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John C Hagan III, MD, FACS, FAAO  
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Consider ALL the Options Before Your Cataract Surgery: Working Through What’s Best For You

Aug 10, 2013 - 186 comments
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Decisions before cataract surg



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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   http://en.wikipedia.org/wiki/Eyeglass_prescription
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.







Comments
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by suezq56, Aug 12, 2013
Thank you very much for a clear and concise article.  It's very helpful.

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by caregiver222, Aug 12, 2013
An excellent article. Thank you.

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by ill13632, Aug 12, 2013
I'm very myopic, nearsighted, if I have lasik surgery will I possibly go blind or have retinal detachment?  Thanks very much!

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by radar7, Aug 18, 2013
I had a cataract operation done on my left eye as night driving was becoming a bit of a problem.  Developed negative dysphotopsia which I feel is more of a bother to me than the cataract that I had.  The consent form that I signed and the literature I was given to read pre-op never mentioned this problem at all. I find this very disappointing. I wish more doctors give patients the pros and cons of cataract surgery as you have done in this excellent article.

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by jerseygirl1046, Aug 20, 2013
My husband had retinal detachment surgery 8 months ago.  He has double vision now, what can he do?  Thank You for anything you can suggest, I am concerned about his driving.  He is 67 years old.

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by John C Hagan III, MD, FACS, FAAOBlank, Aug 20, 2013
Go to the community eye forum, use the search feature and archives and read about double vision and cataractd surgery. Go to www.geteyesmart.org and find a Eye MD ophthalmologist near you that specializes in strabismus/pediatric eye surgery.   Go see him/her for 2nd opinion.

JCH MD

Avatar m tn
by zwar, Aug 21, 2013
Dear sir,
              I am 28 years old and having floughter problem in my right eye that make my job more complex while working in office on PC and one major think spot comes in front of my vision that moves after many tries to move eye from right to left then it disappear for sometime but appears again. I feel little bit heavy eye bearing some wait.so please let me know what should i do?

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by kpbf, Sep 02, 2013
by kpbf

Avatar f tn
by kpbf, Sep 02, 2013
by kpbf, Sept. 2nd, 2013

Dear Dr. Hagan,
I recently had a tecnis Model ZMB00 Diopter +21.0 D +4D multifocal lens put into my right eye on Aug. 8th and then in my left eye on Aug. 22nd.  On my day after appointments, the doctor said I had 20/20 vision in both eyes.

Unfortunately, I did not do enough research before the surgery and now I am very worried that I made a mistake especially after reading your information above.  My right eye had a severe cataract but my left eye had a small one starting.  I said I would love to not have to use glasses and she said I was a perfect candidate for the multifocal lense. The doctor did not discuss my needs or the option of the distance only lense. She also said it would be much better if I had the second eye done quickly.  I should have waited to see how the first eye responded.  It has been 2 weeks and my reading vision is somewhat doubled or shadowed.  I can read the small print but due to it not being clear my eyes feel very strained.  My intermediate vision is poor.  My distance vision is good.  I test children and use the computer for my job therefore this is a serious problem.  I have ghosting and halos during the day which I have not read of anyone else having and severe halos, star bursting, and glare at night that is painful.  I can't even drive.  I live out in the country and have elderly parents.  

My doctor's appt. is this week.  I read an article by Dr. Rosenfeld outlining seven steps to take when caring for unhappy patients.  He said definitely do not have the YAG laser capsulotomy done if you think you may want the lens explanted.  He suggested residual refractive error, residual astigmatism, ocular surface disease, poor IOL centralization, and maculopathy as well as the posterior capsular opacification which involves the YAG laser.  What do you suggest?  Do you feel any of these suggestions will help? Should I avoid any others if I may want my lens explanted.

Can I have the lenses explanted and have distance lenses put in?  How soon would I have to have them done to avoid scar tissue?  What are the risks?  Will the distance lenses cause the severe halos and star bursts that I am experiencing?

Do you know of any eye specialists that do explants in or around Louisiana?  If not, who and where would you recommend?

Thanks so much for your help,
I have been so worried that I may not be able to drive at night!!!
Pam

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by John C Hagan III, MD, FACS, FAAOBlank, Sep 02, 2013
See what your surgeon says. Then get an independent 2nd opinion. LSU has a great ophthalmology department.

JCH MD

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by John C Hagan III, MD, FACS, FAAOBlank, Sep 02, 2013
This is faculty at LSU:



  

LSU Eye Center  





Clinical Faculty

Marie  D.  Acierno, M.D. - Neuro-Ophthalmology
Bruce A. Barron, M.D. - Cornea Service
Donald  R.  Bergsma, M.D. - Comprehensive Ophthalmology
Maria D. Bernal, M.D. - Cornea and Uveitis
Christine Connolly, M.D. - Comprehensive Ophthalmology
Ira  B.  Fuller, M.D. - Retina Service
Yen Ngo, M.D. - Glaucoma
P. Sean O'Sullivan, M.D. - Retina Service
Maria Reinoso, M.D. - Retina Service
Jayne S. Weiss, M.D. - Cornea, Cataract and Refractive Surgery
  
Dr, Jayne S. Weiss MD is the best match for you Pam.

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by kpbf, Sep 03, 2013

Thanks so much!
You are a wonderful person to take time out of your busy schedule to help us!
I had a wonderful quality of life and just want it back.

Sincerely,
Pam

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by dubois564, Sep 15, 2013
Dear Dr. Hagan,

Could you kindly recommend an ophtalmologist in Boston area who is specialized in high myopia and cataract?  

Thank you in advance.

Best regards,

D

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by John C Hagan III, MD, FACS, FAAOBlank, Sep 15, 2013
I do not know anyone personally there but Mass Eye & Ear is as good as they get.
JCH MD

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by AnnSalem, Sep 22, 2013
Dr. Hagan,
I very much wish I had read your article prior to my cataract surgery three months prior.  I had a Restore IOL implant with laser technology and anesthesia applied on a sponge in the eyelid.  My ophthalmologist was pleased with the healing progress, even though my vision still required quite a bit of correction with glasses.  My major concern is that I have experienced a pain in my eye since the few days after the weekly regimen of drops were discontinued.  I can best describe this as a nerve type pain on the cranial nerves on the right orbital side of my eye, and recently pain under the eye towards the bridge of my nose.  I have returned four times to the doctor who prescribed another week of Prednisolone.  This did not work.  The only thing that changes is the intensity of the pain from hour to hour.  Some days, I look at a clock to know when I can take the next pain reliever.  I have tried Excedrin, Ibuprofen, hydrocodone in one episode, ice pack, etc.  On my last visit, the ophthalmologist indicated he had never seen this and didn't know what to recommend.  At my suggestion, he ordered an MRI although he does not suspect this will show any answers.  Subsequently, I went to my internist who tried Celebrex for an anti-inflammatory and Afrin to take off any pressure under the eye.  This is only an experiment, as he expects I have nerve damage.  Next week, he wants to try Neurontin.  The Celebrix/Afrin is not helping.  I have been very patient thinking this was post op inflammation, but now I am fairly frightened that I have permanent nerve damage.  This level of pain is not tolerable long term.  Can you please advise me of appropriate next steps.  Are there cases of anesthesia causing nerve damage?  Any direction you can provide would be most appreciated.

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by John C Hagan III, MD, FACS, FAAOBlank, Sep 22, 2013
No none of the typical complications of cataract surgery include prolonged pain. Painful nerve damage persisting for long periods of time are unknown after cataract surgery. You would need to look for another cause (sinus disease, facial pain syndromes, cluster headaches, etc

JCH MD

Avatar m tn
by Cataractjeweler01, Oct 23, 2013
Dr. Hagen,

I am a 37 year old jeweler who had a cataract in one eye. My Dr. Shoemaker in Sarasota fl, told my that the tecnis multi-focal lens was best to see close up. But now that I had it done I can not see the detail in which I could. But when tested by the card they give me to read I do much better. Even though I could not see out of my left eye will before now it seems it is disrupting both eyes when looking close up detail. I was offered to do a mon-focal lens instead. He suggested near vision and loss distance.  What do you think?

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by John C Hagan III, MD, FACS, FAAOBlank, Oct 23, 2013
The two eyes often fight one another with only one done that is called rivalry. You can try your work with a bifocal lens over the operative eye or even a jeweler's loupe.

I would suggest you get independent 2nd and 3rd opinion about your options. I suspect most will involve glasses some or most time  and/or surgery on the second eye if it has a cataract and you need more power for near vision in that eye.

JCH MD

Avatar n tn
by Sparty1984, Nov 01, 2013
I'm 52 and scheduled to have cataract surgery soon, my right eye was measured at -17 dioptors with just under 2 dioptors of astigmatism ( this eye has a scleral buckle due to detachment 12 years ago). Left eye i believe was -14 dioptors with around 1.25 dioptors of astigmatism. I'm having the lensx procedure and was told that I would need a -3 lens but they only come in powers down to -6, this will be a acrysof toric lens for a target of -2 dioptors of myopia.  The left eye will have a non toric acrysof with the astigmatism corrected by the laser with target of Plano.  My doctors thinks this mono vision should work well and if I'm not satisfied we could tweak the residual myopia with prk later.  My question does this seem reasonable or should the lens selection for the right be a lower number that could get closer to Plano.  I'm just curios to other opinions on this.

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by John C Hagan III, MD, FACS, FAAOBlank, Nov 04, 2013
LE post op uncorrected refractive error of -3.00 and RE of 0.00  would be full mono-vision and is discussed in my blog article. It works for some people not for others.

JCH MD

Avatar n tn
by Sparty1984, Nov 04, 2013
Thanks , should I consider a lowered powered non toric lens for the right eye and worry as much about the astigmatism?

Avatar m tn
by Sfwolfe, Dec 04, 2013
Wonderful,informative article.  Thanks so much!

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by David274, Dec 05, 2013
After reading about increased incidence of complications with multifocal lens, I am rethinking having ReStor lens.  There seems to be less information regarding post-op experience with Toric monofocal lens.  I have astigmatism with -7,0 D and -7.5 D with glaucoma and cataracts in both eyes.  I am leaning toward Toric   The physician recommends cataract surgery on both eyes within one week interval.    Can you comment on Toric lens, and surgery interval?   Shouldn't I wait at least two to three weeks between eye surgery?

Thanks for providing a forum for discussion
David

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by John C Hagan III, MD, FACS, FAAOBlank, Dec 05, 2013
We use toric monofocal IOLS in our practice with much success. They are more predictable for correcting astigmatism than corneal incisions.  We do not operate on the second eye until the eye has healed and the patient is very happy with the result on the first eye;  generally we do surgery about 5-6 weeks apart.
JCH MD

Avatar f tn
by fletch361, Jan 02, 2014
I am 52 years old and require cataract surgery on both eyes as a result of having vitrectomy surgeries on both eyes for macular holes (right eye 15 months ago -- left eye 6 months ago).  I am very nearsighted -8.0  in right and -7.0 in left per contact lenses prescription.  The holes closed successfully in the surgeries.  I have slight distortion out of center of right eye but overall can see pretty clearly with my contacts -- until cataracts started to form.  I am considering the Crystalens implants vs. standard lens to eliminate the need to wear contacts/glasses to see and hopefully may just need readers.  I am a computer analyst and on a computer 10 hours a day so need my near vision.  Do you have any advice on Crystalens?  The cataract specialist I am seeing does do laser cataract surgery as well and will correct slight astigmatism in my left eye.  In my online research I see very few success stories and more complaints making me skeptical; however most only post complaints.  Thank you.  Nancy

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by John C Hagan III, MD, FACS, FAAOBlank, Jan 02, 2014
Refractive and accommodate IOLs like Crystalens are NOT a good choice for someone with macular disease like you have (macular hole repair).  

JCH MD

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by John C Hagan III, MD, FACS, FAAOBlank, Jan 29, 2014
Just returned from a surgical conference in which the results of the femtosecond laser were presented and they were extremely impressive especially when coupled with intraoperative wavefront aberrometry and astigmantism correction at the time of cataract surgery. Anticipate more and more surgeons will be offering this technology which is NOT covered by most insurance plans resulting in out of pocket expenses increase.

JCH MD

Avatar n tn
by penken, Feb 08, 2014
Dr. Hagan,
I cannot thank you enough for taking time to inform so many of us dealing with unusual vision issues.  I will be having a second cataract surgery soon, but I m going to postpone and let one eye heal. My surgeon seems to be rushing me to choose a prescription for my right eye. I am having difficulty deciding on the best option.  I m glad to hear of the successes of the femtosecond laser.  I will have an astigmatism corrected and an IOL put in after cataract is removed. Just wish I didn't need reading glasses but so thankful to see as I was a -19 in the L eye and now have 20/30 vision.  I could not qualify for the Toric lens due to high myopia.  I posted  my entire complicated vision story on another thread earlier  today.  I also have strabismus. Here is my story...
I am happy to have found this blog. I am a 53 year old female, highly myopic.   Glasses at age 2. Which  now is thankfully is correctable with contact lenses. -19.50 in R eye and -19 in left. I also have intermittent strabismus. I did 40 weeks of vision therapy a  year  ago. I am now able to tell when my right eye is on.  I had   2 strabismus  surgeries at ages 6  & 8. Right ye turns in if it isn't on and left eye turns in when R eye is on sometimes. This being said, I have developed cataracts and I was seeing double in L eye due to cataract.  I had successful cataract surgery last week and I am thrilled to see very well in the distance range, but I am disappointed with having to wear reading glasses. I had a standard IOL put in left eye, mild astigmatism.  The glare from lights  and headlights has I improved since cataract was removed, but  some long glare is still apparent along with some halos still remaining.
I am scheduled to have the R eye done at the end of the month. I have changed my mind twice on whether to have a lens put in for near or far vision.  I met with my long time eye doc to get an opinion.  My R eye has a  moderate astigmatism which he will work on with laser to correct.  
I am concerned that my eyes will not team and I will have constant eye turning in if I choose to have near vision in right  eye. I need another opinion and was hoping you coukd give me sone advice.  Thank you for your time.  Sorry for such a long post. I am so thrilled with the technology that has changed my life, just want to make the best decision.  
If I wanted a 2nd opinion here in the Jacksonville Fl area could you recommend someone? I am happy with my eye group of specialists, I just wish they were more forthcoming with information.  Thanks again.  Penny

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by John C Hagan III, MD, FACS, FAAOBlank, Feb 08, 2014
Glad you enjoy the article. I cannot give you an "opinion"  As indicated there are different answers for different people. If you and your surgeon really can't decide see another surgeon for a second opinion.
JCHMD

Avatar n tn
by Terry132, Feb 21, 2014
I had cataract surgery on  left eye about 8 yrs ago with a lens implant - no idea what kind of lens. No problems with that eye since then. Cataract in right eye grew large until vision became blurry (especially if I covered the treated eye). Ophthalmologist said right eye cataract was large and recommended removal & astigmatic lens implant. Had surgery two days ago. After surgery doctor told me that 1) she decided against astigmatic implant and tried 'regular' lens; 2) eye tissue wouldn't hold 'regular' lens during surgery so she withdrew the lens. 3) she said eye was too stressed to insert lens 4) am now without cataract and without lens 5) she says to wait for about 3 or 4 weeks and then insert another 'regular' lens on the outside of the tissue (rather than the inside) 6) meanwhile, I am unable to work -- mostly I work at computer and am very uncomfortable. I am miserable and have 2nd post-operative checkup tomorrow.

