Crystalens HD IOLs for cataract surgery?

[askadvice]

I am scheduled for cataract surgery in both eyes.  Best IOL my doc recommends and uses is ReZoom (he also works with Tecnis).  I read on the web that Crystalens HD has just been FDA-approved in June 2008 and is the superior product on the market.  I would be grateful for any advice.


This discussion is related to Restor Lens: Potential problems.

[Michael J Kutryb, MD]

Rezoom tends to have have the most undesirable side effects and the most severe side effects especially glare and halos and innability to drive at night.  Crystalens tends to give very little near vision and most patients end up neading reading glasses to some degree.  PLEASE don't belive everything you read through press releases and advertisements.  Strongly consider aspheric monofocal like Tecnis.

MJK MD

[askadvice]

Thank you Doctor.   My doc performs 'standard' surgery (which my insurance pays for), Tecnis at an additional fee, and ReZoom at the highest fee.  I had not even considered the 'standard', but am now wondering how you might consider that surgery - Tecnis definitely preferable to standard?  Thank you.

[JodieJ]

The Tecnis aspheric monofocal IOL is "standard" and should not involve an additional fee.  But standard in this case does not mean "less good."  An aspheric monofocal IOL like Tecnis is really "state of the art."  You can get more info about this type of IOL by watching the patient information video at www tecnisiol com.  Alcon and Bausch & Lomb also make excellent aspheric monofocal IOLs.  

[2ndsight]

I have had a very positive outcome with Crystalens. It will not provide complete independence from glasses but I need them generally only for small print and reading the computer. It definitely provides good close-up vision without glasses for closer-up tasks  such as seeing the car dashboard, cooking, makeup/shaving, shopping (sometimes I use glasses to read small print on labels) but just generally getting around doing normal activities I don't need glasses.

[askadvice]

Thank you for your reply.  I called my MD's office and was told that for 'standard' he uses Bausch & Lomb L16IU which would provide good  distance vision, but I will need glasses for reading. Is this considered a Crystalens as it is made by B&L?  Are you familiar with it and do you know if it provides the same results as the Tecnis monofocal lens?

The Tecnis he uses btw I was told is definitely a more expensive lens requiring additional $600+ per eye over the Medicare pay, so I assume it is a multifocal lens (neglected to ask them).  ReStor and ReZoom are much higher.

Also, is an acrylic lens preferable to a silicone lens?  Thanks a lot for any info you can give me.

[askadvice]

Thanks for your input.  Is your Crystalens an aspheric monofocal and do you have sharp distance vision with it for driving?  The new Crystalens HD sounds promising, but is too new on the market to get any feedback from patients for quite a while. After doing quite a bit of research now I am pretty sure I'll go with the aspheric monofocal IOLs and not the multifocals.  

[JodieJ]

I don't know the Bausch & Lomb IOLs by number.  If the L16IU is an aspheric IOL, then it's a very good lens.

I don't know where you're located, but the Tecnis multifocal IOL is not available in the USA.  I've never heard of an American surgeon charging a $600+ surcharge for the Tecnis monofocal IOL.  You might want to get a second opinion about what would work best for you.  I'm a little uncomfortable with your surgeon's top recommendation being the ReZoom.  I'd leave the choice of acrylic vs. silicone to the surgeon.  Unless you have a history of retinal disease (in which case an acrylic IOL might be preferred), probably either would be fine.  

[2ndsight]

Crystalens is not an aspheric monofocal, it is called an "accomodating" lens because of its ability to focus at all distances so it is classified as a multifocal, but does not have 3 planes like ReStor.  From what I have read about the new HD, it incorporates a small aspheric section which is somehow supposed to enhance close-up vision.

yes I have very sharp vision for driving as well as at every distance. I only need glasses to read small print and text on the computer screen.

[askadvice]

Thanks for your comment on B&L #l16iu and Tecnis IOLs.  I now have learned that this particular B&L that my MD uses as a 'standard' is not a Crystalens; it is another type of lens made by B&L, and it is a spheric (not aspheric) monofocal IOL.

The Tecnis he uses is an aspheric monofocal.  The additional cost that he charges  ($620 per eye over and above what Medicare pays) I was told is not for the lens, but for the additional measurements he has to take.  Is that normal procedure?

