Is Monofocal then LASIK a viable option?

[sally7788]

I am extremely myopic (-26 in the right eye and -18 in the left).  I am a healthy 46 year old female and have been wearing contact lenses for 30 years (correctable to 20/20).  The past two years I have needed non-prescription reading glasses (drug store variety).  I was told recently by my eye doctor that I have "mild" cataracts in both eyes (which explains my reluctance to drive at night).  He is suggesting surgery to remove my lenses with a follow up of LASIK to further correct my vision. He can only give me guestimates of what he thinks my vision will correct to with no guarantees.  Fair enough.

I have learned my insurance will cover the cost of this surgery replacing my natural lenses with standard monofocal lenses.  My doctor seems very keen for me to opt for the multi focal "Crystalens" for which I will pay a premium of $4500 (for both eyes).  He reckons the dioptics will be corrected to -6 and -3 respectively.  After which, I will still need follow up with a LASIK procedure to further correct as close to 20/20 as possible--again, no guarantees.

Having cataracts is a blessing in disguise, I'm excited to get new lenses and any improvement in my vision is welcome.  My question is, what advantages am I gaining with the Cystralens?  Presbyopia has already set in and what I've read I would probably need corrective lenses for close work anyway  whether it's a monofocal or cystralens.  Also, with the LASIK surgery, couldn't the doctor do monovision regardless of which lens I have implanted?

[John C Hagan III, MD, FACS, FAAO]

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[JodieJ]

I'm so glad to know that things are working out for you.  Best of luck with your cataract surgery.

[John C Hagan III, MD, FACS, FAAO]

Well done and good luck.

JCH III MD

[sally7788]

I took your advice and met with a retinal specialist.  I found him on a www.asrs.org.  He is the only one listed in our area and turns out, the "go to" guy for most of cataract surgeons in the area to evaluate patients pre-surgery.  Anyway, he did confirm that monofocal would be more appropriate for me (to paraphrase the good Dr. "if it were me, I would select monofocal"). He also gave me a couple of cataract surgeon referrals.  I have scheduled a presurgery eval in mid-December with one of those referrals.

When I mentioned to him the original doctor with whom I spoke regarding my cataracts and his "pushing" of crystalens, the retina specialist responded that he had many a disappointed patient of Dr. X post operative.  Much of it unmet expectation!

thanks again for your input.

[John C Hagan III, MD, FACS, FAAO]

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[JodieJ]

If you haven't already done so, you should see a retinal specialist to make certain that your retinas are in good shape for the surgery.  Maybe the retinal specialist could give you referrals to the best cataract surgeons in your area.  You definitely want to see a highly skilled and experienced surgeon in order to minimize the likelihood of complications.

If you read through this forum, you'll find that the ophthalmologists here are quite frank in expressing their opinions about the multifocal/accommodating IOLs.  It is very difficult to find such honest opinions anywhere.  I suspect that the two surgeons you've consulted are getting most of their information from their manufacturers' reps--hardly an unbiased source.  

[sally7788]

Thank you both for your timely and informative responses.  Thank you for just having this website and forum providing information and a sounding board!  You have shed light on my most pressing question regarding which lense, monofocal or multifocal, to choose.  More to the point, you confirmed my intuitition that the monofocal is probably the right choice.  

I have taken on board the risk associated with this procedure.  Any surgery carries risk.  The figures you stated, quite frankly, mean very little to me. Isn’t this one of the most common and safest of surgeries?  No doubt I will have to sign a consent form prior to surgery indicating I “understand” all the risk as well an arbitration agreement stating I won’t sue the surgeon if thing go awry but wouldn’t I have to be extremely unlucky or  the surgeon not very good to have something go wrong?

I have seen two eye surgeons (the second one right after posting my question) thus far and both, after going through the “proper” disclosure of risk involved, couldn’t slice open my eyes fast enough.  As I mentioned one is “aligned” with Crytalens and the second, Restorelens.   Both downplayed monofocal to the point where I get the feeling neither one will proceed with surgery if I don’t choose their brand!  Believe me, it is not about the money.  I would gladly tens of thousands of dollars if it made sense.

I accept an eye surgeon is also a businessperson and they have to earn a profit and they can't spend to much time allaying fears and dispensing information in an hour visit that has taken decades to acquire.  I also understand that without the profit motive these amazing technological advances would not happen.  But as they say caveat emptor!  Again, a big thank you for your website and your time.  I at least feel more confident I will be making an informed decision.

[John C Hagan III, MD, FACS, FAAO]

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[JodieJ]

Please do more research before proceeding.  The Crystalens is hardly problem-free, and you could very well end up with vision that is not as good as what you have right now with your contacts.  (There are a number of recent threads on both eye forums about Crystalens problems.)  In addition, some retinal specialists (including mine, but certainly not all) are opposed to a Crystalens implant in their patients.  The smaller diameter of the Crystalens might make it more difficult to view the periphery of the retina, and the silicone material of this lens can sometimes be a problem in the event of retinal detachment.

I agree with you that developing cataracts can be a blessing in disguise.  (It definitely was for me when I developed a cataract post-retinal surgery.)  Based on my research and personal experience, I'd recommend aspheric monofocal lenses.  There are three brands available--from AMO, Alcon and Bausch & Lomb--all excellent lenses.  The patient education video at www.tecnisiol.com (from AMO) will give you more information about cataract surgery in general and aspheric monofocal lenses in particular.  (You'll have to ignore the manufacturer's hype about their product.)  I'm not sure which lenses are available in the power you will need, but this will definitely play a role in your selection.  

I consulted more than one cataract surgeon for recommendations before making a decision.  I also got input from my retinal specialist about lens selection.  It was a learning process for me, and I ended up feeling very glad that I hadn't rushed into surgery (although I had initially been tempted to do so).  There's also a wealth of information in the archives of this forum that can help you make the best choice.  Best wishes for an excellent outcome!

[John C Hagan III, MD, FACS, FAAO]

Since you are doing "okay" be sure you clearly understand the risks involved. Besides the risks of infection, bleeding there is a small risk of loss of eye. The risks of surgery are increased because of your high myopia.  

You are already at a high risk of retinal detachment (perhaps as high as 1%) after cataract surgery even successful surgery with no-stitch small incision phacoemulsification the risk of RD will be increase by 5 to ten times (not %) to about 5-10% and if there are complications even higher. Plus you would have to have this done twice once on each eye so you have two exposures.

If you clearly understand this and wish to proceed I would advise my patients to have Monofocal IOLs and not crystalens.  Use the search feature and read all the postings of unhappy patients having trouble with multifocal IOLs.

You can have the surgeon give you the best possible vision at distance then use LASIK to either convert both eyes to distance or go the monovision route.

The reason they most likely can't correct you to zero "plano" at distance is that the weakest IOL has no power on it at all, you might calculate to need a minus power IOL and to my knowledge these are not marketed because of the extremely limited number of people that would need them.

JCH III MD