I think I should get second opinion about how to continue to get right eye fixed.  Right now it is much worse than before surgery. What do you suggest? Can you give me any further information about this failure to be able to insert lens in eye?  Can the eye function reasonably well without a lens implant? I am 65.

Avatar n tn
by OneEyedJill, May 23, 2014
OMG !!  Thank you, Dr. Hagan.  I have never read such comprehensive material about the many considerations involved in cataract surgery.    I think many of us worry that we won't receive such individualized treatment.  My mother, who had Alzheimers, refused cataract surgery from fear and distrust.  In the  late 1980s, she  went blind, and died with what I can only describe as a look of terror that I was legally helpless to prevent.  They say knowledge empowers, but  it doesn't necessarily remove the fear of making the wrong choices.   Still, it is  always better to know the choices and consideratons,  than to later wish I'd known  (-:

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by Fraidycat13, Jun 11, 2014
Dr. Hagan,  Interesting article. I have cataracts in both eyes and trying to decide if permaclear is the right choice. I read articles where people had crystalens or restore lens and had many problems with the crystalens. What is the difference between all 3, pro or con on them? What would you recommend to your patient?  Thank you.

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by John C Hagan III, MD, FACS, FAAOBlank, Jun 11, 2014
Read the article again you'll learn even more.  Our practice uses Crystalens. Personally I would never consider a ReStor IOL in my eye.  Since I am all about precise optics, good night vision and have worn glasses for 50 years I would not personally choose any multifocal IOL and would go with monofocal asphric IOLs like the Technis our practice uses.. However some people hate glasses are willing to pay a lot more to use glasses a lot less and willing to put up with varying levels of dysphotopsia. There are ophthalmologists that have had cataract surgery on themselves and have had ReStor and Crystalens put in their eye.

JCH MD

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by CurlyButterfly, Jul 12, 2014
Dear Dr. John C Hagan III,
   Would you be willing to read my post I've put on medhelp and give me your input? I've been emailing back and forth with a lady who has had similar eyes as mine who has already had surgery for cataracts (which has been helpful). I wondered what your opinion might be. I've read a lot that you've written which has also been very helpful. Here is the medhelp link: http://www.medhelp.org/posts/Eye-Care/Cataracts--Toric-IOL-for-Astigmatism/show/2231723

Thank you for your time, it is TRULY appreciated! My surgery is scheduled for the end of this month. Bless you for doing this work here on medhelp.org.

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by skigirl23, Jul 16, 2014
Gosh, thanks for the great article. I am an artist who has been struggling with what to do so that I will not loose all intermediate vision.  I am also an athlete and love the idea of skiing without glasses---although I already own the goggles with the fan!!  I will reread this article until I get it--thanks.

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by learyeyed, Oct 04, 2014
Dr. Hagan,
  I am a 70 year old female. My only eye problems are cataracts ( both 2+), astigmatism ( both about .75), hyperopia, and I assume presbyopia. Cataract surgery scheduled in a couple of weeks, with a top-notch surgeon MD, in cataracts, lasik,corneal transplant, femtosecond laser cataract surgery, and etc. He will be using the femtosecond laser machine for my surgery.  I want the best clearest crisp uncorrected distance vision possible. I use binoculars for bird, and wildlife watching almost every day, and I can not wear my glasses when I do, because of essential tremors, not being able to hold my hands steady, I hurt my nose with my glasses on. Binoculars have rubber cups.  I would like to be able to see to drive at night, (haven't driven at night for past 3 years). Would like to see better in dim light. I would like to read things on grocery store shelves without glasses, and see at least 11 to 12 feet away for watching TV, and being able to read the on screen guide, when in bed at night without glasses. I would not mind wearing glasses for closeup reading or the computer. I am very active, do all sorts of projects, closeup, like sewing, and far away, like playing golf.  This is what I can dream for, but in the end just be thankful for some kind of vision.  Multifocals and crystalens are out.  With the research I have done, I narrowed it down to toric or monofocal. With the low astigmatism, overcorrection would be a concern, with the toric. My surgeon uses both the Staar and the Tecnis brand lenses. Here is my problem. He wants to use the Staar toric AA4203TL or TF. I don't know which. I wanted the Tecnis toric ZA9003, but he did not want that one.  I think the Staar is inferior to Tecnis because of it being silicone, and all of its other past problems which you are probably aware of without my listing them. One of my concerns is if I would have an eye problem where they would have to use silicone oil in my eye. I can not understand why, with a brilliant of a doctor as he seems to be, why he would choose such and inferior lens which the Staar toric seems to be.  I like the Tecnis with the features it has, and it is aspheric. At my age I don't know if the feature of it being aspheric would benefit me in the long run.  I talked with my surgeons nurse again, and she insists he made the best call with the Starr toric. This is my second surgeon I have been to. The first one wanted to implant torics also.  I am worried about being overcorrected for astigmatism, and getting an older style lens with too many faults, like the Staar. I have already paid this surgeon fully for the toric upgrade so the money is not the issue, and I don't want to go through the hassle of a third opinion.  Should I just go with his choice and hope and pray that everything turns out alright or what. Maybe you or someone who posts on here can enlighten me. Thanks much.

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by John C Hagan III, MD, FACS, FAAOBlank, Oct 04, 2014
There is no best IOL or all surgeons would use it. Just like there is no "best automobile".  All of the lens you mention are by reputable companies with good quality control.  You have set up so many qualifications and stipulations that you have almost guaranteed that no IOL and no surgeon could meet all your expectations.

You can always step back, postpone surgery and get a third opinion.

You might re-read my article again. If both eyes are set for distance 0.00 you will not be able to see a TV set at 12 feet away clearly because "distance" is 20 feet and further.

JCH MD

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by Melliforte, Dec 04, 2014
Dr. Hagan,

I am planning to have cataract surgery in 2015 and came across your helpful and detailed article about the many considerations that should go into decisions made with regard to IOL replacement. I am very interested in the Bausch + Lomb enVista lens that was FDA approved in 2012 and would like to discuss its suitability for me with a surgeon in my area (Atlanta, Georgia) who has experience with it. Have you heard of or worked with this lens enough to have an opinion about it? Do you or does anyone reading this know of a surgeon in Atlanta who has experience performing enVista lens implants?

Bausch + Lomb enVista IOL:
http://www.bausch.com/ecp/our-products/cataract-surgery/lens-systems/envista-iol#.VIEHZFfF9cs

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by John C Hagan III, MD, FACS, FAAOBlank, Dec 04, 2014
Melliforte:   I trained at Emory Dept of Ophthalmology which is world famous. I do not know private practitioners to recommend but I'm sure there are many.  B&L is a quality company. I do not have any experience with the enVista lens.  I have seen hundreds of patients with acrylic lens with glistenings but never had a single complaint so I think the "sizzle" of this lens is overstated.

JHagan MD


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by Canesee, Jan 20, 2015
Dear doctor
I am 54 years old and my eyes were perfect up until I was about 42. Over the last few years they have got worse and I now use 3.0 reading glasses. My long vision has faded but is still ok. I am booked in to have oculentis m plus lens fitted to my right eye this Friday. Now reading all this bad feed back am very worried. Would you recommend this to save me from my reading glasses?
Graham


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by John C Hagan III, MD, FACS, FAAOBlank, Jan 20, 2015
This discussion is only for people with cataracts and reduced vision not corrected with glasses.  Near vision getting worse as we age is normal and is called "Presbyopia"

JCH MD

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by PenelopeLane, Jan 20, 2015
I had cateract surgery 6 days ago.    In addition to cateracts, my eyes have VERY narrow angles, and have been a source of agonizing pain off and on for decades.  The surgeons say that the new lenses will prevent an iridotomy.  After the first surgery of last week, I am seeing light streaks from all lights at night since the 2nd day.  All set for other eye surgery in 4 weeks, also at Wilmer in Md.   My question is simple.  Do light streaks ever go away on their own while the eye heals?   The eye was set for distance 24.0. It is an AcrySof  MA50BM.  

The right eye will be set for near distance only.  

Thank you for your help!


PL

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by John C Hagan III, MD, FACS, FAAOBlank, Jan 20, 2015
Please do discuss with your surgeon, Wilmer at JH is among the best in the world. The MA50BM is a high quality monofocal IOL not associated with a high incidence of "dysphotopsia"  (search the word and read about, I have published studies on same).  In most people these streaks go away as swelling decreases and any residual refractive error is corrected with glasses.

In most cases with monofocal IOL gone by 2-3 weeks post surgery.  Permanent dysphotopsia much more likely in multifocal IOLs like ReStor

JCH MD

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by PenelopeLane, Jan 20, 2015
Thank you.

I understand Wilmer is a superb Hospital, but it takes weeks for them to respond, which is very frustrating.  I have researched the lens only yesterday, but found nothing that indicated how long it could take.  Knowing the facts keeps me calm . . .

I do not want more troubles with my eyes.  Decades of it has been debilitating, and frightening.


Thank you for your kindness, Dr. Hagan.   I feel better!

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by John C Hagan III, MD, FACS, FAAOBlank, Jan 20, 2015
Every reason to suspect you will do well. JCH MD

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by Mizmo412, Feb 10, 2015
Thank you so much for the write up above.  My situation is addressed in #9; non-dominant eye has cataract ready for surgery, dominant eye has cataract as well, but not deemed as significant for surgery yet.  I have very good distance vision, and require +1.5 for reading.

The Dr was pushing ReStor, but I'm not willing to deal with the halos/glare or reducing the sharpness of my distance vision.  I've been trying contacts to mimic monovision and seem to be able to tolerate it.  

Dr is recommending -1.75 or -2.0 anticipating further denigration of my vision.  However, neither worked for me with contact trial; I was unable to read the computer.  

How much additional denigration should I anticipate after implanting an IOL?  I'm 54; I've read that most of the change occurs during 40's & 50's.  My thought is to go with mini-monovision, with -1.5 in the non-dominant eye, which would give me near vision now though I may need readers for near vision in the future.  It also minimizes depth perception issues, which is somewhat of a concern, since I am a skier.

Is there any reason to consider Crystalens?  I initially eliminated after 2nd Dr told me they tend not to work over the long term, but haven't seen that issue validated in the research I've read.  What I have read is that Crystalens is good for intermediate and distance and most likely will require glasses for near vision.  If so, I don't see advantage over mini-monovision -- am I missing something?

Finally, could explain mini-monovision with distance bias in layman's terms?  If I understand correctly, distance glasses would essentially reverse the IOL and near glasses Rx would be for both eyes, with distance eye getting an addition 1.50.  I lost you at +3.00 for progressive bifocals.

Thanks in advance for your response.



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by John C Hagan III, MD, FACS, FAAOBlank, Feb 10, 2015
The loss of focus power with age called presbyopia stops when an IOL is put in the eye.   Mini-mono distance bias would be to leave your operated eye which has good vision at 20 ft or further (  glasses RX would be zero or as we say plano) and in your unoperated eye to put in an IOL to leave you about -1.25 or -1.50     With no glasses distance and mid vision (shopping, speedometer, etc) should be clear. For prolonged reading, very small print or prolonged computer use you would need glasses generally no line progressive     Mini-mono near bias is for myopic people that have always been able to read with out glasses and want to keep it that way.  Their target refraction would be about -1.50 and -2.50   they should be able to read well without glasses and likely use a computer. They would need glasses (again no line progressives for distance like drtiving) they are use to that and don't mind.

Our practices uses Crystalens and when done by a skilled experienced surgeon it is the best of all the multifocal/accommodating IOLs in my opinion. We also have people that have had a monofocal IOL successfully set for distance like you that have a Crystalens in the other eye and they can use computer and read without glasses.  Again to use both eyes need progressive bifocals.

The thing that makes this difficult: there is no best IOL there are lots of good ones, there is no single answer for every person and what makes one person extremely happy another might consider a poor result and be very unhappy

JCH MD



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by Joanlimsaw, Mar 15, 2015
Dr Hagan

I have bilateral cataracts and have been advised to remove them.
Since at a young age I've been rather myopic and at present -9.25 and -10.5
I also have astigmatism but not sure how much
Plus glaucoma in both eyes, the left eye having lost about 20% sight.

