multifocal lens implant mixed with bifocal lens implant

Hi

It is 3/12 months since I had cataract surgery with a Physiol Fine Vision multifocal lens implant. My distance vision was excellent beforehand, intermediate and close up vision poor.  I have had a lot of problems adjusting to the lens, also some inflammation and what I think is probably dry eye, which I never had before.  I sincerely wish I
could reverse things, but I can't.  I have discussed my options with my surgeon and have had second opinions as well.  My surgeon will remove the lens, but made it clear that I would probably need glasses for all distances then and this diagnosis was also given by another surgeon I saw.  

My eyesight is pretty good for distance and close up vision, but the intermediate range is quite blurred.  I tend to still use my glasses quite a lot of the time for the computer.  My surgeon has suggested a Lentis MPlus bifocal lens for the other eye - set for intermediate and distance, as he feels it will improve my intermediate vision and feels I will cope better once both eyes have been done.  My vision is pretty waxy and quite dim in my operated eye, but he has offered a YAG to improve this.

I am very torn, I am wary of having the other eye done (by the way, I don't need to  have it done as the cataract in my left eye is very small), but it may well help my brain to cope better.  I don't relish the thought of taking the risks with explanting the IOL and replacing with a monofocal, especially as I may need to wear glasses all the time - leaving me in a worse state than prior to surgery! (the whole point of the surgery was an attempt to be glasses free).

Can anyone offer advice please? I am particularly interested to know how other patients have gone on with a similar combination of lenses, did you have a good result?  By the same token, anyone have just one monofocal lens and one eye with a natural lens? Does that work well?

Many thanks to anyone able to help,

Susan

[Ray T Oyakawa, MD]

I am not familiar with the Physiol Fine Vision IOL.  It is probably a defractive IOL from what you describe and it is working like it should.  Multifocal IOLs work best when implanted in both eyes.  3 1/2 month is too early to exchange.  In some people it can take more than 6 months to adapt.  There is no presbyopic IOL that will correct all ranges of vision.  Your choice is good distance and near with moderate to poor intermediate-multifocal, or good distance and intermediate with an accommodative IOL.  With the accommodative IOL you will need readers for near.

Dr. O.

[SUSIEQ11]

Many thanks for your reply Dr Oyakawa.  May I just clarify please - is it a good idea to mix different lenses in each eye, or would I get a better result from having the same lens in both eyes.  Also, if I were to have a bifocal lens in my other eye set for intermediate/distance vision, would this improve my intermediate vision and still give me the good distance vision I have at the moment in this unoperated eye,.

Many thanks

Susan

[JodieJ]

I received your personal message requesting my input.  I have no personal experience with this issue.  I think that if you went along with your doctor's suggestions (YAG and bifocal IOL for your second eye), you might be pleased with the improvement in your vision (especially your intermediate vision.) Or you might have vision problems that are far worse than what you have now--problems that impair your ability to read, to use your computer, and to drive.  In this case, your vision might improve over time--or it might not improve at all.

Personally, I'm risk-averse when it comes to my vision.  Why does your doctor think that you would need glasses for all distances if you were to replace the multifocal IOL with a monofocal IOL?  This statement makes no sense to me.  In your place, this option would be my choice.  I'd find a surgeon who is very experienced in exchanging lenses and opt for mini-monovision with monofocal lenses (distance vision in dominant eye, intermediate vision in non-dominant eye).  This gives most people very good distance and intermediate vision and some reading ability without glasses.  Since you currently have good distance vision in your second eye, you could postpone cataract surgery for that eye until you need it.  I'd have the power in the exchanged IOL set according to whether it is the dominant or non-dominant eye.

[SUSIEQ11]

Dear Jodie

Thank you very much for that.  You are right, taking risks with your vision is a bad idea, I have learnt that to my cost.  I agree with your suggestion of mini-monovision.  I have already suggested this to my surgeon, the thing that put me off was the prognosis of having to accept I may need glasses at all distances, in which case I would be in a worse position than before and from what I can gather, you need a good outcome for distance in the dominant eye with monofocals before you can set the other eye for intermediate range.  To complicate things I have been plagued with inflammation since the surgery and I am still on strong steroid drops, which is very concerning.  My eye just does not `feel' right at all and I am aware of it all the time.  It feels like I have a contact lens in and it is getting stuck in the wrong position.  There is also a `pulling, sort of tight sensation' in my eye, which is my dominant eye.  I have searched through the posts on here and done many searches, but this doesn't seem to be a common thing.  I know I must decide fairly soon  whether to have the lens explanted, I just want to make sure I make a good decision this time.

Many thanks

Susan

[JodieJ]

I don't think you have to make a decision real soon, so don't feel pressured to do so.  There isn't a time limit for an explant.  Dr. Oyakawa feels that you may adjust to the multifocal IOL with more time.

The archives of this website contains posts from a number of people who had a multifocal lens explanted and replaced with a monofocal lens.  Most people opted for mini-monovision, and I think that everyone ended up happy with their vision. Try entering key words (e.g., "explant ReStor") in the search engine at the top right corner of this page.  In most cases, the multifocal IOL that was explanted was a ReStor.