From all I have read I think the Tecnis aspheric monofocal is probably the better IOL for me, preferable to the B&L spheric monofocal (though I don't quite understand the difference between spheric and aspheric IOLs), as it would give me better distance and night vision;  also good intermediate for computer, dashboard etc.?  I am ok with glasses for extended reading and small print.   I appreciate any advice.

[JodieJ]

No, it is not normal to pay a $1240 surcharge (both eyes) for Tecnis monofocal IOLs.  I've never heard of such a thing.  I can't imagine what "additional measurements" your doctor is referring to.  You might want to re-post your question in order to get feedback from one of the forum ophthalmologists.

An aspheric monofocal lens might give you a slight edge over a conventional IOL in terms of better distance and/or night vision.  However, no monofocal IOLs will provide good intermediate vision unless you chose to set them for (modified) monovision.  This type of correction could be done using either aspheric or conventional IOLs.

I still think that it would be well worth your time to get recommendations from a second cataract/refractive surgeon before proceeding.  If you live in the USA, you can use the directory at www.aao.org to find a board-certified surgeon.  

[FredZq]

"The Tecnis he uses is an aspheric monofocal.  The additional cost that he charges  ($620 per eye over and above what Medicare pays) I was told is not for the lens, but for the additional measurements he has to take.  Is that normal procedure?"

Total crock! Flee this place! What extra measurement? They have to do the measurement for every lens. I have the Technis aspheric monofocal 2 months now. After much research, I decided that was the way to go. As far as a multifocal allowing you to be glasses-free...well I'd be skeptical. Hells Bells, I' m happy enough not to be going blind, but the surgery and IOL job my Doc did is a OK. Clear vision, sharp vision, no problems with night driving, no problems with peripheral vision. Fixed focus at 11". So I have to wear specs. Small price to pay for none of the problems associated with multifocal IOLs. My $0.02.

[askadvice]

Thank you for your advice.  I have earlier today re-posted my question  "Q for MD: Charges for Tecnis aspheric monofocal IOL", but have not had a reply yet.  I hope one of the MDs on the Forum will answer my questions.  My eye surgeon's office stated that they are allowed to charge this extra 'professional' fee.  Thanks again for your help.

[Ms_MJ]

I just got back from an appt with a surgeon; I need cataract surgery.  Dr was opposed to Rezoom, and recommended ReStor over Crystalens.  He said crystalens is "modified monovision" because in one eye the aim is for close up vision and in the other it is for distance.  He thinks that if a truly independent study was done comparing Crystalens with standard IOL with monovision (one for close up and one for distance), there wouldn't be an appreciable difference.  And, it would be much cheaper.

He said that while some of his patients are very happy with Crystalens, some are unhappy with the poor quality of close up vision.  Also, he says that the crystalens isn't as accomodating as the literature would have you believe, although the recent crystalens HD is an improvement.


I do a lot of reading and have been nearsighted all my life.  I would hate to have to wear reading glasses, so he said ReStor would be best for me.

[JodieJ]

Probably your surgeon is correct:  Monovision with aspheric monofocal IOLs is at least as good (and probably better) than the Crystalens.  But I'd predict the same winner in a contest between monovision with aspheric IOLs vs. ReStor.  ReStor is associated with many problems, including night vision difficulties (glare, halos). poor intermediate vision, "waxy" (Vaseline) vision, and a very long adaptation time (up to a year).  If you've never done monovision, you should attempt a trial with contacts first.  It's a little difficult to get used to initially, but the majority of people end of loving it.

[bstaggs]

I can't say how a Restor would preform against a monofocal IOL since I don't have a monofocal IOL , but I can say that the Restor I have (Restor in one eye & Crystalens in the other) works pretty much as advertised.  Great close vision (I can read very small print) and distance vision is very good.  Mid range vision is not as good as the Crystalens ( I would need glasses to use the computer if I only had the Restor) and I do get the halos from pointed light sources. ( I will try and post a link to a graphic which shows pretty much what I see @ night with the Restor, but I think I have had trouble posting links here before, so no promises)

http://www.staggs.net/images/halos.jpg

www.staggs.net/images/halos.jpg

While they (the halos) did take some time to get used to, they are nowhere near as bad as the glare I get from the Crystalens and night driving is not a problem.  I have not experienced the "waxy" vision or low light contrast problem that some have. Unlike the Crystalens, they have worked from day one.