My doctor suggests that I have intraoccular lens in my dominant eye for far vision and in the less dominant eye for closer/ reading vision as I have been using contact lenses following this principle.
But now I am having the lenses implanted into my eye and would dearly like your opinion on it.
Thanks




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by John C Hagan III, MD, FACS, FAAOBlank, Mar 15, 2015
If you are use to "mono-vision" (discussed in my article) then you might opt for what is called "full mono-vision"  i.e. distance eye Plano (zero power) to -0.25 and for reading -2.75   however there would still be some distances you would still need glasses to see (intermediate vision ) and of course you would only be using one eye for distance and one for near to your acuity and depth perception will be reduced since these require both eyes being used together.

Most myopic patients are use to glasses and do not object to wearing them post operatively and are generally happier with the mini-monovision with near bias or mini-monovision with distance bias.  You might inquire about your astigmatism and if over 1 diopter discuss toric IOL

JCH MD

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by Joanlimsaw, Mar 16, 2015
Dr Hagen

Is it advisable for a bilateral cataract patient who has bilateral glaucoma and has lost,about 20% sight in one eye to have premium multifocal iols?
Also some degree of bilateral astigmatism and highly myopic

Thank you

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by John C Hagan III, MD, FACS, FAAOBlank, Mar 16, 2015
A toric lens would not be a problem but multifocal and accommodating IOLs are something I advise my glaucoma patients against.

JCHMD

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by abrahamic, Mar 17, 2015
Dr. Hagan,

I'm a 30-year old man with big cataracts in the non-dominant right eye. I scheduled for cataract surgery in 7 weeks, but upon seeking a second opinion, I was diagnosed with Uveitis, high cup/disc ratio (I'm not sure how serious this is) in the cataractous right eye, and possibly some signs of Fuch's Corneal Dystrophy in the non-cataractous left eye.

1- Do I have to reschedule my cataract to avoid any complications? (2nd Dr suggested extensive checkup to find out the cuase of Uveitis which may have cuased the cataracts)

3-When I develop presbyopia in my dominant right left eye in 10-15 years, how will that affect the near/intermediate correction I intend to choose with the IOL in the non-dominant eye? (I currently wear 1.25 near correction in the left eye, and my distance is just fine for driving 20/30)

Thank you for taking the time to address our questions.

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by John C Hagan III, MD, FACS, FAAOBlank, Mar 17, 2015
1. Since cataract surgery is elective and uveitis is a special problem I would suggest having the uveitis evaluated before the surgery. It make a difference in which medications and how long they are used before/after your surgery.
2. Assuming the dominant LE does not develop a cataract after presbyopia you will likely need to wear progressive bifocals to use the two eyes together.

JCH MD

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by Joanlimsaw, Mar 25, 2015
Hello Dr Hagan

Does intermediate vision mean the distance referring to an arm's length from the eye?
As I'm considering aspheric iols for long vision in one eye and close/reading vision in the other eye, you stated in your reply that I may need glasses to see in intermediate vision. Are you referring needing glasses to read on the computer screen for example or is it that everything within this distanc of area will be blurred?

Thank you


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by Joanlimsaw, Mar 25, 2015
Hello Dr Hagan

Does intermediate vision mean the distance referring to an arm's length from the eye?
As I'm considering aspheric iols for long vision in one eye and close/reading vision in the other eye, you stated in your reply that I may need glasses to see in intermediate vision. Are you referring needing glasses to read on the computer screen for example or is it that everything within this distanc of area will be blurred?

Thank you


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by John C Hagan III, MD, FACS, FAAOBlank, Mar 25, 2015
It is an admittedly inexact term but roughly 3 to 15 feet, would encompass computer, shopping and watching TV in small to medium size rooms.
JCHMD

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by Joanlimsaw, Apr 03, 2015
Dear Dr Hagan

I am going to have my 1st cataract operation within the next few days.
Can you please tell me if an implanted iol needs to be removed and replaced, would it be complicated and difficult with risk of eye damage?
Thank you for your prompt answer always

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by John C Hagan III, MD, FACS, FAAOBlank, Apr 03, 2015
It is extremely rare to have to remove or replace a intraocular lens.  Probably less than 1 in 1000. And not difficult to replace  if necessary.
JCH. MD.

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by Joanlimsaw, Apr 07, 2015
Dr Hagan

I have just had an aspheric mono iol implanted in the right eye for long distance 6 hours ago
In that eye the image slants somewhat to the right and is not horizontal. Is it too soon to worry? Must I give more time for the eye to adjust?


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by John C Hagan III, MD, FACS, FAAOBlank, Apr 07, 2015
The MedHelp legal staff has advised us not to answer questions asked about surgery or in the immediate post operative period so you will need to ask your surgeon that.
Best of Luck.
JCH MD

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by Joanlimsaw, Apr 07, 2015

Thank you Dr Hagan.
I do understand your stand point.
However I do want to thank you for your help every step of the way to my iol implant.

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by SLMitchell, Apr 13, 2015
First of all, thank-you so much for all your invaluable information! I have cataracts in both eyes, worst in my non-dominant right eye.  I have been myopic since a teenager.  I have to have something done soon; however, I have been researching this issue and iols for many months and am still immobilized by a lack of decision re: which iol to have, whether to have laser-assisted surgery, etc.  I will come up with the additional money for the premium lenses if they are worth it! I thought the nanoflex lens sounded great, but cannot find current information regarding its track-record. Also, is there some "miracle" lens about to be approved that would be worth waiting for?  Thanks for any input you might offer.

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by John C Hagan III, MD, FACS, FAAOBlank, Apr 15, 2015
Since you are myopic you are use to wearing glasses and seeing clearly up close without glasses.  So spending the extra money for an accommodating or multifocal IOL would likely not be worth it for you and these lens are more prone to cause glare (dysphotopsia). If you have astigmatism a toric IOL is worth considering.  Cataract IOL is highly successful and at present very few patient spend the extra money for laser assisted surgery. However the technology while it adds some benefits is not really necessary if money is a problem.  At present 99% of our patients do not opt for femtosecond laser.

There will always be new IOLs coming out none are going to be breakthrough.  If you need the surgery don't put it off. I saw 4 patients yesterday for their last post cataract/IOL surgery visit and they were all ecstatically happy.

JCH MD

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by Joanlimsaw, Apr 18, 2015
Dear Dr Hagan

It's been 11 days since I had an aspheric iol implanted in my right eye.
I received good clear sight all along until yesterday night watching television that the images were not sharp  anymore until this morning
As instructed by my doctor I have Tobradex drops 5 times daily since after the cataract operation
What can cause this and is it temporary?

Thank you

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by Joanlimsaw, Apr 18, 2015
Regarding above letter I forgot to mention that since yesterday morning I have a sore throat so could be an impending cold/ virus infection

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by John C Hagan III, MD, FACS, FAAOBlank, Apr 18, 2015
Sorry have to repeat:

The MedHelp legal staff has advised us not to answer questions asked about surgery or in the immediate post operative period so you will need to ask your surgeon that. All major changes should be reported. Minor day to day fluctuations are not unusual.
Best of Luck.
JCH MD


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by mizdara, Apr 20, 2015
Dr. Hagan, ten years ago I had cataract surgery for my right eye and received an implant for distance vision. Now I have been advised that I required a laser correction. In addition, it is now time to remove the cataract in my left eye. It was recommended to me to get a lens for close vision in that eye and thus eliminate the need for glasses. Two questions: Which proceedure should be done first and because I am a jeweler, should I consider the recommended lens or just get another lens for distance and use reading glasses plus jeweler's optics? I want the easiest and most effective solution.

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by John C Hagan III, MD, FACS, FAAOBlank, Apr 20, 2015
Likely the procedure you need on your RE is a yag laser capsulotomy. If that is the case it is generally done first.  Sometimes the other eye bothers you less and sometimes more when the RE sees better. I suggest you re-read my article and get a second opinion about lens choices.  As a jeweler you need the best possible vision out of both eyes to allow yo to work.  The recommendation you have been given to have one eye for distance and one for near and not need glasses is not really the case.   That is called full mono-vision and is discussed in my article.  If you choose that option you will be doing your jeweler work with one eye, your driving with the other eye, you lose depth perception, don't see as well, there will be distances you can't see well and full mono-vision glasses are often difficult to adjust to and wear.

JCH MD

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by Joanlimsaw, Apr 30, 2015
Dear Dr Hagan

Can you tell me how serious is the possibility of vision loss for post op cataracts patients with glaucoma?
How high an IOP before it poses to be a danger and is vision loss reversible once the IOP is down to normal controlled level again?

Thank you

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by John C Hagan III, MD, FACS, FAAOBlank, Apr 30, 2015
For the great majority of glaucoma patients cataract surgery does not impose increased risk and extremely often the intraocular pressure goes down several points. Cataract surgery is now thought of as a treatment for glaucoma. For patients not well controlled or on several eye drops new types of glaucoma operations called MIGS procedures are often done at the same time.

In both normal and glaucoma patients there is sometimes a spike of IOP after surgery especially if the surgery was complicated but generally can be controlled with eye drops.

So bottom line cataract surgery is usually good for glaucoma and is being done earlier in glaucoma patients than non glaucoma patients.

JCH MD

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by sharmex, May 17, 2015
Dear Dr Hagen :
I am an active 79 year old  Internist from Hickory NC  .I have bilateral cataracts,I could not pass the Driver test at the local DMV, I was sent to an Otholmologist who  gave me Diamox and combigan and few days later wated me to come back. My IOP was 40 initially in the R eyer inputou and 18 in the Left. A few  days later he recheked the pressure in the R eye it was 12, he scheduled me cataract removal surgery.
I went and after 40 min. i came out of sugery,my wife was told he could not put an IOL as there was no tissue to hold it,he told me later the posterior bag collapsed and he put four stiches to hold it. I am blind in in oe eye now!
Thanks for your input
Govind sharma, MD

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by John C Hagan III, MD, FACS, FAAOBlank, May 17, 2015
Dr. Sharma: In a situation like this generally I would recommend going to the finest tertiary eye care center that you can get to and from on a regular basis. Examples might be Duke, U of NC, Vanderbilt or Emory. I would do this ASAP. Likely your local ophthalmologist would be more than happy to have the help of an internationally known department of ophthalmology.
Your most important eye is the unoperated eye and everything needs to be done to be sure that it will not have an attack of glaucoma as the R eye did.  The fact that you failed your drivers license and had cataracts suggests you have not had your eyes examined regularly by an ophthalmologist as these problems with cataracts typically develop over years.
Another question is why did your RE have an IOP of 40.  Was it angle closure glaucoma due to the cataract. This is highly possible especially if you are hyperopic (farsighted). That puts your LE at high risk of having the same problem and hence the need for a world class group of ophthalmologists.
It is likely that your RE will not end of blind but you may need the services of a retina surgeon to be sure there is no retained lens nucleus or cortex, a glaucoma specialist to control the IOP in the RE and examine the LE to be sure it could not suffer the same fate.  After the operative eye has quiet down, inflammation controlled, IOP controlled the Eye will need either fitting with a aphakic contact lens or you would need a posterior chamber IOL sewed into the eye by a ophthalmologist that specializes in cataract surgery complications.
I would urge you to move quickly on this situation. This is why we have referral centers like Duke, UNC, Emory, Vanderbilt and others. Best of luck.
JHaganMD


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by excaptain, May 30, 2015
Dear Dr. Hagan,

First, I can't say enough how grateful I am for your post and for all your contributions to the forum. My situation is probably rather peculiar, I would love to hear your thoughts.

I am male, 39, and in 2007 I had a vitrectomy on my right (dominant) eye for severe floaters (secondary to partial PVD (probably related to a car accident I had in 2006)). There was one complication from the vitrectomy (which was sutureless), and that was severe hypotony. Unfortunately the cause was misdiagnosed as choroidal effusions, whereas in reality it was leakage from the scleral incisions. The hypotony eventually resolved on its own but only after 3 months where for 2 of those 3 months they gave me steroid drops (they thought the cause was choroidal effusion) so that probably delayed resolution of the hypotony (in addition to not suturing the incisions, of course). In any case, after the hypotony resolved vision returned to 20/20 and everything was fine until about 6 months ago, when vision started to gradually deteriorate. Cataract was diagnosed in April.

The questions I have are:

1. Before the cataract in my right eye started, I was -2.00 in both eyes (with minor astigmatism of -0.5 in right eye caused by the vitrectomy). I have been myopic all my life, and I used -2.00 glasses basically for everything (including computer work and reading at arm's length) and I don't mind them at all. I am planning to ask the cataract surgeon to aim for a -2.50 prescription so that I remain myopic, my eyes do not have a big prescription difference (-2.00 and -2.50), and that I can continue to use one pair of glasses "for everything". The idea is that the right eye with -2.50 will allow me to see very near without glasses if I wish, but generally for reading (at arm's length) computer work and far distance I will use the same pair of -2.00 (LE), -2.50 (RE) glasses (instead of having a bunch of readers for the various distances). Am I understanding this correctly or will I still need various pairs of glasses or progressives? Do you think perhaps I should think about trying to aim for -2.75 or -3.00? Also I'm thinking aiming for an IOL that optimizes for "near" reading will also be beneficial once presbyopia sets in in my left eye (this is already happening; I find it harder and hard to focus on very near objects with that eye).

2. I am thinking of asking for the Alcon Monofocal Natural lens (the yellow tilted one). This is for two reasons. First, since the left eye does not have a cataract and hopefully will not have one for several decades, I want the color and brightness seen by both eyes to be roughly the same, and I believe the Alcon Natural lens will do that. Also since, hopefully, I will live several decades with the IOL in my eye, the potential protective benefits against AMD over such a long period seem like something that will have more significance for me as opposed to a very elderly person. Am I on the right track here?

3. Even though the hypotony has not returned since it resolved 8 years ago, I am  worried that the vitrectomy incisions may open up during the cataract surgery and this would cause hypotony again. After all, the vitrectomy incisions were never sutured and they only did heal after 3 months after a lot of steroid drops that were prescribed in error. I of course will mention all this to my surgeon, but is there anything related to this concern that me or my surgeon might specifically need to pay attention to during the operation or in the post-op period?