Look at it this way:  you need a good outcome for distance for a multifocal IOL to work.  If your surgeon can achieve this, then why can't he achieve a good outcome for a monofocal IOL?  He already has feedback about your correct power in a Physiol Fine Vision multifocal IOL.  Worst case scenario (very unlikely with an experienced surgeon):  the power of the monofocal will be slightly off in your dominant eye.  In this case, you could have the IOL in your second eye set for distance.  This would give you good distance vision without glasses, but you would need readers for near/intermediate vision.  (Why would you need glasses for all distances with monofocals?  This makes no sense to me.)

[SUSIEQ11]

Hi Jodie

Thank you so much again for your advice.  This was my surgeon's response by email regarding explanting the lens:

When considering a IOL exchange -  we are in a territory where securing any IOL back into the favoured position of behind the iris (called the posterior chamber) would be a welcome bonus - it would not matter very much at all whether it was aspheric or not -  any difference in real outcome would be within the margins of error anyway. Furthermore what your research may not have revealed is that aspheric implants and especially  prolate surface implants such as the tecnis  have to be very central in order to have any additional benefit. Any decent ration of such implants tend to degrade the quality of vision. When we place an implant in the posterior chamber and even in the bag after an IOL exchange cent ration is much less certain so my preferred option is to use a typical implant that doesn't have any modifications re spherical aberration. As you will appreciate some people can have some  depth of focus even with mono focal implants - that would be a bonus and not any specific aim -  the aim would be to extract the physiol and reimplant a mono focal implant - aiming for a prescription of zero (i.e. good vision for distance) but in these scenarios accuracy is not as high as it would be for primary procedures. If we go down the road of an exchange of the physiol I think its important to be able to accept the certain need for glasses for near , very likely for intermediate and fairly likely for distance too in that eye. The only reason to consider this option is due to the level of dissatisfa_ction that you are experiencing with the implants side effects and thus the aim is to alleviate these side effects but I re iterate you must fully accept that glasses would be a very likely long term requirement in that eventuality. For many people who are really troubled by the side effects of bifocal / multifocal lens implants alleviating the side effects must outweigh the whole issue of desire for spectacle independence.  Regarding your last question in this para - theres every reason to expect your distance vision to be very good  -  but in the corrected state -  i.e. with glasses if there is any notable prescription.

I am still favouring this route and looking into other surgeons now for mini-monovision.  I have been told by another surgeon that my eye has been `over corrected' and another said I appeared to have a myopic refractive surprise, would this affect the eventual outcome of the explant?

Thanks again,

Susan

[JodieJ]

Several other people who have posted on this forum have had a multifocal IOL exchanged for a monofocal, with excellent results.  You can find their posts using the website search engine.

If your eye with the multifocal lens is "overcorrected" and myopic, it means that your surgeon missed the target on his first attempt. (This suggests that your vision with this lens would never be great.)   According to what he wrote to you in his email, his second attempt at the target would likely be even less accurate than his first.  If you do decide to explant the multifocal lens, find a different surgeon to do it.

[SUSIEQ11]

You have been a great help Jodie, thank you again for your advice, the difficulty will be in finding someone experienced enough and willing to do the explant for me.  Two surgeons have already said no to this, but I will carry on looking, as I don't have confidence in my surgeon, especially as you agree with me on this.  My eye just does not feel right at all, even without the aberrations.  If I touch it gently it feels spongy and as though I can feel something moving about, then my vision becomes distorted.  Is it possible for the lens to become dislodged? I don't know, but I swear it feels as though it moves out of position sometimes.  The whole experience has been a nightmare from start to finish, but hopefully if I keep positive I will get it sorted out and feel back to normal again.  

You are very kind to have listened to me.

Susan

[JodieJ]

I don't know how the health care system works in the UK.  I do think that if a surgeon doesn't want to operate, they are not the right one for you.  I'm sure that you can find someone who is skilled and experienced at explanting IOLs--maybe at a major medical center.  Keep the faith; I think that it will work out well for you in the end.

[SUSIEQ11]

Thank you again for your kindness and advice Jodie.  I have managed to contact 2 surgeons in London who may be willing to help me, one of whom has suggested using a light adjustable lens rather than a monofocal lens, as this can be corrected / adjusted after implantation.  Do you know anything about the lens and what would you recommend?

Thank you,

Susan

[JodieJ]

I've heard of it--it sounds good in theory (pro) but it's new (con).  Don't think it's available in the USA.  I'd want to know more about this lens' track record and the surgeon's experience (or lack thereof) with it before making a decision.  Getting opinions from both the London surgeons might be helpful.

[SUSIEQ11]

I hope you don't mind me asking you another question Jodie, but having
read the posts it seems you only had a cataract in one eye, but after having surgery with a monofocal lens you decided to have the other eye done as well.  I was just wondering why.  Did it feel odd having one eye with a natural lens and one with an IOL?  It definitely feels that way to me at the moment with the multifocal IOL, but I am hoping when I have a monofocal lens fitted instead that this will not be the case.  As my other eye is fine, I think I would rather leave it for now and maybe try to attain mini-monovision by using a contact lens in that eye for the time being.

Thanks again,

Susan