Based on my own experience (Your mileage may vary), If I could not have the combination that I now have (which has me glasses free but at the cost of Crystalens side effects) I would take the Restor over the Crystalens as I would then only need glasses for computer work.

Jodie:  not sure if you are aware, but I "believe" the newer Restor are "Aspheric" as well.  At least that is what I gleam from the specs I have read and also the Alcon website. Assuming that is what "Positive Corneal Spherical Aberration: Aspheric Optic" means.  Am I incorrect?

http://www.acrysofrestor.com/acrysof-restor-iol/restor-aconstant.asp

www.acrysofrestor.com/acrysof-restor-iol/restor-aconstant.asp

[JodieJ]

Yes, the new ReStor multifocal is aspheric, which reportedly gives a little boost to distance vision (over the older model ReStor).  However, it still incorporates the light sharing feature that is inherent in all multifocal IOLs.  Only a fraction of the light entering the lens is used to produce an image,  This is what is responsible for the loss of optical quality (as opposed to a monofocal IOL) and the complaints about glare, halos, "waxy" vision, etc.

Although monovision works for most people, it's not for everyone.  I'd expect that monovision would provide better quality vision overall (and better distance and intermediate vision), with a MUCH lower incidence of post-surgery problems (glare, halos, etc.)  ReStor might be better for reading very small print.

[cdn_glenn]

I have multifocals (Tecnis not ReSTOR) and also have had excellent experience with them.  Both day and night vision are excellent.  It is wonderful to see both near, fine detail and distant scenery.  I do miss the mid vision, but have adjusted my life around it.  Halos at first were an issue, but I rarely see them now except around distant lights at night; also prominent around halogen headlights.

Nice photo of the halo.  They were that strong at the beginning.  Interestingly I could not see anything but them.  Now not only are they less prominent, but I look through them.

Several posters on MedHelp reported waxy vision.  I'm not sure JodieJ's hypothesis (I'll address that shortly) is the reason.  I did have waxy vision -- not certain this is exactly what JodieJ is referring to -- in one eye for a couple of weeks after surgery.  It simply went away.  There was a mention of "lack of contrast" and in my experience there was no lack of contrast.

bstaggs:  How do you find the contrast in your ReSTOR eye now?  I actually have greater contrast with my Tecnis multifocals due to the nature of the IOL.

[cdn_glenn]

I don't understand where you equate "light sharing" with "loss of optical quality".  I have read a similar discussion regarding multifocal contact lenses and there is some consensus this is true for multifocal contacts.  However, from first hand with multifocal IOLs is that when I see clearly it is very clear.

Both the ReSTOR (first 3.6 mm) and Tecnis (all 6 mm) multifocals are diffractive.  They focus both near and distant images on the retina, and leave it to the human mind to separate.  You mentioned that, "Only a fraction of the light entering the lens is used to produce an image."  If this were so I would be living in the dark.  But to clarify my surgery was for a CLE.  There was definitely a drop in light throughput between the natural lens and the IOL.  The best way I can describe it is "ten watts".  The bulbs in my living space were 60W long life incandescents -- I think that works out to 51 watts of light output to give those bulbs the long life.  I had to do a fair bit of shopping and trial & error until I found the perfect bulbs to replace the ones I was used to.  I now have the compact florescent equivalent for everything updated.

I will agree that the same split image seems to be the cause of glare, halos, ghosting etc.  Again many seem to neuroadapt to these issues.  Some never do.  Time seems to be the greatest issue.  They simply don't work 100% immediately.

JodieJ:  I would like a clear definition of "waxy vision".  I have experienced something I refer to as waxy vision.  Several people have reported this.  For some it has also gone away with time.  There were a few where I also would have been concerned after that length of time.

For the ReSTOR I'm still wondering if waxy vision is associated with pupil size.  The ReSTOR lens uses two strategies: the first 3.6 mm are diffractive multifocal, but the outer ring is (I think) refractive set for distance.  There are two reasons why the outer ring being set for distance would be beneficial.  Firstly, when one looks at distant objects the pupil naturally dilates (I have to find and post a link to the same discussion I mentioned above) and secondly, I believe this might be a strategy to improve night vision.  The eye would default to the distance ring when the pupil is dilated.  Also this may be why many report difficulty with the ReSTOR lens in low light, yet others are unaffected.