4. The retinal specialist who diagnosed the cataract said that I should have it removed "this year" because, due to the vitrectomy, if I wait the cataract will be harder ("like a rock") than a usual cataract. Are there any issues generally related to cataract after vitrectomy that I need to pay special attention to during the operation or in the post-op period?


I have an appointment with a cataract surgeon next month to discuss options, so more than anything I would be grateful for any information that I could use to query my surgeon in order to have the best surgery and outcome possible. Of course, I understand that this is the internet and that you cannot give specific medical advice for my case, what I am looking for is pointers and what issues I should discuss with my surgeon.

Thank you in advance, and thank you again for all your amazing help in this forum.


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by John C Hagan III, MD, FACS, FAAOBlank, May 30, 2015
No the same glasses won't work because the IOL (intraocular lens) is fixed focus and does not adjust to focus at different lengths. So if you end up -2.50 and have those glasses on you will not be able to see clear at distances closer than 20 feet with them on.  Even if you did not have cataracts in 3-4 years because of presbyopia you would not be able to read with your distance glasses. on.   You will also have problems with your eyes working together with the LE until it has cataract surgery (this may be quite a while as the likely cause of your cataract RE is the vitrectomy and a reason I don't recommend these floater procedures to my patients).  Most surgeons would advise you not to aim for a near reading refraction greater than -2 or -2.25 at most.  

2. All Alcon lens are excellent.   Again I want you to discuss with your surgeon the major problems of your eyes working together post surgery.  Since the LE does not have a cataract you might want to discuss a Crystalens or multifocal IOL for the RE. You should consider getting a second opinion from another one or two cataract surgeons to make sure you understand your problems matching your eyes up.

3. Vitrectomy incisions are small and very very unlikely to "open up"  I would not worry about thiat.

4. A vitrectomized eye usually does not behave much different than one with normal vitreous other than the cataract and anterior chamber are often much deeper during surgery. Most surgeons can work around this easily.

As a summary I think you need to consult with a minimum of one and ideally two cataract/IOL surgeons to discuss further the problems you will have for a long time  with teaming the eyes up when one has had cataract surgery and the other hasn't.

JCH MD

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by excaptain, May 30, 2015
Thank you so much for kindly responding so fast. All of this is extremely important information that I will use to talk to my surgeon. In particular, I think that indeed I will ask to aim for a -2.00 or -2.25 outcome instead of -2.50 to -3.00 that I was thinking about before. I will also definitely ask about the crystalens (I'm not considering a multifocal like Restor because of the huge amount of problems that people have been reporting on this forum and many other places).

Most importantly, I will thoroughly discuss post-surgery expectations and how the eyes might be expected to work together. Probably the solution will be progressive lenses of some sort. Actually it is quite surprising to me how well my brain has been able to cope with the cataract: even though my right eye basically has had a myopic shift from -2.00 to at least -5.75, with severe monoocular diplopia in that eye and -1.25 astigmatism (up from -0.5), and even though I am wearing cheap temporary glasses that don't correct all that (-5.25 for right eye with -0.5 astigmatism) the amazing thing is that when both eyes are open basically the brain takes all the image from my left eye but keeps good 3D vision (depth perception) by somehow incorporating the right eye information and eliminating all the unwanted artefacts such as the monocular diplopia, and I get very good 20/20 vision if both eyes are open. This is probably a little similar to full monovision? Of course, the cataract is getting worse and fast (it was about a diopter a increase in prescription every month, though that has now slowed down it seems) so I'm not sure how much longer I will be able to tolerate it going forwards. Anyways the fact that I can tolerate a 3.75 diopter difference without major problems gives me some hope regarding the eyes being able to work together after the surgery.

Thanks again for all your help, and the amazingly fast response. I am so grateful. God bless you.

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by John C Hagan III, MD, FACS, FAAOBlank, May 31, 2015
Yes best of luck. Your "can do" attitude will help as well as your ability to wear glasses now with -5.25 in one eye and -2.00 in the other. Most people can't handle that at all.
JCH MD

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by excaptain, Jun 02, 2015
Thank you again Dr. Hagan. Also, I am writing here because due to your comments regarding thinking about how the eyes would work together after surgery, I was searching around and I found an amazing technology I was unaware of until yesterday, from a company called Adlens, which have just come out with variable prescription glasses which can adjust the prescription INDEPENDENTLY for each eye, whenever you wish (using a knob for each eye) over a range of 2.5 diopters, and you can have those glasses made to a distance prescription up to -6.00!

I am posting here because I think this will be of great interest not only for single-cataract patients like myself, but rather also to all monofocal lens cataract patients and actually everyone who is currently using progressives for any reason. Actually the company specifically mentions the post-cataract use and also has a white paper on how this might help with fluctuating vision due to diabetic retinal disorders (not that I have them, but others in this forum might). Here is the link:

https://www.adlens.com/product/adlensfocuss-quantum/

and here is an explanation of the technology:

https://www.adlens.com/our-technology/

and a video:

https://youtu.be/BWB3grviSKs

These seem to be much better than progressives because they have a much larger field of view without distortions. Actually they JUST started offering this widely for consumers, and I do mean JUST: I searched for this yesterday, and it turns out that yesterday, June 1, 2015, was their official nationwide rollout day for these glasses! How is that for great timing! here is the site of the rollout:

http://adlensfocuss.com/

I also continued to dig around and I found this in-depth (very positive) review of these glasses (by an "early adopter" during the testing phase):

http://encinitascomputerhelp.com/techblog2/?p=311

and there is even a youtube review of the glasses:

https://www.youtube.com/watch?v=bPXDIqC4af4

I gave Adlens a call today, and they confirmed that I can get these glasses with my prescription, including astigmatism. It is not cheap though: about $900. So definitely more expensive than regular glasses, however, maybe that's not the fair comparison: it is much cheaper than an accommodating lens such as Crystalens and without the increased risks of a bad outcome that I've seen people report on this forum. Also the convenience of adjusting the prescription on each eye is so much better than tilting my head up an down, and the field of view is much better, so I can definitely see myself shelling out the extra money for these glasses. I'm just amazed that this thing came on market at the exact same day that I searched for it.

Anyways, this was a long post, but I think this information may be useful for many cataract patients and eye patients in general, so I thought I should post it.

Thanks again Dr. Hagan for pointing out how wrong I was regarding the thought about using the distance glasses post-cataract; this set me on the path to finding these things. I did a search on "adlens" on medhelp and I could not find any references, so this is probably new information to forum participants - I hope it is useful.

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by John C Hagan III, MD, FACS, FAAOBlank, Jun 02, 2015
I have no experience or knowledge of this lens and cannot make any comments.  Any progressive multifocal glasses can have the reading/intermediate lens separately adjusted. I did this today on a patient in late 40s with a traumatic cataract in one eye   RE. The LE eye does not have a cataract.  This is what the RX looked like:

RE: -1.25                                      Add: +3.25        20/20 Vision
LE: +0.50 + 0.75 axis 180            Add: +1.75        20/20 Vision


JCH MD

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by taniakbsn123, Jun 20, 2015
My Mother in Law just had cataract surgery with corrective lens placement.  I don't have specifics on how they corrected her vision, but I believe she was expecting to have 20/20 vision or better.  She is very disappointed as she is only able to see 20/30 at this time.  It has been less than a month since her surgeries.  We are trying to be supportive and I'm a RN, but this is just not my field.  What is the success rate for this type of surgery and can you expect to have crisp perfect vision after the procedure?  What are the risks for changing out lenses if the are not working out correctly?  

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by John C Hagan III, MD, FACS, FAAOBlank, Jun 20, 2015
I don't think you've read the introduction paper I wrote for  these series of discussions.   Go read it and then if you have any questions please post.

JCH MD

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by Cooper2013, Jun 23, 2015
I'm 58 female and I was diagnosed with cataracts in both eyes about 3 years ago and they had not been bothering me much until recently the one in my R (dominant) eye (fuzzy vision, difficulty reading street signs, words on TV). My left eye improved with new corrective eyeglass lenses, but not my right which remained fuzzy with updated lens.  The eye surgeon I went to said that even though my left isn't bothering me as much, cataract surgery would need to be done on both eyes due to my high myopia which I understand. He said there would be no reason to postpone cataract surgery given the vision my right eye is giving me.
I inquired about Multifocal lenses as I would like to be less dependent on glasses.
As a high myopic, are there special considerations for a multifocal lens?  Or would I be better off with the regular IOL.  I was given information on Tecnis 2.75 and Crystalens HD.
I have worn glasses since I was 6 years old, so if I need to have "readers" while doing computer work it wouldn't bother me much, however I would like to have more freedom from glasses while out and about at the grocery store reading labels, texting on my iphone or ipad and driving, although I don't do alot of night driving I like to feel confident of my vision behind the wheel.
I was fairly confident of wanting to go with the Crystalens or Tecnis 2.75 until I started reading some posts and the problems associated with them.  I want to feel like I've made an improvement with my cataract surgery and not created more problems for myself.  As I age will these mulitfocal lenses not perform as well? Also, my astigmatism is not very bad?  But I see comments about Lasik to correct and my astigmatism wasn't addressed at my consult and I forgot to ask.

OD -9.25     cylinder +1.25     Axis 120     Add +2.00
OS -9.25                   +0.75             050            +2.00


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by John C Hagan III, MD, FACS, FAAOBlank, Jun 23, 2015
Our practice uses the Crystalens and its success is very much dependent on the skill and experience of the surgeon. Fortunately our lead refractive surgeons are superb. I do not know if the Crystalens comes in the power you would need, you would need some measurements on the length of your eye, corneal curve, etc then compare with their power range.  I have no experience with the Technis lens for multifocal use but the monofocal IOLs are excellent.

Please re-read my intro article as it has very helpful and important information for you.

The IOL does not age like the human lens so the glasses RX and post operative refraction does not change with age like the human eye ages. Whether you choose a monofocal IOL or a accommodating IOL you likely will be much happier, see much better and be much less glasses dependent after your surgery given the high myopia you have now.

The risk of a retinal detachment is higher in high myopes and goes up even more after cataract surgery. Consider asking your cataract surgeon to refer you to a retinal surgeon before surgery to carefully examine your retina for holes, thin areas that might need to be treated BEFORE cataract surgery and ask about having the retina surgeon re-examine your eye a week or two after cataract surgery.

JCH MD

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by Cooper2013, Jun 24, 2015
Dr. Hagen,

Thank you for the info, in particular about examining the retina for holes and thin areas before cataract surgery.  You have also reassured me that I would probably be happier with my vision after surgery and less dependent on glasses...YEA!

I'm still wondering about astigmatism..having worn contacts that didn't correct astigmatism when I was younger, I'm familiar with what the vision was like then.  Witih glasses, my astigmatism has been corrected but with cataract surgery I would not have that correction?  I know my astigmatism is not enough to warrant toric lenses and in some of these posts I've read where some people have thought their astigmatism got worse.  Would that be able to be fixed if it got to be an issue?

Thank you for any and all info, this has been informative for me.


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by John C Hagan III, MD, FACS, FAAOBlank, Jun 24, 2015
Multifocal IOLs are not available with toric corrections.  The placement of the incision can be altered to reduce astigmatism by operating on the steep axis,  corneal relaxing incisions can be use or you can wait and see how you do after surgery. If it should be a problem then post operative astigmatic lasik could be done.

Since you're shopping for high end surgery you might also investigate femtoscecond laser surgery.  It adds to the cost but its the state of the art. The femtosecond laser makes the incision into the eye, reshapes the cornea to eliminate astigmatism, makes the opening into the lens, breaks the cataract into very small particles that are much easier to remove, double checks the power and alignment of the IOL while its still in the eye.

JCH MD

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by carolyn_mw, Jun 24, 2015
Dr. Hagan,

I'd like to add my thanks also for your information and the time you take to offer advice.

I'm a 58 yr old female with a cataract in my right eye.  It developed fairly quickly over the last 18 months and interferes with daily activities.  I just had an appointment with a well known doctor and was pretty much just told that I would 'love' the results of going with a multifocal IOL and not really presented with information about the monofocal lenses.  After reading your information I definitely want to get a second opinion.

I work with computers all day and enjoy other close up activities such as fly tying, beading, and gardening.  I'm nearsighted and have worn glasses since early teens and am comfortable with them so being 'glasses independent' is not a big factor for me.  I have had progressive lenses in the past but did not like having to always tilt my head to find the 'sweet spot' for the focus I needed and have had tri-focals for about 5 years now.  My mother developed the wet version of AMD in her late 60's so the chance of my developing this also has me concerned about the mulitfocal lenses.

I'm thinking that I would be happier with mono focal IOLs and am wondering if you have any recommendations for other doctors or facilities in Omaha, NE.

Thanks,
Carolyn

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by John C Hagan III, MD, FACS, FAAOBlank, Jun 25, 2015
One thing that I have pointed out and acknowledge exists everywhere is "pressure to upgrade". Reimbursement for cataract surgery and IOL insertion has decreased dramatically over the past two decades even though the operation is much more complex, the patient expectations much higher, expenses have gone up dramatically and malpractice insurance and junk lawsuits have escalated.  That is why cataract surgery is no longer done in hospitals and is in outpatient surgery centers in which the surgeons have an ownership.   There is something wrong when putting a crown on a tooth costs the patient 2 to 3 times what cataract/IOL surgery costs.  

Some upgrades like toric IOLs and femtosecond lasers I think can be justified. We have many happy patients with Crystalens in their eyes including one of my best friends. The majority of our IOLs however are monofocal. At this time 6/25/15  if I were having cataract surgery I would choose a monofocal or toric IOL.  This is not true for everyone especially people that hate glasses or that would put up with reduced quality of vision and glare to avoid glasses as much as possible.

