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Consider ALL the Options Before Your Cataract Surgery: Working Through What’s Best For You

Aug 27, 2015 - 21 comments

Consider ALL the Options Before Your Cataract Surgery: Working Through What’s Best For You

John C. Hagan, MD, Fellow American Academy of Ophthalmology, Fellow American College of Surgeons.

Many decisions have to be made before having cataract surgery. The first is whether you need the surgery or not. Assuming you have made the decision to have surgery this is a discussion of the many options and choices you have.  THERE IS NO “BEST” TYPE OF PHACOEMULSIFICATION CATARACT SURGERY AND NO “BEST” INTRAOCULAR LENS. NO TARGETED POST SURGERY REFRACTIVE ERROR IS FOR EVERYONE. THESE DECISIONS WILL VARY FROM PERSON TO PERSON AND MUST BE INDIVIDUALIZED.  

We all have different visual needs.  Cataract surgery will be done earlier on a person needing perfect vision in all lighting circumstances, think airline pilots, truck drivers and heart surgeons. Surgery is done much later, if at all, on the very, very elderly, functioning combative or uncooperative dementia patients, those with terminal illnesses. In general cataract surgery is generally offered when a person is experiencing moderate or severe visual difficulties in activities they enjoy or need to do and the cataract is the sole or main cause.

Although the person is usually the one that makes the determination about how much of a problem his/her vision is in some cases surgery is strongly recommended by the ophthalmologist, optometrist or family.  Examples include inability to drive safely or legally; difficulty seeing the inside of the eye, major progressive physical or psychiatric disease, and if center of the cataract is getting “rock hard” (so called ‘brunescent or brown/black cataract) or could start to break up in the eye (so called ‘too ripe’).

Assuming cataract surgery is appropriate, the decisions that must be made include: which eye to operate on first, what type of IOL to insert, desired-targeted post-operative refractive error, how much glasses will need to be worn post operatively [NOTE: glasses are almost uniformly needed post operatively and are usually modern progressive bifocals]  SOME OF THE TIME a small % of people after cataract surgery can function without glasses or with inexpensive over the counter reading glasses.  Equally important is the choice of surgeon-ophthalmologist (Eye MD: a physician Doctor of Medicine or Doctor of Osteopathy that has been to medical school, medical-surgical residency and in many cases taken a special surgical fellowship.  Ophthalmologists provide a complete range of medical and surgical services.  Eye MDs must be distinguished from non-physician optometrists (OD) and opticians).

This discussion is not meant to be encyclopedic nor to give you “the answer.” As stated previous “the correct” answer will be different for different people. Informative is based on the most common questions posted on the American Academy of Ophthalmology MedHelp Eye Forums.

