,000 to $10,000 per eye, for a total of $10,000 to $20,000 for both eyes. For example, at Park Nicollet, a hospital in Minneapolis, Minn., it costs about $4,365 per eye -- a total of $8,730 for both eyes. At Dartmouth-Hitchcock Medical Center[1] in New Hampshire, with an uninsured discount, it costs about $7,140 per eye -- a total of $14,280 for both eyes."


This medical tourism site:

https://www.treatmentabroad.com/costs/eye-surgery/cataract-surgery?fromCountry=211&totPeople=1&sortBy=sortCountry&currency=USD

gives an average price for a few countries, in the Czech Republic it gives  $1086/eye, which is presumably for a monofocal (I was assuming a premium lens in the range I gave above I realized). In my case since the trifocals and Symfony weren't approved here at the time, the US wasn't an option.
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In terms of choosing a surgeon, some cities, like nearby here in Denver, have "best doctors" lists published by a city magazine or local newspaper which are based on asking doctors who they would go to for treatment (assuming they are better able to figure out who is best than the general public). There is a national source or two I think that does that and provides the information for a fee  to some publications or insurers who might make it available, but I don't recall that you could pay for it yourself when I checked, and I don't  remember company names offhand , I'll let you search.

Although some worry that doctors who do clinical trials might be biased towards a company they work with, I figure that lens companies wouldn't wish the results of clinical trials to be tainted bad surgical results so doctors who participate are likely at least competent (though I hadn't confirmed that speculation). Doctors who are on faculty at medical schools, and/or are asked for their views at conference panels are likely respected by their peers for their medical judgement (which is separate of course from physical surgical skill, though presumably teaching requires competence at demonstrating surgery). You want a surgeon that has a decent volume, aside from practice makes perfect in general, I'd seen one sources citing that those who had (I think I remember the figure as being something around this, not positive) > 1000/surgeries a year (might have been 1500) had better results with fewer complications. The more surgeries they've done, the higher the odds they've seen some unavoidable complication before.

I tended to like the idea of surgeons that kept up with the latest technology to show they kept up to date with their field, though sometimes as with laser cataract surgery the technology is new and cool but hasn't yet proven its benefit for the average patient. (my surgeon had a laser, but agreed it wasn't really needed in my case,that the benefit was more consistent results for less experienced surgeons, once they were past the initial laser learning curve,  but not a big deal for an experienced one for a typical case).
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Thanks Softwaredeveloper!

I really appreciate all the information you and Dr Hagan have provided!!

After much reading I am looking to investigate the symfony IOL

I was wondering what you and Dr Hagan thought of the Sympfony IOL VS the minimonovision in my case
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177275 tn?1511758844
I don't have much more to say. No one size fits all. Most people are very happy with a monofocal IOL. It's less expensive, fewer complications, better optics.  Some people hate glasses and will do anything, pay any price not to wear them. They often do well with multifocal, accommodating or newer technology like synfony lens. I don't need cataract surgery but if I did I would have a toric IOL put in by one of my associates. I have 2 diopters of astimatism.  So going forward you need to make your choices of what is best for you, not me, not SD,  It's just like automobiles some people are happy driving Fords or Chevy's, some people F-150's and some Lamborghini's.
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Yup, as the doctor said you need to figure out what is best for your needs, everyone's needs and risk preferences  are different. If you get a premium lens, you do need to be prepared for at least some slight risk of needing a lens exchange, even if its unlikely, someone winds up being the "statistic".  

Some people go for a monfocal hoping for  the absolute crispest distance vision, figuring they can correct to other distances with glasses, though its questionable if most would notice the difference with the Symfony. A presentation I saw (don't have the link handy, Dr. Holladay I think)  indicated that although in theory it might be better, in the real world studies show the typical best corrected vision with an aspheric monofocal is like 20/17 vs. 20/18 with the Symfony, 20/20 with a spheric monofocal (which doesn't tend to be used now), or 20/22 with a diffractive multifocal  IOL. However what is most important in this case is uncorrected vision and the Symfony's extended depth of focus makes it more tolerant of the power being off so that  is why at least one study I saw suggested the Symfony had better uncorrected distance vision (though usually the studies just put them as comparable). Also of course even with a monofocal you aren't looking at exactly the best focal distance, which means that for other distances you aren't getting that theoretically best vision.

It depends for instance how much you want really near vision vs. intermediate, since for some people the low add bifocals are a good bet since they provide a little more near than the Symfony, but with a bit higher risk of night vision issues. The new lower add bifocals seem to be a better bet than older multifocals (as are the trifocals outside the US). Others do a mix and match of the Symfony and a bifocal, or even the Symfony and a monofocal.


Most people adapt   to monovision, I liked contact lenses in monovision, I merely liked multifocal contacts better which is why I initially planned on a trifocal (before the Symfony came out).  I liked the idea of having a larger range of vision in each eye, for instance if i ever had some accident that caused problems for one eye then it seems useful to have a larger range of vision for the other to reduce the need for correction.

Many use the Symfony with micro-monovision, where the difference between the eyes isn't enough to have much impact on stereopsis or distance vision, but provides a slight bit more near.  