Regards,
Glenn

[cdn_glenn]

I think this is the link for the discussion I was referring to.  It's on AC Lens Contact Lens Forums.  The resident physician Ag-i-doc describes the effects of annular and aspheric design on vision with soft multifocal contact lenses.

http://www.contactlensforums.com/default.asp?sub=show&action=posts&fid=7&tid=47648

[JodieJ]

There are many professional papers which discuss the light-sharing feature involved in multifocal IOL design.  One of the better ones is Howard Larkins' "Reduced contrast sensitivity will dim the future for multifocal IOLs."  (His discussion does touch on "waxy" vision.)  Try entering the following into Google:  multifocal iol light sharing.  

Unfortunately, it seems that everything that expands the range of focus for IOL recipients involves some kind of compromise.  Full monovision with monofocal IOLs sacrifices some acuity and depth perception.  Accomodating IOLs seem to have limited accomodation capacity.  All of the multifocal IOLs involve a loss of contrast sensitivity.  I think we need to establish our personal priorities and choose accordingly.  There's no "best" solution for everyone, but it sounds like you've found one that works for you.  

[cdn_glenn]

You said, "All of the multifocal IOLs involve a loss of contrast sensitivity."

I have proven increased contrast sensitivity with multifocals.  It is a design feature of the IOLs I have implanted.

I disagree with your generalization.

[JodieJ]

It's not MY generalization.  In fact, it was the topic of an address made last year by Dr. Woodhams to a session of the American Cataract and Refractive Surgery Symposium.

I realize that the Tecnis multifocal IOL is aspheric, which does improve contrast sensitivity somewhat.  But it's the the light-sharing feature inherent in the design of multifocal IOLs that I was referring to.  Please take a look at the paper by Larkins which I sited above.  It provides a far more articulate explanation than I could possibly write.

[bstaggs]

I was informed by my doctor (prior to surgery) that due to the nature of a multifocus lens splitting the light for more than one image, I should expect some loss of contrast and would probably need good light to be able to read.  Oddly enough that has not been the case. I have not experienced any contrast issues. I can even read a menu in a dimly light restaurant.  

Another issue that I find odd is that very often in an indoor situation where light is marginal and at distance (large Church or other venue) I can see more detail with the Restor vs the Crystalens.  I would have thought that since the Crystalens is essentially a monofocus IOL with the ability (or arguably, lack thereof) to move, and not dividing the light the way a multifocus does it would out preform the Restor in low light.  ??

[JodieJ]

According to the Larkins article, the loss of contrast sensitivity results in ghosting, "waxy" vision, halos, and a general decline in vision quality (i.e., loss of fine detail).  The impact is reported to be greater in low light conditions.  I can imagine that there are significant individual differences in visual experience.  (The gain, of course, is in the ability to see both near and far without glasses.)

Bstaggs, I've read that it's easier to read with ReStor in bright light.  Maybe your excellent reading ability is attributable to pupil size--who know?  ReStor is supposed to work best with small pupils, and you seem to have had an outstanding result with this lens.  Congratulations!  Is your vision plano with your Crystalens eye?

[cdn_glenn]

I know exactly what you mean regarding reading under dim light.  It's good.  It doesn't appear to manifest itself as a loss of contrast, as much as the text looking a touch unsharp.  That is under -extremely- dim lighting.

Regarding better distance vision with the ReSTOR eye vs. the Crystalens eye under low light conditions:  it's the design of the ReSTOR.  The outer ring is refractive, and focused for distance.  With a dilated pupil in you should be looking through that ring.  That also could reduce the amount of halos, etc. you encounter in night time situations.

http://www.acrysofrestor.com/apodization-diffraction/restor-lens.asp

It looks like your surgeon got your prescription spot-on for that eye.  Congrats!

[cdn_glenn]

Could you please provide a link to the Larkins article?  I would be interested in reading it.  Thanks.

