IOLs for Astigmatism

[browneyesblue]

I have worn glasses and/or contacts since age 7 for fairly severe myopia & astigmatism. I am now 53 yrs. old and have slight presbyopia. I was diagnosed two years ago with small cortical cataracts.  I am hoping to arrange for cataract surgery within the next few months, but would like some advice on lenses recommended for astigmatism and whether LRIs should be considered to correct this.  The presbyopia is the least of my concerns.  (If I only needed to wear glasses to read -- I would be in heaven!)  I am concerned about glare because I now avoid driving at night whenever possible. I would also like to retain as much depth perception as possible.  I am a  heavy computer user at work and at home.  What lenses or procedures should I consider?  

[John C Hagan III, MD, FACS]

LRI = limbal relaxing incisions. These are small cuts made in the peripheral cornea paralleling the edge of the cornea (limbus) used to reduce astigmatism (lopsided or aspherical corneas). They are not part of a regular cataract surgery and Medicare and many insurance does not pay for the LRIs.

It depends on how much you have. If its less than 1.25 diopters it can often be corrected by placing the incision in the steep axis, making it larger than normal and using lots of steroid drops in the post op period. Sometime in the future toric IOLs will be widely available but not at present.

Larger amounts require LRI incisions. If its worth the money to you and your surgeon is experienced there is no reason not to do the extra work. On the other hand since you're okay with glasses residual astigmatism can be corrected in them. Some astigmatism actually helps the eye see and mid range and near without the glasses.

I would suggest trying for "plano" in both eyes for distance to give you the best distance depth perception and planning on wearing no line bifocals for computer and near.

JCH III MD

[JodieJ]

The Alcon AcrySof toric IOL (new last year) did a better job of eliminating astigmatism (on average) than limbal relaxing incisions, at least in the clinical trials.  It did not tend to rotate in the eye like older toric IOL models.  It was my first choice lens, but unfortunately didn't come in the power I needed to correct my high myopia.  (I think that the power stops at 16, which may or may not work for you.)

Not all cataract surgeons charge a fee for limbal relaxing incisions (mine didn't), and some are not experienced doing this refractive procedure.  So you may want to consult more than one surgeon.  At least in my case, the LRI's really helped to make my outcome excellent.  (Getting aspheric monofocal lenses also contributed, together with my surgeon's skills.)  Best wishes for successful surgery.

[browneyesblue]

Thank you so much for your knowledgeable response.  Would the LRI procedure be contraindicated if one had a "hint" of a pre-keratoconus corneal condition (bulge on rear side of the cornea) which (prior to discovery of the cataracts) caused an experienced surgeon to strongly discourage Lasik surgery.  Does the LRI procedure weaken or thin the cornea?  
Also, I have read that Medicare has "approved" astigmatism-correcting lenses if the patient wishes to pay for the extra features. (I use Medicare approval only as a reference point that other insurance plans may follow) Do you think this will rapidly make them more available? Are toric and aspheric lenses the same thing?

Thank you so much for sharing your knowledge of this rapidly advancing and confusing area of advanced cataract surgery.

[browneyesblue]

I would like to hear more about your experience, your eye condition sounds fairly similar to mine. Did you end up with an aspheric monofocal lens in combination with LRI to correct your astigmatism & myopia?  How is an aspheric lens different from a toric lens?   (I'm ashamed to admit that I don't actually know what my numbers are.  I've heard -7 & -9 tossed around, but am not sure what that refers to.  I just know that correcting to 20/20 has never been considered within the realm of possibilities with glasses or contacts.)  Did you or do you have any presbyopia?  If so, how do you deal with it ?  (When I was younger, I thought than when advancing years eventually caused my to develop "farsightedness" that my eye sight would improve overall--how little did I know!!) Do you wear glasses for any particular activities?

[John C Hagan III, MD, FACS]

A toric IOL is not the same as an aspheric IOL. The former as most often used is to correct astigmatism, the latter is a monofocial IOL specially ground to reduce optical aberrations.

LRI in a pre-K-conus eye will be a decision that each surgeon will have to make but I don't think that anyone will be anxious to do it.. LRI do not thin the corneas to any significant degree, whether they weaken the cornea and promote further development of K-conus has not and probably will never be studied (for a wide variety of reasons).

As to the availablity and Medicare approval of toric IOLs I have no personal knowledge. As yet our practice does not use them.

JCH III MD

[JodieJ]

Don't feel bad about not knowing all the technical stuff.  Initially, I didn't even know that cataract surgery could correct myopia.  I learned a lot online, especially from forums like this one.  I also consulted three cataract surgeons and learned more at each consultation.

Yes, I had LRI's and aspheric monofocal lenses for astigmatism and high myopia.  There are three aspheric IOLs currently available, from Alcon, AMO and Baush & Lomb.  Check out the patient education video for AMO's aspheric Tecnis IOL at www.tecnisiol.com.  It's reported that aspheric lenses reduce glare and improve night vision.  My Blue Cross covered the full cost of my aspheric lenses (and so will Medicare).  As I recall, there was a $500 surcharge per eye for the new Alcon toric lens.  Unfortunately, given your Rx, it's doubtful that this lens will come in the power you need--but your surgeon can check.  (Maybe Alcon has added more powers since I had surgery a year ago.)  The toric IOL is a good option, I think, for someone with significant astigmatism.

Yes, I had presbyopia before surgery.  I had worn monovision contact lenses (which I loved, until they caused a breakdown of my eye alignment and double vision).  So getting my IOLs set for monovision (or even modified monovision) was not an option for me.   Selecting the correct power IOL is not an exact science, especially for someone with astigmatism.  The target for my first eye was very mild myopia, but I ended up plano with minimal astigmatism.  My surgeon matched my second eye to the first--so both my eyes are plano.  I either wear progressive glasses with plano tops or (occasionally) bifocal contacts.  But in your case, you might want to consider "modified monovision," with one eye plano and the other set for intermediate vision.  (Or you could use one eye for intermediate vision and the other for near, and then wear glasses for distance.)

It might be helpful for you to set up consultations with more than one experienced cataract/refractive surgeon.  You'd learn a lot from hearing their suggestions for you.    

[John C Hagan III, MD, FACS]

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[browneyesblue]

Thank you both for your input and recommendations. It is wonderful to receive current,  targeted input from both a doctor and a consumer.  What a great forum! This info will help me ask more precise questions & better understand the options presented to me when I see a cataract/refractive surgeon in 4 weeks.   I am going to continue my research and will probably be back with more questions before too long.  Thanks again!

[John C Hagan III, MD, FACS]

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