1. Where there is a difference of more than 1.50 diopters between the eyes post operatively glasses are often difficult or impossible to adjust to. The condition is called "aneisometrophia".  Part of the problem is due to the difference in image size each eye has with the glasses on; this is called “aneisokonia”.  Seek out Eye Forum posts on this problem by JodieJ. She had this problem post operatively and she clearly outlines her struggle and eventual success.
2. With modern cataract surgery not only do we try and make the person see better but we want the best possible vision without glasses and the two eyes to "work together" comfortably.  Tests are done preoperatively to help pick the proper IOL power to leave a targeted post op refractive error. This is not an exact science and the margin of error is +/- 0.50 but INCREASES with high myopia (long eye) or high hyperopia (short eye), eyes with previous RK, lasik, injury or additional eye diseases.
3. Typically the targeted post op refraction is between 0.00 (not needing glasses for distances of 20 feet (6 meter) or more) and -3.00 which has great vision for tiny detail at reading distance 13-14 inches.  Any difference of greater than 1.50 diopter post op may have trouble with glasses (some people tolerate much larger numbers but you never know). The range of relatively clear vision without glasses on is called “depth of focus” and will vary from person to person based on things like pupil size and corneal structure.
4. Some people that are highly myopic or highly hyperopic that do not have cataracts elect to have the lens of the eye removed (same technique as cataract surgery) and an intra-ocular lens (IOL) put in to eliminate thick glasses and improve vision without glasses. It is called "clear lensectomy" or "clear lens cataract surgery” or “refractive lens exchange”. This is done to reduce the thickness of their glasses or make them much more glasses independent.  We are not discussing whether that is appropriate surgery. The IOL and refractive problems are the same as those having cataract surgery.
5. A refractive error that makes some people happy post cataract surgery and often enables them to function without glasses for many things is 0.00 in the dominant eye for distance and -1.25 or -1.50 for the "reading eye." In good lighting they often can read without glasses. With glasses (the RX would be 0.00 distance eye -1.50 near eye and reading add of +3.00 diopters and the type glasses a no line bifocal) The glasses would be worn when best binocular vision is needed e.g. driving especially at night, sporting events or sports participation (gives the best depth perception) and prolonged reading or computer use. (This is called mini-monovision with distance bias)  If a person wanted to shift the clearest vision to intermediate and near (example some accountants, engraver, graphic design artist) the numbers change: -1.25 intermediate vision and -2.75 or -3.00 for reading/near eye. The glasses RX would be -1.25 and -2.75 with +3.00 add in progressive bifocals.
6.   If the person having surgery has astigmatism (aspherical or not round cornea) then the glasses RX will need a "cylinder" lens (second and third part of RX indicated by “cylinder and axis).  The vision without glasses will be less clear due to uncorrected astigmatism.   Assuming our models listed in above example and 1.50 diopters of corneal astigmatism the mini-monofocal distance bias will be 0.00 +1.00 axis 180 and the intermediate/near bias eye will be -1.25 +1.00 axis 180 and a +3.00 add in no line bifocals. This is more blurry vision than 0.00 at distance or -1.25 for near/intermediate.
7. NOTE: glasses can be written in PLUS CYLINDERS OR MINUS CYLINDERS (you can tell which by whether the sign in front of the cylinder number is + (plus) or – (minus) The two formula look very different and prescriptions in plus cylinder cannot be compared with minus cylinder.  Think about your body weight: your weight numbers will look very different whether it is recorded as pounds or kilograms since 1 kg = 2.2 lbs.  A discussion of this subject and the formula for changing plus cylinder to minus cylinders or vice versa is available at
8.  Correction of astigmatism at the time of cataract surgery is desirable.  There are different ways to accomplish this; some are simple while others complex. Some will not generate extra surgical or IOL fees but others will:  placement of incision along steep axis of cornea-make incision larger-use more steroid drops; surgical or laser corneal relaxing incisions; toric IOLs or toric mutifocal IOLs; rounding the cornea at time of surgery with brand new (2013) femtosecond laser; post operatively using  lasik surgery to remove residual astigmatism.
9. In cases where one eye has a cataract that is symptomatic and causing problems with important functions such as driving, reading, recognizing faces, glare avoidance, etc.  but the other eye has no cataract or a cataract that is small and not troublesome in people with large refractive errors special attention needs to be made to choice of IOL.   If targeting of the patient/surgeon desired refractive error post operatively generates a difference in the two eyes greater than 1.50 diopters, the person should know it may be difficult to wear glasses conformably and/or glasses (no line bifocals usually) plus a contact lens on the un-operated eye. Or  lasik or other post-operative refractive surgery may need to be done on the un-operated or operated eye to help them work together.
10. The problems outlined in #9 above may require surgery on the “other” eye to re-establish the ability of the eyes to work together with and without glasses. This can be true even if the cataract is small or even non-cataractous.  
11. So called “Premium” IOLs (toric, multi-focal and accommodating) are used to reduce dependence on glasses. For almost all people they do not eliminate glasses 100% of the time. Even people that consider themselves “not needing glasses after cataract surgery” often wear glasses for special purposes such as night driving and prolonged reading or computer use. Premium IOLs are more expensive, have a greater chance of complication (although in the hands of an experienced ophthalmic surgery the risk is small), and produce unwanted glare and scattered light (dysphotopsia) more than modern aspheric monofocal IOLs.  
12. It is also fair to say that some ophthalmology and optometry offices exert effort to encourage people to “upgrade’ from monofocal IOLs to “premium” IOLs. In sales this is not called “upgrading” but “upselling”. Also it’s important to know that some optometrists receive part of the surgical payment for cataract/IOL surgery, this is known as “co-management”.  Premium IOLs are not better than monofocal IOLs; they are not designed to make everyone 100% glasses independent all the time. Most ophthalmologists and optometrists do present a fair discussion of each type of IOL and let an informed patient make the choice that suits them best.
13. While cataract/IOL surgery is the most common type of surgery done on adults and has a very low complication rate it is not risk free NO SURGERY IS RISK FREE; THAT’S WHY YOU READ (or have read to you) AND SIGN A SURGICAL CONSENT FORM THAT INFORMS YOU OF THE DIAGNOSIS, YOUR OPTIONS AND POSSIBLE RISKS AND COMPLICATIONS. These risks cannot be entirely eliminated. No surgery is entirely “routine and risk free”   Think about driving an automobile. Driving is “routine” to most of us. Yet everyday there are people injured or killed in automobiles. We continue to drive because, with care, the risk is relatively low. Think of cataract surgery the same way.
14. In most all cases cataract surgery is elective. You can take your time and make these important decisions. There is nothing wrong with seeking a second opinion from a different ophthalmic surgeon. You can also access the many helpful discussions on these topics at the two AAO Medhelp Eye Forums by using the search feature or looking in the archives.

