Ashperic Restor vs. Monofocal for 33 year old eye?

[javadesigner]

Hi:

I am male, 33 years old, with bilateral (and growing) PSC cataracts. Also a huge (and growing number) of floaters as well. Have had many dilated eye exams from very good doctors and there are no retinal complications (although, there may be faint signs of PVD, but no retinal tears or detachment).

I've consulted with some doctors who have performed upwards of 25,000 cataract operations and several thousand Restor implants. (Dr. Christerbury in North Carolina, Dr. Mckool in NYC, some others in teaching hospitals)  

No one can really recommend a lens to me. They've all gone over pros/cons of monofocal (Alcon IQ aspheric, for example) and multifocal (Restor). They've all said that Restor has "good" performance but does leave halos around bright lights which will never go away.
No one is sure whether mono or multi is good for me, everyone has said that although most people are happy with restors, some people are never able to adjust.

Also restor is similar to Monofocal for distance but not great for intermediate vision.

I'm a computer programmer, heavy web surfing, cell phone, video game use. Reading finely printed computer manuals and switching back and forth from the manual to the screen is important to me. I've worn glasses since 14 and have -5.50D in both eyes.

So my questions are:

1) Does the Aspheric restor improve intermediate vision over the previous version ? Does this newer version make going with restor now, a no-brainer ?

2) I've read that with monofocals, vision is quite blurry less than 5 feet inwards. With monofocals, could I switch easily from keyboard, monitor, open manual etc with bifocals or would i have to keep switching glasses to read a monitor 22 inches away vs. a book 12 inches away ? IF this is possible with MONOfocals, then maybe they are a safer option ?

3) Having the ability to read my wristwatch when I get up in the morning or a book to fall asleep to would also be great :-)

4) What other advise would forum members give me ? I really need to get surgery in the next year or so (I have too much glare, halos, smudged vision as of now with PSC). I'm
generally quite fussy (a smudge on my glasses really bothers me) but as I grow older, I think I can learn to compromise/adjust better with whatever type of IOL I choose.

Thanks so much for all your advice and replies.

Best regards,
--j
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[JodieJ]

There is ample information in the archives of this forum about multifocal problems/issues.  According to the recent medical literature, the best results from a multifocal/accommodating IOL seem to involve the Crystalens, with ReStor second, and ReZoom last.  In your case, getting the Crystalens (set for slight monovision) makes sense to me, especially if you don't have astigmatism.  Frankly, since your work involves computers, getting bilateral ReStors sounds like a terrible idea to me; intermediate (computer) vision is the biggest weakness with this lens.

Getting aspheric monofocal lenses set for monovision or modified monovision (AKA "blended vision") might also be a good choice.  It would give you good vision immediately after surgery, and you'd probably need glasses only for a few activities (like reading small print for a long time.)

So my vote in your case would either be for Crystalens or aspheric monofocals, probably with blended vision.  I'd suggest that you see more than one experienced surgeon and get their recommendations.  

[javadesigner]

Jodie:
Crysalens is out, it's too gimmicky and unreliable. I do have very slight (0.5) astigmatism.

I've gone through a lot of the forum archives and read all about the monofocal and multifocal pros/cons. I'm stil very confused and can't figure out what to do! Intermediate is awful with monofocals too (as with restor), so I'd have to wear glasses for computer work with both.

But I won't need glasses for near with restor whereas I would with monofocals. So are the halos etc., an acceptable trade off, especially as one gets older ? That's the question I am trying to wrestle with. Would restors or monofocals (perhaps with -0.5D) would be better to switch back and forth from books, finely printed manuals, cell phone and computer screen (all of which are varyingly situated between 6 inches and 24 inches away from my eye).

[cdn_glenn]

I have multifocal implants (Tecnis not ReSTOR).

1) Does the Aspheric restor improve intermediate vision over the previous version ? Does this newer version make going with restor now, a no-brainer ?