I believe everything else I can say is covered in the long article. I do not know any surgeons to recommend in Omaha.  Consider 3 different opinions and don't be afraid to resist the pressure to upgrade.

As far as the wet AMD.  There is a big lifestyle component to reducing the risks of developing: don't smoke or us any nicotine or marijuana products; protect your eyes (skin also) from sun exposure with sunglasses, UV blocking coating on all glasses, hat, high SPF sunscreen; eat a great diet----vegetables, fruit, fish, fiber, nuts, berries. Avoid fatty foods both saturated fats and high calorie processed carbs;  look up food that is rich in lutein (spinach and kale are highest) and eat lots of lutein rich food. Obesity is a risk factor for AMD so watch your weight and exercise moderately.  AREDS 2 supplements have not been shown to reduce the risk of AMD developing in people that eat good diets so there is no evidence taking them will help.  I suggest to my patients with this type of family history that they consider taking lutein 10-20 mgm/day as a supplement. The amount of Lutein in centrum generic vitamins is miniscule (1/4 mgm).

JCH MD

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by excaptain, Jun 25, 2015
Dear Dr. Hagan,

I have seen two cataract surgeons and I thought I'd post an update. Both surgeons are highly respected in the area I live in. I discussed with both surgeons aiming for -2.00 prescription, and they both agreed it was a good idea to aim for that target. Both surgeons said they are very comfortable operating on vitrectomized eye (have done hundreds of those procedures) so they were very confident they could operate successfully. I discussed at length how the eyes would work together after surgery with the first surgeon, who said that we could explore usage of progressives but that in his experience for young eyes it may still be possible to use distance correction for lenses, where for near vision I would look beneath the glasses and for intermediate vision the accommodating eye would take over. Perhaps that is possible though that sounds a little optimistic to me.

The first surgeon does not work with Alcon natural lens (only with Tecnis) so that is the primary reason why I will choose to do the surgery with the second surgeon, who uses Alcon lenses exclusively. Actually the first surgeon did work with Alcon natural lenses a few years back, but the hospital he works in got a better deal for the Tecnis lenses so he does not have access to the Alcon lenses anymore, though he said they are great lenses. I think it is prudent to insist on a blue-blocking IOL because a clear IOL is more likely to produce a color and brightness imbalance with the other eye. The first surgeon said that the brain will successfully meld the two colors together, which is probably correct, but still, I don't want colors and brightness to be completely different in the other eye - it might be bothersome and weird. Also the potential AMD protection benefits of the blue light filter seem important, especially since the lens will (hopefully) be in my eye for several decades.

Another reason I will be going with the second surgeon is that she agreed to do the operation under general anesthesia. I know that this is generally a topical/IV anesthesia sort of procedure, however, it boggles my mind that such a surgery would be done under such minimal anesthesia when the lens capsule walls are only 20 microns thin. Wouldn't even a slight movement of the eye or head during surgery be dangerous (cause a capsular tear)? Of course this has to be weighed against the dangers of general anesthesia but, still, my gut tells me that it would be better for me to be complete immobilized. I also had general anesthesia for the vitrectomy. The surgeon said that usually general anesthesia is not indicated for cataract surgery, however if I was anxious about it she had no problem in offering it.

One thing I did want to ask you, Dr. Hagan, is, in your experience (speaking generally of course), how long after a cataract in a vitrectomized eye starts to affect vision does the cataract need to be operated upon? Specifically, when does it become too "hard" for it to be operated upon? After a year? Two years? The retinal specialist who diagnosed me said I should get it operated on "this year" (2015), so I assume in the next 6 months. The first cataract surgeon who saw me said my cataract is a 6 or 7 on a scale of 1 to 10, but that a cataract that is too hard would be a "9" and that comfortably I have one year before it reaches that state. I told the second cataract surgeon about what the retinal specialist said but she was not too worried, even though she said my cataract was "dense". The only reason I am asking is that while I am on the waiting list for surgery for the second cataract surgeon, the wait list is up to a year (she is very much in demand). She said she has done 1000 cataract surgeries a year for the past 15 years. I really think she is "the one" to do my cataract operation but I am a little concerned that the cataract will "harden" during the wait. Do you have any experience with predicting when a cataract is too "hard" (of course, asking generally, not my specific case)? How long after a cataract is diagnosed for vitrectomized patients does it in your experience, on average, become too hard to be operated upon without major complications? Note that my cataract was NOT present in August 2014 (as per a routine annual examination by a retinal specialist) and I was -2.00 in that eye. My vision started to be affected by November 2014 and by April 2015 my prescription had gone up from -2.00 to -5.75 in the affected eye. Is this a particularly fast cataract progression in your experience?

Thanks (again) in advance!


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by John C Hagan III, MD, FACS, FAAOBlank, Jun 25, 2015
99.9% of cataract surgery in USA is done under topical/injection. It is much safer, less expensive and faster recovery.  General anesthesia does not guarantee that there will be no movement as patients can "get light" and move. The only patients we do under general are patients with agitated dementia and combative/non-cooperative.  The cataract/IOL usually takes 15 minutes whereas a vitrectomy can take several hours.  Your call. We would not do a "nervous patient" under general just use sedation and injection (not topical) and reassurance and "Vocal local".

There is no way to predict how fast any cataract will grown, by anyone, all we can do is speak in generalizations. Understanding this is a generalization most patients with vitrectomies will need cataract surgery in 3-5 years.  Also grading a cataract on any scale is non-standardized and what might be a "hard cataract" for one surgery might be middle hardness for another.   Even rock hard cataracts can be operated on its just that the complication rate may be 2=5% higher.   The main complications of cataract surgery are 1. capsular tear  2. vitreous loss   3. nuclear fragments dropping into the back of the eye  4. hemorrhagic problems.   With small to medium cataracts one of these might occur 1-3% of the time with rock hard it might be 5-7%  so the odds are still in your favor.

Several of our local surgeons staff the only eye hospital in Northern Haiti and virtually every cataract is rock hard or a tense white "over-ripe" cataract. Their complications rate is only about 4-5% even in a primitive setting.

A surgeon could not do 1000 cases a year and be booked a year ahead of time if their results were anything less than stellar. Just be aware that some of these mega-cataract practices use huge pressure to upsell things like toric, multifocal, femtosecond laser and gift staff bonuses for every person that upgrades from the plain vanilla monofocal IOL.

JCH MD

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by excaptain, Jun 26, 2015
Thanks as always Dr. Hagan for the quick and very informative response. I had no idea your staff does such amazing work in Haiti - you and your colleagues are truly what medicine is all about. Your comments regarding hard/mature cataracts as well as the fact that both surgeons I saw were not overly concerned give me hope that this is not as critical an issue as I thought it was.

Regarding the surgeon I chose, indeed she is very respected and she seemed very thorough and attentive during the appointment. It took 2 months just to get an appointment with her. What's REALLY nice about her is that she ONLY offers monofocal and toric monofocal lenses, not multifocal and not femtosecond laser. When I arrived at the office the first thing her staff handed me is a page explaining the different lenses, and for multifocal lenses it specifically said that they do not do them because (I'm quoting) "for most people, the benefits of the multifocal IOL are not worth the potential side effects, including reduced vision in dim lighting and permanent glare and halos".  So she is very patient-focused, and that is the impression I got from meeting her.

Regarding the general anesthesia, I hear you and really I'm not too sure what would be the best course of action. I never had conscious sedation but on the other hand the general anesthesia for the vitrectomy was perfectly done and I had absolutely no side effects (not even nausea). Also the general anesthesia for the cataract will be done with an anesthesiologist in a hospital which has an emergency department, so it is not being done in a clinic which would be ill-equipped to handle an emergency. Not that I expect an emergency - I understand that most complications from general anesthesia happen to older people who have heart problems. But, there is an additional risk there, no doubt. From my point of view there is another advantage to general anesthesia - I will probably get to do the operation sooner, since the timing of the operation is based mainly on the availability of the hospital anesthesiologist - and the surgeon said that while she has no control upon when the hospital assigns an anesthesiologist to her, it may be possible to have the operation in September of October, but I will get only 2 weeks notice. On the other hand, for IV conscious sedation anesthesia the wait list is 10 months long - I will get more advanced notice but the wait will be quite long. So actually choosing general anesthesia might be beneficial in terms of timing for this particular surgeon. We'll see. Anyways the important point is (and I believe this is the point of this entire thread) is that one has to do "homework" before choosing a cataract surgeon. In fact, there are a lot of clinics here that would be able to do the surgery within 2 weeks, but they are the sort of "mega cataract" clinic that you mentioned that are mostly about money; as much as I want the cataract to be taken care of ASAP, I'm not considering going to those clinics.

Once again, thank you so much for the quick response and all the information, it is gratefully appreciated.

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by John C Hagan III, MD, FACS, FAAOBlank, Jun 27, 2015
Okay best of luck.  JCH MD

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by Anne2485, Jul 07, 2015
Dear Dr. Hagan, My elderly Mother is having Cataract surgery so I was reading diifferent online sites. I ran across your article. I do not have a question but I do want to tell you that I think you are a very special man and Doctor.  I can see how your  expertise, wisdom and support means the world to your readers seeking help.  So many of them are distressed. I know getting your advice must feel like a blessing and relief . Whether your parents are on earth or heaven, I know they would be proud of you and your good works. I hope your practice is thriving. I can only imagine it is. About 7 years ago my 84 year old Mother had a medical issue. I was worried sick. We could not get it figured out. I was able to get direction about how to proceed from an expert such as you online. I will never forget how much thankfulness  I felt reading that Doctors advice.. Here I am all these years later and my gratitude burns bright.  Thanks for your service to your fellow man. You and your loved ones are in my prayers tonight. Most Sincerely, Anne in Irvine (Southern California)

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by John C Hagan III, MD, FACS, FAAOBlank, Jul 07, 2015
Anne, thank you for your comments. My only regret is that this forum started in 2007 in conjunction with the American Academy of Ophthalmology is no longer taking new questions since the sale and restructure. However they have their own website www.geteyesmart.org    JCH MD

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by Temmytee31, Jul 13, 2015
Dear Dr. Hagan, I really appreciate you using this platform to reach out to people and solving their problems through your expertised skill.

I had a retinal detachment in my right eye Aug. 2014 where my Dr. inserted silicon oil(PPV). Six months after, I had the silicon oil removed and long lasting gas was inserted in the same eye again.  Now cataract is detected in the eye. I'm so angry with myself. My vision hasn't improved in the operated eye but rather gone worse. Presently I'm monocular as it's only my left eye that is  100% active.  I've heard of retinal redetachment after cataract surgery and this makes me skeptical in having a cataract surgery. I need to know if I should attempt the surgery and in case I decide not to do it, what are the negative consequences?

Drs. say my low vision can't be restored again cos 1. the retinal has been detached for long before surgery and gone lazy, 2. there is a macular hole and 3. Exotropia .. So I'm presently confused if I the cataract surgery will improve a bit of vision and if it won't, can I stay without doing it and just continue with my left active eye.

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by John C Hagan III, MD, FACS, FAAOBlank, Jul 13, 2015
I would start out by getting 2-3 different opinions from both retina and cataract surgeons. Cataract surgery, even successful-small incision surgery does increase the risk of retinal detachment (RD). However given all the surgery you've had the risks to that eye would be relatively small.

The advantages:  you might see better (not normal but better than before the surgery), the doctors taking care of you can see the back of your eye better, the cataract will be easier to remove now than in 3-5 years, there is a small risk the cataract could get "too ripe" and break up in the eye causing pain and requiring an emergency surgery.

The disadvantages: you might see worse, you might have another RD, you might have double vision since you have exotropia, the eye might become inflamed or painful

REMEMBER: your most important eye is the one you see out of, protect it from injury and live a healthy lifestyle. When you have a RD in one eye the risk of a RD in the other eye may be as high as 5-10%.  Wear glasses for safety, have your eyes checked every 6-12 months the rest of your life.

JCH MD

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by EyeSeeStars, Jul 14, 2015
Dr. Hagan, I am a 58-year-old female, full time professional, sewing is my biggest hobby, and I'm essentially healthy in all respects.  However, I'm in a somewhat unusual eye predicament.

In the past few years, I have been diagnosed with mild cataracts bilaterally, with some further growth in the R eye (eye exam 7/9/15). I was recently told that I have very dry eyes, also.  Uncorrected vision is 20/100 in L eye and 20/200 in right eye. Corrected, vision is very good...20/20 to /30 in L eye, and 20/30 to 20/40 in R, depending on the day (weak eye muscles & how much eye strain that day).  Vision corrected is great in office, definitely not as good functionally.  My as-yet not filled new prescription reads:

OD +125  +025 165            
OS +125  +075  015                                                                  
ADD +275                                                                                
ADD +275

Last year's (current) script reads +125 Sphere
                                                     +175 = 50x100
                                                     //+250 Add      
2 different doctors wrote the prescriptions. Four or so years ago, I was able to drive fine without glasses! Not any more.

MAIN PROBLEMS- All unsettling to me, and sometimes scary:

• Glare in sunlight, rain, dusk, night driving.  I see halos (smudges) around all lights, and small/medium to sometimes huge stars (spikes) that radiate from vehicle headlights (especially at night), that oftentimes obliterate L turn signals- or most of the vehicle.  Even during the day, if drivers have headlights on, I sometimes think the people are just stopping in the middle of the road because I often can't see that the vehicle's turn signal is on until I am just in front of it.
• Headlights and taillights in mid to further distance on major roadways are something of a blur of lights, haloes and stars.  
• Road signs are harder to see until I get much closer to them.  
• During the day, I see sunlight reflecting off of vehicles 'down the street' as white shimmering or "flashing," which makes them look like emergency vehicles.  
• Dark always seems too dark and bright seems too bright to me, even reading the computer screen or smartphone. Small print is difficult to read even with glasses. Up close work such as sewing, is difficult.

