Questions about choosing an IOL after Restor Explant

For the past month my surgeon at MASS Eye and Ear and the associated optometrist had me try contacts over my Restor with the purpose of assessing whether or not I can correct my vision adequately with refraction to give me an approximation of what the Yag and subsequent lasix might accomplish. I tried both a +2.50 for mid distance and a +1.25 astigmatism lens in my Restor eye (which is now moderately farsighted) and a -7.5 in my non Restor dominant eye, without an astigmatism correction. That eye has a small cataract.
After all of this I was able to achieve about 20/40 best correction. While the two eyes seemed to function okay for distance, the Restor eye alone was pretty much the same, maybe a little better having better focus. Ghosting is less than six months ago, the implant was July, but still present. Night glare is bad, but compensated by my non Restor eye.  My surgeon said if done by January he would attempt to remove the restore and place an aspheric monofocal in my Restor eye. We would then wait to decide about the other eye.
Here are my questions.
1. I have read about the "new technology status" technis. My surgeon is considering a toric lens to correct my .75 to .100 astigmatism. (he does not recommend limbic relaxing incision). What is your experience with toric IOL's and does technis have them available in the "new technology lens" ? Would I be better off not doing a toric IOL. My other eye has a similar astigmatism and I don't mind wearing a regular contact in it.
2. I would like to capture some intermediate distance for seeing things on my counter top, etc. (I am almost there but not quite with my -7.5 distance contact) However I don't wont to sacrifice distance. Would blended mono vision give me enough distance and a little better intermediate ( I don't mind reading glasses). ?  If I go straight distance in both eyes  would I will still be unable to get progressive glasses for intermediate and near given that my unoperated eye is very myopic -7.5.
3. Would you do the first eye (non dominate) for far distance instead and leave the intermediate distance until later or change my contact in the dominant eye to an intermediate distance? (I am pretty happy with it for distance now)
4. My surgeon is world renowned but honestly does not do very many explants of restors. He is however conservative and I trust his judgement. Would you seek out someone who has done many of these instead?
Obviously I realize these decisions are mine and my doctors to make. I know I have asked some of these same questions before at different times. It is just that I am becoming more "focused" excuse the pun on my solution.
With regard to the consent issue. It might be helpful for patients to view a video of the effects of these premimun IOL risks, benefits etc and sign off that they have seen this, such as what we did when my children had their wisdom teeth removed. There are so many questions that patients may not know to ask.
Thanks again.
londonbrideg.
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[JodieJ]

Your astigmatism is mild, and a toric IOL might be overkill.  Another woman posting here who had  .75D of astigmatism before surgery ended up over-corrected with the lowest power toric IOL, and she was very unhappy.  (Why doesn't your surgeon like limbal relaxing incisions?)  The newest toric IOL is made by Alcon (not AMO, who makes the Tecnis), and it is not aspheric.  It is reported to be an excellent choice for people with more than a diopter of astigmatism.

Blended vision should give you good distance and intermediate vision.  You'd need glasses for prolonged reading or seeing small print.  I'd do distance vision in my dominant eye, intermediate vision in non-dominant.

Progressive glasses should give you excellent vision at all distances with either a distance/distance or distance/intermediate correction.

I'm in my 50's and can still wear a contact lens comfortably.  But this might not be the case if/when I'm in my 70's.   It's probably wise not to count on long-term use of contacts.

[Flavius G Pernoud III, MD]

You have a complex situation. And you are asking a lot of good questions. I agree that you may have too little astigmatism for a toric although I like these lenses a lot and have had nothing but good experience but I have only used them for patients with much more astigmatism. Some people take 6 months to a year to adapt to Restore but it doesn't sound promising for you. Do not attempt monovision unless you have tried it with contacts for at least a couple of months first. Many people love it but there may be 10 to 20% of patients who hate it. Explanting any IOL is difficult and could be risky. If you go for it, find someone who has experience doing it. Also, if you do remove it, I would go for a straight distance monofocal lens. Once your doctor and you are satisfied with your result, have the cataract removed from the other eye and have a monofocal distance lens implanted. Then go with progressive bifocals when you need them for intermediate and near vision.

[JodieJ]

The problem with having two monofocal distance lenses (from my perspective, anyway) is that you need intermediate and near vision in just about all situations, which means practically full-time dependence on progressive glasses.  My friend who has "blended vision" only needs glasses for prolonged reading or seeing small print.

I agree with Dr. Pernoud--I'd want a surgeon who was very experienced doing explants.  (I'm not sure that explanting a ReStor is very different than explanting a monofocal IOL.)  If your doctor lacks this type of experience, why can't s/he refer you to someone who does have it?