15. This information is not meant to give you specific recommendations. This posting is for information purposes only. You should rely on your own multi-source research and discussions with your ophthalmologist, optometrist and personal physician.

Original MedHelp Blog  - August 10, 2013

Post a Comment
Avatar universal
by Candice7575, Apr 03, 2016
What an enlightening article! Thank You for this helpful information.

177275 tn?1438375244
by JohnHaganMD, Apr 03, 2016
Happy to help. Wish everyone would read before having surgery.

Avatar universal
by hassim, Jun 08, 2016
I am 55. I have astigmatism (0.50 and 1.25) in both eyes and myopia with cataract. I live in USA and I am considering to have Symfony EDOF IOL however it is not approved by FDA yet.
Where I can find statistical information about results of surgical implants on patients? Appreciate sharing.

177275 tn?1438375244
by JohnHaganMD, Jun 08, 2016
There are number our discussions on the eye forum on the Symphony lens especially Software Developer who is wildly enthusiastic about it.  Other sources would be the company website, the FDA website and doing Internet search. I have no personal experience with that IOL

Avatar universal
by PollyJKS, Jul 06, 2016
Dear Jon, Please could you advise me.
I had cataract surgery on my non dominant eye first(right eye) and the surgeon corrected it for distance. When I came round I was devastated to find that I could no longer see my watch or phone. I had not asked the question nad had not been told this might be the case.
At this point the difference between my two eyes was 9 / 10 dioptres. I could not cope so decided to have the second eye done. I explained to the surgeon that I wanted to retain my near vision and he has put in a lens that gives me -2 I can now see things close up.
It is only a week since surgery but I am struggling when I try and do things like typing this message and watching TV - I actually feel quite sick.
Could this be because my dominant eye (left eye) is now my near vision eye...if thats the case do you think it will improve as I get use to my new lenses.

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by JohnHaganMD, Jul 06, 2016
It could be due to the dominant being used for reading and non-dominant for distance. On the other had you have opted for what is called "Full Monofocal" vision and if a person has never done that before (usually with contacts one to read one to see distance) if is frequently very difficult to adjust to and glasses are also difficult as the RX is Plano  RE  -2.00 LE and a +3 add in the form of a progressive bifocal. Anytime there is more than 1-2 diopter difference in glasses many people have trouble adjusting.  Also for anything you do one eye is out of focus and the other is doing all the work.

No way to tell if it will get bette with time. Some do some don't. You can ask for a glassesRX to equalize the eye and see how that works.

The LE could have lasik to make it 0.00 but then you will not be able to read, use a computer, shop or see anything well closer than 20 feet. Most previously myopic people hate that.