Two different highly-regarded opthamologists were surprised that I experienced any difficulties, based on the size of the cataracts. My top-notch optometrist disagrees. During exam, I've heard numbers 1.5 to 2+ mentioned.  I have been given every other test possible I was told, (twice) so everything else has been ruled out.  My glare test results were not top-notch, however.  Contrast at night is also a problem.  I have pretty much stopped driving at night.

Now my optho says, "Let's take out the cataract on the right eye, since that is the worse eye." He does not feel that the left needs to be done, unless I am ecstatic with the results of the right eye.  I'm scheduled for Aug. 10, for one monofocal IOL.  I'M A WRECK. Am I making too much of this?  Am I risking very good corrected vision for potentially serious problems?  I just don't know what to do and am sick with worry.  I tell myself that I should be happy with the good vision I have, stop making a mountain out of a molehill, and just deal with it.  I would never forgive myself if anything went wrong.  I have myself on hold to call and cancel the measurement appointment and surgery.

I'm sorry this is a long post, doctor, but I wanted to include as much information as I could.

I look forward to your opinion on this matter.  Thank you in advance.


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by John C Hagan III, MD, FACS, FAAOBlank, Jul 14, 2015
Your problem is one of "glare disability" and one of the tests that should have been done is "glare testing"  this tries to simulate your vision at night while driving or in glare situations like sun/snow  or sun/water. Many people can see 20/20 in the office eye exam when there is no glare and letters are high contrast but may be 20/200 when driving at night.

For a middle age active person to have to give up driving at night and having your list of complaints if the glare test confirms glare vision of worse than 20/60-20/100 cataract surgery would generally be indicated if you consider your vision a medium or big problem and you understand the "informed consent".

You are farsighted and you vision without glasses is not good even if you had no cataract it would not be good. When surgery is done a IOL (intraocular lens) is put in the eye to correct the farsightedness. This helps the glare and vision but also makes the vision without glasses much better.  You will not do well with just one eye fixed as the difference between the sizes of the eye glass lens will be hard to adjust to. Most hyperopic people have the second eye operated on 4-7 weeks after the first when they are happy and pleased with the first eye. Often the second eye is left a little myopic so that without glasses the person can read in good light, use a computer and see themselves in a mirror without glasses.

Be sure to read my original post again slowly and carefully. I would get a third opinion from a cataract/IOL surgery of high regard.  Almost all the patients I've treated in the past with your history are very happy to ecstatic about the results of cataract/IOL surgery.

JCH MD

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by EyeSeeStars, Jul 14, 2015
Dr. Hagan, thank you so much for the very quick reply.  

I had the glare test done on two occasions.  This past Thursday, the technician administered the glare test, and without a word at the test's conclusion, she handed me a packet of brochures about cataracts and the surgeon.  She did not tell me the results in numbers, but I know that I had a hard time with the test.  I actually have gone to 3 highly regarded specialists. #1 (two years ago, 2nd opinion at the request of my regular optho, described by my regular as 'the only other optho that I would trust') "You're not crazy, they're small but may be better to take them out sooner than later" #2, (last year, at another patient's referral) "I wasn't even going to mention the cataracts because they're so small," #3 (my long-standing optho) "Based on your symptoms, let's take out the right one."  This is what has led me to be so darned confused.

Question: If I have such a problem with distance, how can I still be considered only "farsighted?"  And yes, I am highly concerned about the the resulting difference in vision between R & L eyes following surgery.  Doc suggested monofocal IOL's in both eyes for optimum results, should he do both.

I will definitely reread your article as well.

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by John C Hagan III, MD, FACS, FAAOBlank, Jul 14, 2015
Farsighted or hyperopic means your eye is shorter than normal.  When your eye was young it was strong enough and the natural lens flexible enough to correct the hyperopia without problem. They eye loses the ability to do this as we age so farsighted people end up in no line bifocals and vision is not clear at any distance without glasses. The glasses that correct hyperopia start with a plus (+) sign, they bend light waves in and they make things look slightly larger than normal. Farsighted does not mean you can see far away and not up close nor does myopia or near-sighted mean you can see up close well and not at distance. That is an inaccurate, overly simplified way of thinking of the problem and those definitions will not go away

Generally speaking without glasses after surgery the "distance eye" (further than 20 ft away is left ideally 0.00 (Plano or not farsighted or nearsighted) to -0.50 and the "intermediate vision or near vision eye"  -1.25  (again see original posting)

JCH MD

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by EyeSeeStars, Jul 15, 2015
Thank you for your valuable input. It helps me to make a much more informed choice.

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by TexS, Jul 18, 2015
I'm 65 with cataracts qualifiable for surgery under Medicare in only in one eye (right- dominant eye).  I am actively involved in workshop/outdoor activities and prefer stronger distance vision but require near vision for iPad work.  Use of home computer is minimal.  I would like to be as "glasses independent" as possible since I have worn contacts for 35 years.  Current Rx for contacts is: right eye = aspheric single vision pwr -5.50/ BC 8.5/Dia 14.2; left eye = multi focal pwr -2.50/ BC 8.5/ ADD High.

My best hoped for cataract surgery post-op scenario would be continued (or not) required use of a contact for the left eye with only reading glasses needed for fine print reading.  From my recent discussion with a surgeon it appears my choices through him are: monofocal IOL, ReStor 2.5 or ReStor 3.0.  He was not pushing the ReStor lenses and did fully explain the downside of glare and haloes with the upgrade lenses.  From our discussion and my subsequent research, I am leaning toward the ReStor 2.5 but would like to see what you might recommend to achieve or approach my desired objectives.  Are there other alternatives which I might discuss with the surgeon?

As other posts have stated, it is admirable that you take your time to thoughtfully respond to such detailed inquiries from so many people facing such variety of vision decisions. Thank you so much!

TexS

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by John C Hagan III, MD, FACS, FAAOBlank, Jul 18, 2015
TexS  I think my original post has all the information you would need.  JCH MD

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by EyeSeeStars, Jul 19, 2015
Dr. Hagan, regarding my original post and ensuing post beginning July 14, 2015....

Following your reply, and further research on vision as we age, it occurred to me that perhaps my 'glare disability' is not completely related to cataracts.  Last week, my optho asked me what happens when I cover my right (allegedly worse) eye, do things improve at night.  I said I didn't know, hadn't tried it.  Well, I did try it the other night while my husband was driving. I noticed two things:

1. My primary problem, the amount of glare and starbursting that I see around headlights now with both eyes even with glasses, has escalated significantly at night.  Most starbursts are huge, and lights are SO bright as to be painful. I thought I was making too much of it, but I'm definitely not. It’s quite the light show.  During the day, it is there but usually less noticeable, and more tolerable with sunglasses.

2. "Small" cataract in R 20/200 eye without correction, is supposedly larger than cataract in L eye, although uncorrected vision in L eye is better at 20/100.  If I take turns covering each eye on the road at night, without my glasses on, I see no difference at all either in the amount or size of starbursting, or the amount of blurriness.  I do notice that with glasses on, starbusting only minimally gets better, and L eye is somewhat clearer than R eye with glasses on. In general, both eyes appear to see the exact same way without glasses. I don't know how this is possible.

Supposedly, every test has been done more than once, including glare testing.  All tests are WNL except for farsightnedness, glare testing, and my "baby" cataracts.

***Is there any way to tell what part, if any, my small cataracts play in this scenario?  Is it possible that this is just the way my eyes have become due to age (58)?  I can tell that my optho is not convinced that the small cataracts can cause this much grief, even though after 3 years of my symptoms getting progressively worse, he has suggested cataract surgery on the R eye to start.

  ***If the R cataract is slightly larger and the vision is worse in that eye, why would I be seeing the exact same way at     night with each eye?***

I do not want to risk unnecessary surgery, especially if it will not help me. In your expert opinion, what are the chances that cataract surgery would benefit me in any way under these circumstances?  If I do not get the surgery, is there anything that helps this kind of glare disability?

Thank you again for your valuable input, especially that I'm so lost right now...


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by John C Hagan III, MD, FACS, FAAOBlank, Jul 19, 2015
1.  The amount of glare disability does not correlate with "small, medium, large".   First of all those terms are relative and not strictly quantifiable. What one doctor might call a small cataract another might call normal aging changes, another cataract might be medium to one ophthalmologist and large to another.
2. A "small cataract" like a posterior subcapsular can cause severe glare if located in the exact visual axis and a large cataract may cause little glare if a cortical cataract not in visual axis.
3. There are other causes of glare disability besides cataracts. If the amount of glare is totally out of line with the size and location of a cataract other common causes are:   uncorrected refractive error especially astigmatism; irregular corneal astigmatism; macular pathology.  So if that is the case with you your ophthalmologist might consider a cornea topography and a macular OCT.
4. I would consider another opinion with a corneal specialist.
5. Far and away the most common cause of your glare are the cataracts.

JCH MD

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by EyeSeeStars, Jul 22, 2015
Dr. Hagan, last follow-up...I promise! :)  I requested an in-person consult with my optho/surgeon before I decided whether or not to keep my surgery date.  I wanted to know specifics from my testing <2 weeks ago.  I failed to ask the right questions when I was there, and he failed to fill me in on test results.  I went yesterday and thought you might be interested in the results.

As it turns out,

1. I have all 3 types of cataracts in both eyes, and the doctor's 1-4 grading system places them between 1.5 and 2+.  One or more are apparently in my visual axis. They are also subjectively categorized now as "mild to moderate" rather than "tiny" or "baby." They have increased in size.

2. My glare testing results were 20/400 in both eyes. I remember looking at the screen during that test and feeling extreme discomfort.  I told the tech "forget it!"

3. My cornea looks "beautiful;" absolutely no problems with it, the macula, or anything else.  He showed me digital imaging of my cornea (he is also a corneal specialist).

3. My optho admitted that he is conservative, and he twice said that he 'let me suffer' long enough.  He apparently likes to wait until cataract surgery will make a BIG difference. He feels that 'oh wow' outcomes yield a happier patient and happier surgeon. Ugh! Regardless, he is highly accomplished, having a long list of accolades, including co-inventor of the Phaco-Gard™ blade used in surgery.

4.  He feels that the surgery will either reduce or eliminate my extreme glare/starbursting at night.  Although I want the IOL's set for modified monovision, he advises against it and basically didn't even want to talk about it due to the potential glare problems, when that's my chief complaint now.  I'm not sure what to do about that.

I hope others on this board can learn from my experience.  If a patient wants specific answers from a doctor, he or she needs to ask specific questions.  Now I can go ahead with my surgery knowing that the cataracts are almost undoubtedly causing my problems.

And Dr. Hagan, without your input, I would have canceled the surgery without having consulted with my doctor.  I realized that I had the right to go in there and find out exactly what was going on so that I could make a fully informed decision.  Thank you again.

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by John C Hagan III, MD, FACS, FAAOBlank, Jul 22, 2015
Okay best of luck. BEFORE surgery is the time to work through all these problems. If there is communication or friction between patient and surgeon the post operative course is difficult and in the event of complications often mutually very unsatisfactory.

JCH MD

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by sredsy2k, Aug 01, 2015
I have had myopia in my right eye, about -4.50  -1.75 (using negative cyl measurements) - and hyperopia in my left eye, The Rx last being +1.25 for distance and +2.75 for closer up (I don't recall the cyl, but it's done in negative), but the corrected vision in the left eye is not good.  I can NOT read with my left eye, no matter what they do - it can't be corrected even if I can "see the letters."  I read with my right eye, and I do most of my "seeing" with my right eye, even if I 'm actually using both eyes.  The myopic Right is dominant, with or without glasses, no matter what I look at.  

I also have AMD - the R eye was wet in March 2013, I had HUGE distortion (faces looked monstrous if I looked a bit to the right of the face) - and that was fixed with 4 or 5 injections of Avastin in the eye and I have no distortion at all now in the R eye since Oct 2013.  The thing is, I got the distortions in Dec 2012 and the eye tested dry.  Only a few months later did it test wet and treatment start.  By Oct 2013 it was fixed and it's been stable since, perfect amsler grid.  

But best corrected vision in R eye is now 20/40.  I don't need anything to read with the R eye normal reading distance - but for about 16  - 30 inches I have an Rx about -2.25 in R eye.  My left eye has deteriorated in vision over the last year, from about 20/60 with glasses to now 20/200 with glasses.  I also now have BIG distortion in the left eye, starting Dec 2014, again, when I look to the right of a letter (the eye is too poor to notice distortions in faces) and I expect he L eye  to go wet, though it has not been wet in last exam in April 2015.  I was surprised.  Retina doctor (Retina Consultants of Ft. Myers, FL - experts) thinks it's the cataract, but I never heard of cataracts causing that and he admits he doesn't know cataracts.  AMD causes it when it goes wet.  This I DO know - and so does he - though the eye was DRY last test, as I said.

So I went to cataract doctor.  I have a cataract that cataract doctor (one of the doctors in one of those BIG outfits that advertise in SW Florida) said could be operated on in the left eye, but not necessary.  But the right eye - NO.  He's the cataract specialist.  The retina doctor I go to wanted me to get them removed from both eyes.  I stalled with that for over a year, since I didn't see any cloudiness and I have a pretty low opinion of such surgery and the outcomes - I have read the horror stories.  Cataract surgeon said no.  BUT.....

I asked, when the time comes, if he could put distance lens in left eye and close lens in right, so that I'd have what I have now.  Cataract surgeon said, "usually with people who have AMD they put in distance lenses in both eyes."  

Right now, and for over 40 years, I'm very used to being myopic in right and hyperopic in left - and as bad as my vision is, even right now, I DO NOT need glasses to do everything and anything at all literally - except read from 16-30 inches away (I do that due to where I place the book or Nook - and where the computer screen is right now, past where my stretched out arm can reach.  I read books far like that because they are on my folded leg, on my knee because disability in arms prevents me from holding a book up for anywhere between 4 to 8 hours.  I sit far from computer as I am now so I won't get sciatica again.)  I'm an AVID reader.  I guess I have monovision right now - and I'd like to keep that if I had to get IOLs.  