One issue with having a noticeable amount of monovision is that if you ever want crisp vision for both eyes for some distance, that you'd need prescription glasses since the eye's are different (vs. say off the shelf readers, which would only focus 1 eye at a particular distance).
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Thanks so much SD!

I am still researching surgeons in the San Antonio area and now will have several questions to ask them.

Also if I did go with Micro monovision is there a particular brand/make that I should look into more than others?

Appreciate all your help!

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177275 tn?1511758844
With mini-mono you would be getting a monofocal or toric IOL. You generally do not have a choice of brand models like you do when you pay extra for multifocal/accommodating/Synfony type IOLs.  All the standard IOLs in US are high quality and most all are of aspheric optics.
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With a monofocal it'd likely be more "mini monovision" or full monovision, though there is no exact standard for how much of a difference each term refers to. Micro monovision is usually more for something like the Symfony or the Crystalens. The Crystalens is another option, but although its a single focus lens which may accommodate a bit, some study data suggests that it may have a higher risk of halo&glare issues than the Symfony (but I've seen no direct head to head comparisons, and comparing different studies can be problematic since the patient demographics and surgical results may differ), and it has higher risk of certain complications, and although the near data seems somewhat comparable, the reports I've seen are that more people need readers with it. Although I didn't consider it as good an option, some folks prefer the idea of a simple single focus lens that might accommodate.

Doctors differ in terms of which of the major brand monofocals they like, the differences tend to be minor so there tend to be few studies comparing them and less debate over the issue. The higher abbe number of the Tecnis monofocal provides less chromatic aberration, and some surgeons I've seen overall tend to prefer the Tecnis, but the Alcon has a large marketshare. The Alcon lens is subject to glistenings, but there seems to be dispute over whether ever would have any noticeable impact on visual quality so it may be academic.

The Alcon IOLs tend to be blue blockers, which many surgeons consider marketing hype, though obviously some think its of value.  My reading suggested it wasn't something I should be concerned so I didn't factor that into my decision making.

There are some claims that certain monofocal IOLs like the Lenstec HD (and I think perhaps another I can't remember offhand) provide a slight bit more  depth of focus than other monofocals (but not as much as a premium lens), but I haven't checked on the data to confirm it, and I don't know how they compare in terms of other factors like risk of PCO, etc.  I  recall someone saying they may charge more out of pocket for the IOL despite it being a monofocal.

There is oddly a Hoya monofocal IOL, the gemetric that did have good data indicating an extended depth of focus from a Dr. Graham Barrett in Austrailia, but weirdly after going to the trouble to get it FDA approved, as far as I could discover it was never actually put on the market here.

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FYI, for those who haven't read it on other pages, my results with the Symfony are at least 20/15 at distance (they didn't have a line below to test and that one was easy), and at 80cm 20/20 plus a bit, and best near has been 20/25. They tested at 40cm and it was 20/30 but they didn't have a 20/25 line on that chart  and since I saw the 20/20 line a bit, I'm guessing its 20/25. (i really should just get a near eye chart). Unfortunately of course results will vary by person, even studies only show averages.

I am one of the small minority that see halos, but I've never considered them a problem since they are so translucent/mild that I see through/past them, and to counter balance that the brightness of the headlights seems far less distracting than in the past, less glare disability, and so overall my night vision just feels better than it was in the past. I likely have some reduction in dim light vision, like a dimly lit restaurant, but it is noticeably better than when I wore multifocal contacts.  I compared vision with someone here who has the Crystalens who is about the same age, and oddly he has more issues with dim light than I do. If he holds a folder over the near chart in a well lighted room, that reduces his near by some lines, but had no impact on mine.
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In terms of choosing monofocals, I just saw a news article about a meta-study (study of multiple studies) about the issue of blue blocking IOLs, which notes in summary:

http://ophthalmologytimes.modernmedicine.com/ophthalmologytimes/news/evidence-weak-blue-light-filtering-iols
“On the basis of currently available evidence, one cannot advocate for the use of blue-light-filtering IOLs over UV-only filtering IOLs,” wroite X. Li, Waterford Institute of Technology, Waterford, Ireland, and colleagues. "

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Here are some recommendations I got from doctors when I had emailed them last year.

San Antonio - Harrison Bowes,
Charles Reilly,
James Lehman.

Bill Flynn:  http://www.rashidriceflynn.com/doctors.html

Dr. Robert P. Green, Jr., at 414 Navarro

Dr. Dudley H. Harris, at 800 McCollough

Dr. Nader Iskander, MD  
https://mysaeyes.com/about/

Dr. Gregory Parkhurst, MD

Houston: Dr Stephen slade, Michael Mann, Douglas Koch

Austin, there is Steven Dell.
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FYI, I see a comment on another page which references surgeons in Houston. Search this page:

http://www.medhelp.org/posts/Eye-Care/One-month-post-op-cataract/show/452336

for Jodiej's comment, which has a new reply which confirms one  recommendation, and her posts gives   a source for doctor options.
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177275 tn?1511758844
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Kansas City, MO
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Grand Prairie, TX
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San Diego, CA