With my lenses I have an area of "soft focus" between 18" and 4 feet.  I can read text on a computer screen in that zone, but with +1.00 readers I can see the screen and everything in my work area clearly.  For typing and reading copy I often take off my reading glasses.  I have my screen tucked up to the front of the desk (always had it that way).  I can both copy and screen with amazing clarity.  I believe the area of "soft focus" for the ReSTOR is closer to 6 feet, making them the multifocal IOL choice for computer work.

2) I've read that with monofocals, vision is quite blurry less than 5 feet inwards ...

I have quite a few neighbours with monofocal lenses focused for distance.  They need reading glasses for anything close, but can drive and see the speedometer, etc. clearly enough without glasses.  I have one neighbour who chose to have monofocal lenses focused for near vision.  Yes she can see clearly up close, but wears her familiar frames (with a different prescription) for distance.

Jodie's discussion of monovision / blended vision IOLs is workable and is a personal choice, as is selecting a multifocal IOL.  Not to be decided quickly.

3) Having the ability to read my wristwatch when I get up in the morning or a book to fall asleep to would also be great :-)

It's a joy to do this again after years of wearing bifocals.  I can read the morning paper on the train and glance around to see what's happening.  No glasses; no waiting to focus.

4) What other advise would forum members give me ? ...

I can only describe the experience of receiving multifocal IOLs.  Functionally my eyes are as good as they were twenty years ago (I'm 52 now).  I can read the finest of type and see distant objects clearly -- I think better than I could with glasses.  In practice there are some trade offs.  Halos is the big one.  Initially -- first three months -- they were unbearable.  Will these ever go away?  No they won't.  But they've become minimal due to Neuroadaptation -- the brain getting used to seeing through the lenses and filtering out unwanted information.  Halos mostly display at night around bright, distant lights.  It's very workable.  I certainly can operate better than I have for years.  But I'll never see exactly in-the-way I used to.  All said, it was an excellent choice.

Cheers,
Glenn

[MMEE]

I have monofocals.  I can read the computer screen without blur at 2 feet.  Within that distance, I use 1.0 readers.  The characters on the car's dashboard are very clear without glasses.   If I squint, I can read most nutrition statements on packaging at the grocery store.  Some of these are small print, but of course, the lighting is  very good in these instances.   I was told before the surgery that I am slightly nearsighted in one eye.
Keep in mind that with regard to cataract surgery, the phrase "Your mileage may vary" seems appropriate when anyone describes their results.

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

If it were me. I would chose a monofocal aspheric IOL and set my dominant right eye at about -1.00 and my non-dominate left eye at -2.50  I would then expect to be able to read and use my computer nicely without glasses. With no line bifocals (the prescription would be RE -1.00  LE -2.50 and +3.00 Add) I would expect to have great night vision and excellent vision and depth perception to do surgery with.

If I wanted to emphasize my distance vision then I would ask the surgeon to shoot for -0.50 for distance and -1.50 for intermediate and wear glasses to read.

JCH III MD Eye Physician & Surgeon

[JodieJ]

Much of the available Information about multifocal/accommodating lenses is filled with hype.  I will try to link you to the least biased information I'm aware of.  One of these sources is the report on the 2007 symposium of the American Society of Cataract and Refractive Surgery (May 2007).  This forum will not allow me to post the website address, but if you enter the following information into Google, you should be able to find the report:  "EyeQ Report 11 ASCRS lachmanconsulting"  (If you can't find it, I'll send you the website address in a personal email.)  I'll give you a few highlights of the report.  Sales of multifocal IOLs (ReStor, ReZoom) in the US have been on the decline this year.  Among the reasons for this decline are the vision problems associated with multifocals, including glare and haloes, "waxy" or "Vaseline" vision, loss of contrast sensitivity, loss of intermediate vision (ReStor), and the long (up to 12 month) time needed to neuroadapt to multifocal vision.  Bilateral implantation of the Crystalens in now considered to be the "ideal" correction, at least among the surgeons attending the 2007 symposium.  In an informal survey, when the surgeons were asked which lens they would choose to have implanted in their own eyes, 43% chose Crystalens, 16% chose Restor, and 8% chose ReZoom.  (BTW, the Tecnis multifocal lens described above by Glenn has not yet received FDA approval, so it is not available in the US.)