BIG question that I can't find the answer to anywhere:  Would putting distance IOL in my myopic R eye make it into a hyperopic eye?  Or would it just make the right eye less myopic, but still a bit myopic?  I expect to wear glasses, two pairs as I do now, if I get IOLs because medicare approved IOLs don't fix astigmatism and there is NO  problem anyone has with tried and true, standard, old fashioned IOLs - and I'm poor but not poor enough to get any kind of aid.  I don't mind glasses at all - I'm totally used to them.  

I guess my  main question is - would putting a distance monofocal lens in my myopic eye, make it into hyperopic, or would it  just be less myopic?  

I did not get on with the doctor because I was 100% shocked and visibly upset to find my R eye on refraction was -6 something (I thought, OMG, it got THAT bad?) - and when he mentioned that my current glasses were -6 I argued that I have the Rx to prove it's a -4.50. And HE got all flustered and upset, accused me of remembering wrong.  Heh, NO, I can show him the Rx I said.  He got mad!  He could have just told me that they use positive cylinders - something that, in my over 40 years of wearing glasses and my husband wearing them for almost 60 years - NEVER HEARD OF OR SAW on an Rx.  Instead of yelling at me, he could have just explained it.  Perhaps he didn't know this?   If that's the case, then that's amazing.  

I did not get on with this doctor - and I'm easy to get along with according to every doctor I have (my retina MD thinks I'm tough because I don't think injections in the eye hurt - but lidocaine from dentist is torture) - and this cataract doctor is one that works with a BIG outfit where I am in SW Florida with BIG unreasonable, fairytale adds about the wonders of cataract surgery.  He thinks I have "unreasonable expectations."  "I won't do the surgery because patient has unreasonable expectations."  WHAT?  I do?  He doesn't know my expectations - they are in fact VERY LOW because I have done quite a bit of research, but so far, have NOT run into anyone addressing my far/near type of eyes.  I see a ton of info on hyperopic people or myopic people - BUT NOTHING on people who have both.  My brain is obviously used to seeing this way - and despite my horrible vision, this is probably WHY I can do everything and anything without needing  to scramble to find my glasses.  I can even see fine in a room with 7 watt night light if I have to get up in the middle of the night. No need for glasses there either.  

I expect to be wearing my 2 pairs of glasses and I hope only that when it's all done, IF it ever gets done, that my vision is not WORSE.  As I said, I can do anything and everything, cook, plant, sew,  you name it, without glasses at all.  I need them for 3 activities, driving, TV and reading the way I do from far away.  That's it.  

An example, he mentioned that if he did my left eye, the best I could get might be 20/60.  So I asked "with or without glasses" and he got all upset!  imo, that was a good question.  They also use this laser technique - and I'm poor.  I don't see why that's not covered since it's becoming the standard and it's definitely not some "cosmetic" thing.  

Do you know a good surgeon in SW Florida?  And what's the deal with putting a distance lens in a myopic eye - what results from that?  

Thank you  and sorry for long post.  But I was SO upset from this cataract MD that my BP went up.  

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by JohnHaganMD, Aug 01, 2015
First  read through this very carefully 2 or 3 times:  http://www.medhelp.org/user_journals/show/841991/Consider-ALL-the-Options-Before-Your-Cataract-Surgery-Working-Through-Whats-Best-For-You

Cataract and refractive surgeons Never want to leave an eye hyperopic because without glasses neither distance, midrange nor near is good.  So the eye without glasses is left either needing nothing for distance (20 feet) or 0.00 also called plano or mildly myopic to see intermediate without glasses or myopic enough to read without glasses.

There are tons of ethical, talented cataract surgeons in SW Florida and I'm sure you can find one you can comfortably relate to.   Try using the physician finder on the American Academy of Ophthalmology website www.geteyesmart.org

JCHMD

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by sredsy2k, Aug 01, 2015
Dr. Hagen, thanks for replying, but I DID read what you wrote - and I DID read elsewhere that surgeons don't want to leave a person far sighted, usually.  I read 5 experts discussing IOLs with AMD - and they didn't all agree with each other.  Here

http://www.reviewofophthalmology.com/content/i/1448/c/27352/#sthash.iP5LHViy.dpuf

However, a waitress we know got two distance monofocal lenses in her eyes.  She is doing nothing now but griping about how she can NOT see without glasses to write orders and bills, and then, she can't see the computer with those glasses or without glasses, nothing she is seeing is clear.  She is a waitress - not a rich person.  Her doctor DID make her far sighted in both eyes.  THAT is the issue.  I told her to try to see someone who can remove the IOL and put in another one for close - but she can't afford it.  The doctor that did this won't fix it.  

I'm asking this:  could a distance lense put into a myopic eye like my right eye make the eye LESS myopic, but STILL myopic - or would it make me far sighted?  If I can already see close up, normal reading distance, what would an IOL do in such an eye?  That is the question - and the doctor I asked this of, would NOT answer it!  I can see how a distance lense could do this -  since my right eye HAS been getting a tad "far" (compared to before) due to age, I AM less myopic in the right eye; but still myopic.  But I don't know much about IOLs. Again, IF an IOL was put into my insanely far sighted left eye, an IOL for mildly myopic - what would that do?  Since he said the best I could get would be 20/60, I assume with glasses, but I'm not sure - that's not too good at all.    

I'm not sure what you mean by diopter between the two eyes.  As you can see from my numbers, my two eyes are FAR from each other when it comes to diopters.  Probably insanely far when I'm going about with no glasses on yet seeing well enough to do most things.  I'm used to it.  

I checked out the site - and got a few names.  THAT doctor is on there too, on the second page, interesting that his first specialty is plastics and reconstructive surgery - but I can tell you that the outfit he works for does big ads on TV, on billboards, their website is filled with fairyland expectations - and they go about pushing that "no glasses" bit - as if glasses are bad.  They really do give people expectations that are ridiculous, imo.  

Other people since have told me that the outfit might have been great once, but now they run it like mass production.  Oh well.  

I know as a fact that unfortunate people having flashes of light or shadow and even worse; you read the complaints, I've seen you on there in the discussions, these people are left out in the rain with it, doctors won't even see them as patients claiming that "nothing is wrong" yet, I see opthos have their own discussions theorizing and making hypotheses about what could be causing it, square edges of the IOLs or what. Why don't they  just STOP USING THOSE  IOLs?  Just STOP.  One of the doctors that dismissed a patient suffering like this (flashes and a sharp feeling, as if he could feel the IOL like a contact lens put into the eye wrong) IS on that list!  He's the other BIG GUY in the area, ads, TV, billboards, etc.  Enough people have problems with these newer IOLs - the decent thing to do would be to stop using them - period.  Zicam that makes that zinc gel that does prevent colds or shorten them, two people lost their sense of smell, just two people - and that company decided NOT to fight this, but they just stopped making the product.  Decent.  

Most of the other doctors I see on there I've never heard of - so they might be quite good :)  I'm in no rush.  I know my left eye is going to get wet AMD - the symptoms are there.  I don't want to do anything to exacerbate my AMD.  

I would guess then, that if/when I need this surgery, I should ask for the left eye to be made LESS hyperopic - and the right eye to be made LESS myopic?  As I said, I don't know about IOLs - or what kind of field of depth they have.  I know one person that has medicare standard IOLs for distance and can see everything from 6 feet to infinity with crystal clearness - and he also has AMD.  He needs two pairs of glasses for anything closer, OTC readers.  But from 6 feet to infinity is a big depth.  This is the KIND of information I need to know about - the depth.  eg, my 16 to 30 inch glasses - that's the field of depth (or perhaps more, I never tried reading further away from that).  I don't know what the fields for depth are for ANY of these monofocal IOLs.   I assume the medicare lenses come in distance, intermediate and close?  These, imo, are simple questions that I can't seem to find answers to.  So I'm asking :)

Thanks.  

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by JohnHaganMD, Aug 01, 2015
First of all cataract/IOL surgery is the most common and successful surgery done on Americans. There are over 4.5M operations/year and the complication rate is about 2-3%.  If you try and draw opinion about the procedure by trolling discussions among the very small number of unhappy patients you'll have a distorted view of the procedure over-all. If all you did was talk to people that had been in serious automobile wrecks you would be terrified of taking a trip in a car.

As you said you're in no rush and that seems like a good course of action given your experiences and reservations.

JCHMD

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by sredsy2k, Aug 02, 2015
two questions:

What is the general field of depth with
1. distance IOL
2. intermediate IOL
3. close IOL

PLEASE explain - does anyone use a distance lense to give a myopic person LESS myopia?

thank you.  

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by JohnHaganMD, Aug 02, 2015
These questions can't be answered because they vary from person to person with a primary factor being the pupil size and how active it is.    Yes an IOL is often used to make the distance eye less myopic as explained in my article. For instance if a person's glasses RX was -6.00 and -5.00   and they opted for mini-mono with distance bias the post operative glasses RX might be 0.00 (distance)  -1.25 (intermediate)..

I have given you all the information I can and will have no further comments

JCH MD

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by Mclavew, Aug 04, 2015
Do you have any recommendations for a good surgeon in the Dallas/Fort Worth area?

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by JohnHaganMD, Aug 04, 2015
You can go to the website of the American Academy of Ophthalmology  www.geteyesmart.org and use the physician locator to find a surgeon member.

JCH MD

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by Mikegp, Aug 13, 2015
Six months ago I had a crystalens -50AO implanted in one eye. I'm somewhat disappointed in the result. I now feel the added cost was not worth it , so for the second eye I'm considering having a monofocal lens implanted.  Do you have an opinion on mixing crystalens with a monofocal lens such as the NanoFlex?

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by JohnHaganMD, Aug 13, 2015
It works out well for most people. You need to discuss with your ophthalmologist why you are disappointed with the crystalens. Is it distance? If so your monofocal should likely be aimed to give your better distance vision without glasses; is it near vision then reversed to give you better reading vision without glasses.

JCH MD

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by dm082015, Aug 19, 2015
Doctor Hagan,

I had a cataract surgery on my right eye in July 2015.   After cataract surgey, my right was left at -2.5d monovision  instead of the planned -1.5d.  

My left eye is nearsighted  at -4.25-0.75x132, and it is having cataract too.  With the corrected lens, my left eye vision is 20/20 .   I am considering to have a cataract surgegy on my left eye too.

My left eye is the dorminant eye, and I like to have a clear far distance vision without wearing eye glasses after cataract surgery.  Is it possible to have my left eye at 0.0 and my right eye at -2.5 without cntact lens or eye glass?  

What would be the best options for me with the unoperated left eye and the already operated right eye?

Thank you

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by JohnHaganMD, Aug 19, 2015
Read my article again as it covers this situation.   Having your LE at 0.0 and your RE at -2.50 is true monovision and a lot of people don't tolerate it well. Again it is covered in my article.   Are you happy with your reading vision in your RE and how close you have to get to something to see it clearly when you don't wear glasses?  You also want to discuss with the surgeon why your IOL power was "off" by 1 diopter. The measurements on both eyes need to be repeated. You don't want to be off a diopter on the other eye.

If you got your wish and you had trouble with the difference in the two eyes the RE could have lasik and reduce the -2.5 to the planned -1.50  or all of it could be corrected to 0.0 and the LE could be left myopic as the reading eye.

Discuss in great detail with your surgeon; don't be shy about getting a second opinion.

JCH MD

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by dm082015, Aug 20, 2015
Doctor Hagan,

Thank you very much for your answers.  
With -2.5d on my operated RE, I can see thing clearly within on feet without the glass on my RE.  I feel not bad.
I will discuss the details with my surgeon.
I also would like to know if i can have multifocal IOL on my LE,  would this be a good option?
My hobby is photography.

Regards,

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by JohnHaganMD, Aug 20, 2015
It is an option.  I hesitate to call any of these "good" options; they are "different" options that are good for some people and not good for others. Discuss with your surgeon. Know that the optics of a multifocal are not as good as a single monofocal IOL or toric IOL. Use the search feature and read the posts here about multifocal IOLs; use a search engine and read articles appearing about the pros/cons

re-read my original article.

JCH MD

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by EyeSeeStars, Sep 08, 2015
Dr. Hagan,

You answered questions for me back in July regarding the possible need for cataract surgery.  As it turns out, I had both eyes done, OS on 8/19/15 and OD on 8/25/15.  I really dislike that the general population thinks of cataract surgery as a "nothing" operation; a 'walk in the park.'  These past few weeks have been anything but.

My surgeries were done using the dropless method, which would not have been my first choice. However, I had switched surgeons and this is the method he uses.  I was given an Abbott Technis Z9002 monofocal IOL in each eye. The doctor chose this model due to the claim of less aberrations at night, etc, since that was my chief complaint pre-surgery.  Surgery was said to have gone very well, and that I am healing fine.

That being said, my regular optometrist can see a fold in the capsular bag of my right eye.  I visited him due to my dry eye and mentioned the haziness as well as the horizontal streaks that I am seeing through any light source with my right eye.  My night vision thus far is at least 2x worse than it was pre-surgery in that eye, and it was terrible before.  This effect has not changed at all in the 11 days since surgery on that eye.  When I mentioned the fold, my surgeon explained at the 5-day post check that the capsular bag often becomes stretched from side to side during surgery but will contract as it heals, and that the fold should diminish or go away.  "Be patient. You're still healing," he said. My optometrist said it probably won't go away. Visual acuity in that eye is good for intermediate, not great for distance thus far.

My left eye has a light wax paper haze over it as well. Visual acuity in that eye is very good, if only the haze would go away. I constantly have the feeling that I want to wipe something out of it. I am already 3 weeks post op as tomorrow (9/9) on that eye. I was told that the Tri-Moxi-Vanc used via injection during surgery can cause this.  Again, I was told to be patient, that I was still healing. Easier said than done. My vision just isn't good enough to function well.