Avatar universal
by epoints, Aug 30, 2016
Dr. Hagen, thanks for a very comprehensive post.  Everyone who is considering IOL or cataract surgery should read this post.  

I have cataract condition on my right eye and right now, my dominant left eye is doing both distant and near (computer) work.  I have to use reading glasses for phone or anything that's within 16".  One surgeon recommneded monofocal (Softec HD) set for distance,  and the other recommended Crystalens for distance.  Crystalens Doctor said I would have no problem working on computer but would still require reading glasses, which I am ok.  The Softec Doctor said I would most likely need glasses for reading and  possibly for near vision.

Knowing I will need reading glasses for close reading, My questions are
1. If my dominant eye (left eye without cataract) can see everything 16" away, will any of two options counter the existing ability on the left eye?  Shouldn't I be able to see everything 16" away after my surgery?

2. I read so many horror experiences with Crystalens.  Is this more of a surgeon experience and training issue or more of a lens design issue? is there anything to gain if I go with  Crystalens?

3. If I want to maintain my ability to see distance and near (up arm's length), which option will have higher probability of achieved in such goal?

Appreciate any guidance you can give.

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by JohnHaganMD, Aug 30, 2016
To answer your questions I need your age, your glasses prescription and your vision with the glasses on.

Avatar universal
by Eyeazman, Oct 01, 2016
For post LASIK patients are you concern about increase in glare with the use symphony IOL ? What would you recommend for your loved one if (s)he had LASIK and doesn't care about wearing readers

Avatar universal
by Stan_Site, Oct 01, 2016
Distance or Monovision in the dominant eye.

I had cataract surgery and IOL lens set for distance in my left, non-dominant eye done when I was 55.  Correction in left eye is 20/20 and quite crisp.   I like having the clear distance vision and was able to function well using a contact lens in my right dominant eye (contacts: -3.5).  I used OTC readers for computer work and could read paper text directly without the contact or with the contact and a OTC reader for the right eye.

Now, 4 years later, my right, dominant eye has developed cataracts and is not correctable for far vision.   Night driving is hazardous due to the flare of oncoming lights.  I can't match right and left eyes for computer work and reading is possible but now too close (4-5 inches) with my right (super-macro) eye.  

Time for surgery again.  I was going to get a distance lens for the right (why I chose distance in the first place-photograpy), but I don't like seeing everything blur closer than 30 inches.  I am a photographer and writer and need good distance and good intermediate vision.   I am definitely right-eyed because I still have to remind myself to switch and shoot looking through the camera viewfinder with my left eye.

My doctor is recommending distance, but now I think monovision on right eye set for -1.5 or so.  My right eye is dominant, and I have been reading (above) that dominant should be set for distance.  If I went with monovision, I would probably wear contacts on my right eye for photography & driving, readers for computer and nothing for reading.

Do you have suggestions for trying to figure this out?

177275 tn?1438375244
by JohnHaganMD, Oct 02, 2016
The distance-dominant  and reading-non-dominant is just a generalization that works best for most people.    This is a generalization also.  Most myopic patients are very unhappy with a post op refractive error of 0.00 in both eyes. even if its 20/20 at distance. (20 feet or more). They can't read without glasses, can't see computer or TV.   You could aim at -1.25 in your RE that is mini-monofocal distance bias.     If you went -2.50 that would be full monofocal.   How did you feel before the RE developed the cataract. Without your contact in your Rx would be LE 0.00 and your RE -3.50  That is full monofocal PLUS

WIth your RX   LE  0.00 and RE -1.50      You would do pretty well without glasses.  The difference between the two eye is still small enough most people could wear glasses either for distance, near of multifocal lineless bifocals for all distances.

177275 tn?1438375244
by JohnHaganMD, Oct 02, 2016
by Eyeazman, 18 hours

As you know the symphony IOL was just released for use in USA. I have not managed anyone with that IOL.   My advice for family members, myself if I ever needed cataract surgery and my patients is the same.   If you've made your peace with glasses go for a monofocal IOL or toric IOL.. The optics are better, its less complication prone, less expensive, have lower rates of re-ops.

For "glasses haters" the additonal risks, expense and reduced optics may make sense.   Again not to me.