[JodieJ]

www visiometrics com/abu/pdf/OQAS%20papers/Reducedcontrastsensitivity.pdf

I don't think this site might censor the link, even with the dots omitted.

Google the following sequence:  multifocal iol light sharing

You'll find the Larkins article at visiometrics com.

[bstaggs]

My vision from the Crystalens is as follows:

Distance is great except indoors under low light (large indoor buildings).  I believe this has gotten worse since the surgery. Doctor told me that I was going to need a YAG at my last visit but I am reluctant to comply.  

Mid range is super (details like I have never seen before) under all conditions.

Close up is not good.  I wouldn't be able to read a newspaper or a normal print book without glasses (Thankfully the Restor does this very well)  I can tell that it does try to focus, it just stops short of being able to pull it off.  Some have said that it may get better in time, but I am not holding my breath.  

Contrary to what others have experienced, I have much more side effects from the Crystalens (Glare, Flares & flickers) than the Restor (light Halos from pointed light sources only).  The side effects from the Crystalens might actually cause me to be reluctant to drive at night if that is all I had.  With the Restor I hardly notice anything at all.  

Honestly if I had only the Restor or only the Crystalens I would be less happy than I am now.  They seem to be complementing each other very well.  The Restor's weak point seems to be mid range and that is where the Crystalens is at it's best.  The only real shortcoming of the pair (other than the previously mentioned side effects) is that the Restor's near vision stop just before the Crystalens' mid ragne start working well.  So I have a windows of a few inches between near and far that could be better.

I work behind a computer all day and read ALOT in my spare time and since the last surgery I have not worn glasses period.  As I read on this forum and see that not everyone has had the same results I feel doubly blessed.  

[JodieJ]

Re the Crystalens eye:  Why are you reluctant to YAG?  It might improve your indoor vision. Other Crystalens recipients have reported that their night vision problems have diminished over time.

Your ReStor results are fantastic.  

[bstaggs]

I know that this is probably silly, but I have read about the fluid behind the lens membrane pushing the Crystalens forward (which is made to move by design) and causing problems after a YAG.  I discussed this with my doctor and he smilingly said that he has done hundreds without incident.  He also told me that he makes the YAG hole as small as possible with the Crystalens though. I am also concerned about possible "laser scuff".  

Honestly the more I read about YAGs the less interested I become.  I was born with cataracts and my eye sight progressively worsened all my life.  My new found vision is such a blessing that I am hesitant to role the dice.

There is an air of permanency about the whole YAG procedure that makes me nervous. If I understand correctly, having a lens replaced after a YAG is much more complicated. Again my doctor seems to believe that my fear is misplace.  Especially considering that with the cataracts I had there was a high risk of tearing the lens membrane during the removal of the cataract itself.  In his mind I have already taken a much bigger risk by having cataract surgeries in the first place.  But as I have told him, my vision had gotten so bad that I had little to lose.

I will have to resolve my issues shortly as I have a six month follow up in November and I am certain that he will want to do the YAGs.

[JodieJ]

Don't feel pressured to decide.  You can postpone doing a YAG for as long as you want.

[Eye-Kant-C]

PLEASE, don't do the YAG unless you absolutely have to. I just had it done 3 weeks ago after my doctor also laughed off my concerns. (About detached retina, etc.)

I have had nothing but problems with the Crystalenses and now have HUGE starbursts after the YAG. Here's a link to what it looks like. I guess it's caused by laser scuff and I don't know if anything can fix it.

Don't do it!!!

http://i15.photobucket.com/albums/a358/bkchickenboy/moms%20pics/eyes.jpg

[mmrudy]

Great photo! How did you focus your camera to get it?

Sheer curiosity on my part, but do the starbursts that you see decrease as you come closer to the light sources?

I see starbursts (not as big as in the photo) at night and find that they increase in size as I approach the source, then diminish as I get even closer.  If I look at light sources w/o glasses, I see a semi circle of holiday lights. These seem to be caused by a cataract combined with moderate astigmatism. Weird and sort of fascinating.

[crystannot_lens]

You too? I'd say to all, stay away from Crystalens. Huge problem with right eye and B&L avoids the issues. B&L also does not disclose any of the problems which they have "known" about for a long time!
Unless you like to feed dishonest companies that are only interested in ripping you off!