[mmrudy]

An aside on wearing contacts into one's seventies. Back in the 1970's, apparently IOL's for cataracts were not available (or not widely available? or not approved by Medicare?). My Dad and his sister both had lenses removed due to cataracts at that time. Both were given contacts to correct their vision. This was considered innovative. My Dad wore contacts (and glasses) til his death in his 80's. My aunt, now 90, still wears a contact in one eye. (Her second eye was corrected with an IOL.)

Perhaps their experience is (was) unusual, and neither wore contacts over an IOL. But it is possible to wear contacts later in life.

[Lerbea]

This is what we've done for my restor problems.  My dominant eye was IOL exchanged with the AMO aspheric for distance.  The surgeon and I are hoping that doing the dominate eye will override the ghosting problems.  Right now it's been 3 weeks so I am still healing and can't give outcomes as yet. The original Restor's were put in in June.

I have just got a Rx for glasses for reading and to correct the residual distance problem. Will get them next week I hope.  

Night driving is a horror.  Tried it just 1 time.  Moisture seems to help temporarily.

[londonbridge]

First of all, thanks to all of you for your responses to my queries. Honestly I couldn't wait to get home from work to check the forum. The support and advice I have found here from everyone is truly a gift.
I think that perhaps a toric for me may not be needed and I am obviously quite nervous about any possible problems although I do realize that Dr. Pernoud has had good results.
I am still mulling over what power to go for. It would be easier if I planned to do both eyes close together so I could be sure of having good distance vision for driving without relying on one eye with a contact (my dominant). I may wind up having to do the second eye sooner than later.My fear is what if I do the intermediate eye first and then when it comes time to do the second eye I don't get good distance vision for whatever reason, since measurements can be off. Well I will have to think about it more. I am trying blended monovision now with changing lenses over my Restor eye either for distance or intemediate, however that is probably not a good indication of what I would see if the contact wasn't over the Restor. Any bit of better focus with the Restor is an improovement so it is hard to tell. It would also be nice to only need glasses for reading close up. I never realized  how much easier life was with my progressive glasses, they did all that I needed and never left my face!

With regard to the surgeon I think I need to ask him how many explants of any kind he has done. I would have to think he is familiar with this since he has written textbooks on cataract surgery and teachers at Harvard Medical School. I am not sure how many explants is reasonable to expect most surgeons have done? Any thoughts on this.

Thinking about some resolution is comforting though. Once again thank you everyone. I will keep you posted.
londonbridge

[texasrn08]

I'm not sure what Ghosting is? I'm having difficulties with my left eye (restore) with some partial vision loss in my right periphery. I'm just not sure if I'm seeing the outer edge of the lens or not. I have a rezoom in my rt eye and driving is horrible with large halos! i would just as soon have my rezoom removed for a restore to reduce glare and "light shows"! Again, what is 'ghosting"?

[Flavius G Pernoud III, MD]

Ghosting is caused by more than one focal point in your eye. Of course, multifocal lenses like Restore and Rezoom cause this on purpose to provide both distance and near focal points. Astigmatism, or a distorted corneal surface, also creates different focal planes in the eye--it causes ghosting also. So light rays coming into your eye from all different directions cannot be focused at one fine point hence ghosting or blurring. For Restore or Rezoom to work, the eye and the brain have to learn to ignore the non-focused light rays. Some people can never do this. Multifocal contact lenses do the same thing but of course can be removed safely in two seconds. One thing that you can try is instilling a miotic eyedrop. This is the opposite of dilation. This makes the pupil smaller. This limits the light rays entering through the pupil and often sharpens the vision in these instances. A good example of this is Alphagan or its generic Bromididine. Your doctor may have a sample laying around for you to try. Instilling these drops may make your situation livable. Have you ever noticed that you don't have ghosting in bright light. That is because the pupil becomes small in bright light.

[londonbridge]

I have a question related to deciding if and when I explant my one restor lens in my nondominant eye ( dominant eye has no IOL with small cataract, contact -7.5 for distance- works fine); what are the various distances (in feet and inches) for monofocal lens and what would be an example of what you would be able to see at these distances:
1. Far Distance
2. Intermediate Distance
3. Close up Distance

I realize this is not an exact science and an IOL can be off by .5 diopters. My goal if I choose blended monofocal is to have sharp distance and some intermediate i.e. eating, seeing microwave buttons etc. Sorry to beat this to death but I am trying to make a better decision than I obviously did in getting the Restor.
londonbridge

[Lerbea]

This is a link to a ghosting simulator.  If it won't pull up type in the

www.thevisioncommunity.com  and search it.

http://www.thevisioncommunity.com/index.php?option=com_content&task=view&id=52&Itemid=145&phpMyAdmin=B4iGOWMpQ9L9TeOvCcp5aNVlEW1