Avatar universal
by Stan_Site, Oct 03, 2016
Thanks for the suggestions.   I think I will go with mono-vision.  As an experiment, I wore a patch on my right eye this weekend and negotiated a day with only distance vision.  Every though I have readers, I found the experience disturbing for any close up work or reading, or eating breakfast, for that matter.  As you wrote, being near-sighted all my life will make it difficult to adjust to farsightedness.

With mono-vision, I could wear a contact lens prescription in the right eye after the transplant whenever I needed especially good distance, such as in driving long distance.  For camera work,  the near-far will work better, since I can sight far, yet see the controls and commands on both camera and equipment.

177275 tn?1438375244
by JohnHaganMD, Oct 03, 2016
Sounds like a thought out plan

Avatar universal
by TallahasseeLassie, Oct 29, 2016
Thanks to all (especially to Dr. Hagan and the ever so knowledgeable software writer) who post here regularly.  i have learned so much from all of you here!

I'm a 65 yr. old with bilateral cataracts, high myopia  (L eye -6+, R eye -8+)  with moderate astigmatism.  I've never been able to see well enough to do anything without glasses or contacts, and hated  "monovision" when I tried it with contacts years ago. I know someone less nearsighted than I who recently had Symfony Torics put in, and he got GREAT results--- he says he does not even need glasses to read now, except in low light,  AND he sees well at intermediate and distance.   I had planned to go with a toric monodical, as suggested by the ophthalmologist l consulted, but decided to consult the doc who does symphony IOLs in my city. However...I had a retinal tear 25+ years ago in my R eye, which was lasered and gave no further problems.  But the Symphony warnings list "history of retinal  detachment" as a contraindication for  IOLs in general, and notes that Symfony may not be suitable for those needing retinal coagulation (lasering of future tears/detachment?) Reason given:  the design of Symfony may make exam/treament difficult.

Does any one know if retinal detachments might be less likely (or less likely to be disastrous) with a toric monofcal vs. Symfony?  (I have an appointment with a vitreoretinal specialist for exam and, hopefully, advice.)

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by JohnHaganMD, Oct 29, 2016
retinal detachment (RD) is not a contraindication for cataract/IOL. In fact the rate of RD post cataract surgery is higher if no IOL is used.  Silicone IOLs might not be a good choice if silicone oil might need to be used to fix RD. I don't know about the Symphony its a new IOL. One of our surgeons did some of the FDA studies and loved it. Your best advice will be the retina surgeon on types/material for IOL.

My brother use to practice plastic surgery in Tallahassee and its a lovely city I've visited often.

Avatar universal
by TallahasseeLassie, Nov 02, 2016
Thanks for your somewhat reassuring comments, Dr. Hagan.  I'm glad to learn that a colleague of yours who is familiar with the Symfony loved it.  I've been to two surgeons so far, one recommending Symfony toric and the other recommending an alcon toric monofocal, he didn't mention Symfony.  I will avoid silicone IOLs, thanks for that suggestion. .
Yes, I think Tallahassee is still lovely, especially all the moss-draped canopy oaks and roads.  But we always lose electric power for days whenever a hurricane hits because of them, as we did in early September.    

Avatar universal
by Nicklee, Mar 27, 2017
Dear Dr Hagan,  I have just stumbled upon this article and found it very useful.  Thanks for writing this up.  I do have some questions I want to ask but the last response was almost 6 months back.  Are you still entertaing questions here before I proceed? Thanks.

177275 tn?1438375244
by JohnHaganMD, Mar 27, 2017
Yes I monitor this but the preferred thing is to post on the eye forum where questions and answers are visible to everyone and more people benefit from the discussion. But I'll answer either place.

Avatar universal
by mohan_mahajan, May 06, 2017
Dear Dr Hagan - This is an excellent article and I feel a must read for patients who are considering cataract surgery.
Thanks for the share.

177275 tn?1438375244
by JohnHaganMD, May 06, 2017
Thank you. Far too many people rush into cataract surgery when they might not even need surgery and without any thought to the huge number of variables that need to be decided on before surgery.

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