Dr. Hagan, one of the forum M.D.'s, recently gave the results of a new study comparing multifocal/accommodating lenses in which some of his associates participated.  As I recall, the Crystalens yielded the best visual outcomes, with ReStor second and ReZoom third.  (Please try to find the post in the recent archives, so you can get the info first-hand.)

The other alternative for you would be getting aspheric monofocal lenses set for monovision or modified monovision (AKA "blended" vision).  This would give you excellent distance and intermediate vision and fair-to-very good near vision (depending on the correction).  If possible, you might consider trying out a full monovision correction with contact lenses to see if monovision would be an option for you.  This would probably be my first choice in your situation (but our priorities may differ.)

Your best bet might be to consult a surgeon who is experienced with more than one of the multifocal/accommodated lenses as well as with "blended" vision.  I don't think your astigmatism would be a problem except perhaps with ReStor, which is supposed to be very sensitive to even minimal astigmatism.  I hope that the forum M.D.'s can provide further insights for you.  Best wishes.      

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

One of the things that everyone needs to know is that there is no "BEST" answer. No BEST implant. Different people will have different expectations. The surgeon cannot decide what is best for you.

As a young person you want good night visiion. As a myope you're use to wearing glasses and also having good vision at near without glasses.

Without being presumptious your best choice might be as I outline above in my "what would I do" posting.

JCH III MD   Ophthalmologist

[javadesigner]

Hi everyone:

Thanks for all your replies. I've been on the internet since the days of NCSA Mosaic and I must say, this forum is among the best I've encountered in many years.

When something as basic as vision starts to go awry, one appreciates the human eye a whole lot more than taking it all for granted.

I just read this really great simulation of nighttime halos with different multifocals. Here's the
link:

http://www.eyeworld.org/article.php?sid=4036

After looking at that simulation, I think I'll probably go with monofocal lenses. More certaintly in the end result, better in low-light and I don't mind wearing glasses..worn them since 14 and I look better with glasses anyway :-)

It's a pain to have to keep taking glasses off/on all the time though. I see my dad (who needs readers now) has also become more reluctant to read things than before..because of the additional effort required to put his glasses on for reading.

Does anyone in this forum (with monofocals) also wear 24x7 progressive glasses with the far part clear (no rx) and the rest set as progressive ? That way, one is free to read anything, anytime one wants, with no extra effort...

Anyway, thanks again for all your suggestions and comments.

[JodieJ]

I have both bifocal contacts and progressive glasses with no distance script.  I did not want monovision or "blended vision" because I have a (rare) history of strabismus related to monovision contact lens wear, and both my eyes are plano post cataract surgery.  But I really think the type of blended vision that Dr. Hagan suggested above would be the best choice for most people.

My reaction to the Eyeworld article was different than yours.  I thought it made Alcon's ReStor lens look like the superior product, with "manageable" halos.  Then I read that the article's first author was a paid consultant for Alcon, and I concluded that this was really more of an advertisement than a scientific publication.

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

Medical research sponsored by a drug company or medical equipment manufacturer does not necessarily taint research findings. It is good that almost all medical meetings and medical journals (including the one I edit) now require Disclosure Statements identifiying possible conflicts of interest.

JCH III MD

[JodieJ]

I'm glad to know about the current Disclosure Statement requirement.  But it still makes it very hard for prospective patients (and maybe some doctors) to get accurate information, without the hype or the slanted perspective.  (In the above study, for example, was the goal an objective effort to compare the performance of three multifocal lenses?  Or was it to design a study with conditions which would make one lens look superior?)  This forum is one of the few (only?) places I'm aware of that provides frank, direct advice about choosing an IOL--and this is certainly a valuable service.

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

Okay for the record, I am not a paid consultant for any drug company or ophthalmic manufacturer.
As Editor of Missouri Medicine and leader in the state, I try and set a good example and also pass up free dinners and lunches sponsored by drug companies. I do acccept free drug samples which are given to patients and save them tens of thousands of dollars/year. I do not own stock in any drug companies nor do any of my family.

JCH III MD

[JodieJ]

That makes your opinions about IOL options all the more valuable to the readers of this forum.  I hope that more people are linked to this website BEFORE they have cataract surgery.

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

The most recent statistics on the Two Eye Forums for the past 3 months indicate that it is one of the fastest growing sites on MedHelp.org.

JCH III MD

[BobbieB]

I just had one ReStor lens in my left eye. I had been wearing mono contacts for around 20 years. The surgery was fine...nothing bad. Now, I have a flickering on the other vision of the implant. I cant' read without my glasses at a normal reading distance. The distant vision is awesome...very clear and far. I have to have glasses now on here at my computer is at at normal distance. Or, I can read the computer at about 30 plus inches awaw or more. I dont' like to have to be soooo far away from my screen. I need to decide if I want this implant taken out and a mon focal put in and the another in the other eye....now. They want to change if needed to, withing three weeks after surgery, Yesterday was two weeks. I need help but dont' have anyone to talk with about this. BobbieiB

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

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[JodieJ]

First, be sure that an explant procedure will be covered by your insurance.  Then make certain that your surgeon is experienced doing IOL explants.  Finally, you need to decide whether the potential improvement in your vision is worth the risk of having more surgery.  (Since you have a history of successful monovision contact lens wear, you would be very likely to be happy with surgical monovision with aspheric monofocal IOLs.)

[seriousperson]

Sounds like the Tecnis would be worth waiting for. After I had my surgery (crystalens in one eye, ReStor in the other), for at least the first year I was overwhelmed with regret that I had not waited for further developments in intraocular lenses.
javadesigner, your pre-op eye condition and life style mirrors my own.
I hope you are satisfied with your choice, whatever you decide.

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

____________________

[BobbieB]

Thanks for the reply, I did ask about if the insurance will pay for the change and the nurse said yes,. I was ok on last thursday, but nothing good since that...to me it's almost like I'm blind in the outer half of that eye with the ReStor implant...but it has cleared up and was ok for some time...but not much. I have to wear my glasses to see good at close and arm length, like  working in the kitchen, which is where I like to be most of the time... I might like the monofocals but now afraid it will be too late to change them also, how bad is it to keep going into the eye.seems like that alone could be bad and damage the eye. BobbieB

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

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[JodieJ]

You are only about three weeks post-surgery.  Given your 20 years of successful monovision contact lens wear, I think it's extremely likely that you'd be happy with monovision with aspheric monofocal IOLs.  I believe that the forum doctors have commented elsewhere that an explant is safe, especially if it is done early in the healing process process by a surgeon who is experienced doing this procedure.  I'm guessing that you are only in your 60's, so what's at stake is your vision for the next 20+ years.  In your place, I'd probably opt for the explant, because the vision you describe with the ReStor might drive me crazy.  But only you can weigh the risks and benefits of an explant in your situation, after discussing your options with your surgeon.  Best of luck, and keep us posted.

Jodie      

[jefields]

I based my decision of which implant lenses to get mostly on the type work I do, how I spend my free time, what level of inconvenience I would consider keeping up with different glasses. In the last six weeks, I had a Crystalens implant in my left eye, and three weeks later, a ReStor in the right eye (left eye dominant). This is working great for computer use. In fact, the afternoon after my Crystalens surgery, I was sitting at the computer enjoying not needing glasses and being able to see my screen extrememly well (I did have to lower the screen's brightness, due to dilated eyes). Reading was good too, as long as it wasn't really small print and the lighting was decent.

Distance was the problem for me with the Crystalens, as beyond 4-5 feet, everything starting getting blurry. That's why my surgeon asked me to consider a ReStor lens for the right eye. So that's what I chose and can see very well to drive. If I didn't have that Crystalens in the other eye though, I would definitely have to have glasses for the computer and reading. Reading with the ReStor is okay if the print is really close (like about 8").

The halos are there and I'm learning over time that they become less bothersome. But they really only bother me when I'm driving at night, which isn't something I do much of. If my job or lifestyle required lots of nighttime driving, I would have had to consider other choices. For me, this combination is working out really well, and continues to improve.

Good luck with your decision. Please keep us posted.

jefields

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

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