Doesn't "healing" mean that I should see SOME improvement in either eye? This haziness (not opaque, thank heavens) is worse than it was pre-surgery and I have become an anxious wreck over these things that are not improving. The OD's light streaking/ghosting makes night driving completely impossible, and viewing any headlights even in daytime, difficult. I was told to come back on 9/29 for the 'final check' and for an eyeglass prescription if it is deemed necessary.  To h*ll with eyeglasses. Right now I feel like I need new eyes.

I realize that I have to reiterate these difficulties to my surgeon, but what are your thoughts about the kinds of after effects that I am experiencing? Am I overreacting? Is there any chance that these problems may resolve with time? What might be causing them?

As always, thank you for your time.

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by JohnHaganMD, Sep 08, 2015
The fold in the capsular bag is not a big deal, very common and often does go away. It would not account for your poor vision and other symptoms. Our practice does not use the "dropless method".  It's new, its different, it has to be really excellent and stand the test of time before we switch from what works extraordinarily well for us.

I'm hoping your 9/29 visit is with the surgeon and not your optometrist.  It is especially important to see the surgeon when things are not going well and obviously they are not. I can only tell you what most surgeons do. If a person is anxious or having problems extra visits are scheduled. I would consider calling the surgeon. Stating your concerns clearly as you have hear and go in to see him/her.  At that visit I would suggest you ask if you have any cornea swelling (corneal edema) or macular swelling (cystoid macular edema)  to check this they would need to do a macular OCT a simple easy test.   Hopefully you have neither.  I would insist the surgeon follow you till you're back on track.  some high volume surgeons farm all the post op care to referring optometrists. The fee if medicare is often split. This use to be called fee splitting now its called co-management and its legal even if not optimal for the patient.

Last resort is go to a different surgeon for an outside 2nd opinion.

JCH MD



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by peterkent, Sep 14, 2015
DEAR DR HAGAN        I AM A 68 YEAR OLD ORTHOPEDIC SURGEON .GETTING READY TO RETIRE . I NEED CATARACT SUGERY IN BOTH EYES . I HAVE AN EXCELLENT SURGEON . MY DILEMMA IS WHAT IS BEST POST REFRACTORY ERROR FOR ME . I HAVE BEEN MYOPIC SINCE HIGH SCHOOL   I EXPECT TO WEAR GLASSES POST OP . I KNOW THERE IS ONLY ONE FOCAL LENGTH CHOICE. I DO NOT WANT TO RISK THE MULTIFOCAL LENS . I AM GETTING A REGULAR TECNIS AMO ZCB00  NON TORIC . R EYE IS  SPH - 3.00 CYL - 0.75 AXIS  097 LEFT EYE  SPH - 3.00  CYL - 1.50  AXIS 092     MY DR IS VERY NEARSIGHTED AND YOUNGER ABOUT 47 HE SAYS HIS VISION IS ABOUT  -7.OO   HE SAID FOR HIMSELF HE WOULD PROBABLY WANT TO BE SET AT A REFRACTORY ERROR OF ABOUT -1.00  HE SUGGESTED  I SHOOT FOR ABOUT - 2.50 AND THEREFORE WOUD NOT NEED GLASSES FOR ABOUT THE 16 INCH DISTANCE.  I HAVE RESEARCHED THIS A GOOD BIT AND REALIZE THERE IS NO ONE PERFECT SOLUTION BECAUSE OF THE PRESBYOPIA WE ALL HAVE PRE OP AND OF COURSE POST OP .I SAW A JAPANESE ARTICLE THAT SUGGESTED A TARGET REFRACTION OF - 2.00 FOR NEAR AND INTERMEDIATE VISION POST OP WITHOUT GLASSES  ANOTHER STUDY SUGGESTED A POST OP ERROR OF  -1.00 TO  - 1.50 AS  SORT OF IN BETWEEN BOTH WORLDS  . ONE OF THE PROBLEMS I SEE IS THAT EVEN WITH THE BEST PRE OP MEASUREMENTS  THERE IS PROBABLY A CHANCE OF BEING OFF UP OR DOWN BY .25 TO .50 DIOPTERS..  I PLAN TO DO THE LEFT NON DOMINANT EYE FIRST IN ABOUT 5 WEEKS . I WONDER ABOUT THE  JAPANESE ARTICLE AUTHOR IS HAYASHI K     J. CATARACT REFRACT SURG  2007 FEB OPTIMUM TARGET REFRACTION FOR HIGHLY AND MODERATELY MYOPIC PATIENTS AFTER MONOFOCAL  INTROCULAR LENS IMPLANTATION.  IT SUGGESTS IF SET AT - 2.00 GOOD VISUAL ACUITY WAS ACHIEVED AT 0.7 M  , 0.5 M AND 0.3 M, THIS IS 28 INCHES , 20 INCHES AND 12 INCHES   . IS THAT TOO OPTIMISTIC OF A SPREAD   I THINK 13 INCHES IS FOCAL LENTH OF 3 DIOPTERS  ,16 INCH IS FOCAL LENGTH OF 2.5 DIOPTERS, 20 INCH IS THE FOCAL LENGTH OF 2.00 DIOPTERS AND 26 INCHES IS THE FOCAL LENGTH OF 1.50 DIOPTERS  IE THEY ARE SAYING THAT THESE PATIENTS HAD GOOD VISION  FROM  ROUGHLY 26 INCHES TO 13 INCHES WITH 16 INCHES BEING THE BEST OR SWEET SPOT   MY DR SAYS MANY MYOPIC PEOPLE LIKE ME ARE NOT ALL THAT HAPPY BEING SET FOR DISTANCE EMMETROPIA I THINK IS THE WORD  SINCE WE ARE SO USED TO TAKING OUR GLASSES OFF TO SEE WELL CLOSE UP ,HE SAID IT IS HARD TO GET USED TO ALL THAT MAGNIFICATION . WORDING I DO NOT COMPLETELY UNDERSTAND IE THE MAGNIFICATION WORD. I WAS THINKING OF HEDGING MY BETS AND ASKING HIM TO SHOOT FOR A REFRACTORY ERROR OF -2.00 KNOWING IT COULD BE UPOR DOWN SOME FROM THIS . WHY HE WAS SUGGESTING -1.0 FOR HIMSELF AND -2.50 FOR ME REALLY CONFUSED ME. I KNOW YOU CAN NOT HAVE IT ALL GOOD DISTANCE AND NEAR WITH A MONOFOCAL  DO YOU HAVE ANY SUGGESTIONS OR INSIGHT  THANK YOU VERY MUCH    THE  MAJORITY OF PATIENTS I KNOW ARE JUST SET FOR DISTANCE BUT MY INSTINCTS SAY HE IS CORRECT, I MIGHT NOT LIKE THAT ISSUE OF BLURY VISION UP CLOSE WITHOUT GLASSES I DO NOT HUNT OR FLY AIRPLANES  THANKS  VERY MUCH  KENT THRUSH



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by JohnHaganMD, Sep 14, 2015
Hello Kent. First be sure you have read my article at the beginning of this discussion thread as it addresses many of your concerns and others that you might not have considered. You also can scan the discussions as it will help your understanding.

I will try and be succinct. In my long career and dealings with over a 100,000's of cataract patients I have never met a moderate or highly myopic patient that was happy with post op refractive error of 0.00 in each eye even if they are 20/20. They need progressive bifocals for distances closer than 18 feet or so and rue not being able to see at near.

My refractive error is about -3.25 with some cylinder and I do all my near work, reading and computer with out glasses.  For patients that do not have strong preferences, who have not had to wear glasses all the time or wear them for reading but not for distance  a current favorite  refraction is -0.25 for distance and -1.25 for intermediate and near. Especially in those people that have small pupils or pupils that react briskly and constrict in light and near they often are glasses free for many things.

While you can calculate the focal point of a lens system you cannot state with certainty that that will be your focal length post operative. Variable include the quoted error range for IOL calculations is + or - .50 diopters with larger errors for very long or short eyes or eyes with previous refractive surgery or trauma. Also the depth of focus will depend on where the IOL comes to rest within the capsular bag and the size and reactiveness of the pupil.

I would not shoot for a -2.00 in each eye for a patient like you or your surgeon.  I would also suggest you ask your surgeon about a toric lens at least for your left eye.  For an experienced surgeon they give excellent results and do not have the optical problems, poor night vision and dysphotopsia of accommodating and multifocal IOLs. I personally would not put either type of these lens in my eyes but would consider a toric IOL.

This is just a suggestion for you to research and discuss with your surgeon. On your left eye consider a target of -2.50.  Don't hurry into doing the second eye. See how you do reading with the LE   If you want more magnification you could target -3.00 for the RE.  If you're happy with reading using the LE then you might want to consider more range in the second eye and something like -1.25   Remember the amount of myopia can be reduced after surgery doing lasik but  cannot be made more myopic.

I hope this is helpful. Good luck

JCH MD

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by excaptain, Sep 16, 2015
Hi Kent,

Actually a few months ago, researching the same thing that you did and for the same reason, I read the same Japanese article that you mentioned, and it is one of the best written medical articles that I have seen. It seems very thorough and it really helped me in my decision. I have the same issue as you since I am -2.00 on both eyes and want to stay myopic. I would just say that the article analyzes the target refractions in increments of 0.5. I am interpolating from the graphs for -2.00 and -2.50 in the article that had they analyzed in increments of 0.25, -2.25 would probably be optimal. As it turns out, this was also about what Dr. Hagan kindly recommended in my case. Also taking into account the +-0.5 diopter error, I think that anything in the range of -1.75 to -2.75 would be good for me. Therefore I asked my surgeon to aim for -2.25 and she agreed. Actually I made a more specific request that if she could not aim exactly for -2.25 that she aim for the range -2.00 to -2.50. I think that is probably optimal for my situation. I haven't had my surgery yet, I will update when I do.



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by jennks, Sep 18, 2015
Please excuse my ignorance, but my doctor told me 1.5 diopter astigmatism in LE indicates need for "astigmatism correction surgery and lens."  This is an extra $2,600 out of pocket expense.  I don't know how to judge if 1.5 diopter astigmatism is severe enough to warrant this extra expense. Currently my LE long distance is blurred and involves glares/halos at night, but I suspect that may be due mostly to the cataract which needs removal.  Can you comment?

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by PHale, Sep 26, 2015
I had cataract surgery on my right eye which was the worse Dec 2014. And cataract surgery on my left March 2015. The cataracts were in the center of my eye and also on the edges but not as bad as the center. I also went back mad he made cuts to help my asigmatsim. I am a 58 year old woman who has worn hard contacts then gas permeable since I was 16. I have extreme astigmatism   A week after surgery I could see 20/20 but as time went on my vision got worse and worse. In August, I went back to the surgeon who said I had warped cores from wearing the hard or gas permeable contacts for so many years. I am back in gas permeable contacts but my eyes are very sore. I did slowly start wearing them    I would rather have glasses because I have to use reading glasses anyway. The doctor told me I couldn't use glasses. It would not correct the warped cornea. Can you tell me what my options are? I can see very good with the contact in but am unable to wear them all day so part of the day I can't see! My vision now in 20/50 and was getting worse. Will Lasix correct the warped cornea? Or will glasses work? Thanks for your help and opinions.

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by JohnHaganMD, Sep 26, 2015
To PHale   I would strongly suggest you get a second and even third opinion from a highly regarded corneal/refractive surgeon.    While it is possible to have permanent irregular corneal astigmatism from long term GPCTL wear it is unusual; usually goes away after  3-6 months of going without the contacts.

This is what I have problem with:  1. the irregular astigmatism should have been detected before you had your cataract surgery and you advised of it  2. a cornea with irregular astigmatism would NOT BE a good cornea to do incisions to correct astigmatism  3. the cornea incisions themselves could cause irregular astigmatism.

So  you should consider seeing corneal surgeons not in the practice that did the surgery.

JCH MD

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by brucenaples, Oct 10, 2015
what does pciol power of +14.50 mean?

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by cicuta, Oct 25, 2015
Good information; however, no comment was done for diabetic people. That probably could be the subject of another article as I believe that in the case of diabetic people any eye surgery could lead to serious problems including sight loss. Any comments?

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by JohnHaganMD, Oct 25, 2015
to Cicuta: that is absolutely not the case. With the new technology of small incision, one or no stitch, powerful anti-inflammatory medications diabetes heal almost as fast from cataract surgery as non-diabetics. Certainly the operation is 10 times better and safer than the old large incision, multi-stitch surgery done prior to 1980.

Diabetics get cataracts more often than non diabetics and poorly controlled diabetics get cataracts more often than well controlled. The problems with diabetes causing bad vision and blindness are almost all related to diabetic retinopathy or disease of the retina and macula.

Brucenaples:  14.50 is the bending power of the IOL.  Diopters are the standard unit of bending of light used on cameras, telescopes and all optical systems.  It's low indicating that prior to surgery the person was likely myopic or nearsighted.

JCH MD

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by JohnHaganMD, Oct 25, 2015
to Cicuta: that is absolutely not the case. With the new technology of small incision, one or no stitch, powerful anti-inflammatory medications diabetes heal almost as fast from cataract surgery as non-diabetics. Certainly the operation is 10 times better and safer than the old large incision, multi-stitch surgery done prior to 1980.

Diabetics get cataracts more often than non diabetics and poorly controlled diabetics get cataracts more often than well controlled. The problems with diabetes causing bad vision and blindness are almost all related to diabetic retinopathy or disease of the retina and macula.

Brucenaples:  14.50 is the bending power of the IOL.  Diopters are the standard unit of bending of light used on cameras, telescopes and all optical systems.  It's low indicating that prior to surgery the person was likely myopic or nearsighted.

JCH MD

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by DropShotPete, Nov 17, 2015
Hello Doctor Hagan,

I read through all these questions and answers and appreciate the time you spend answering in such detail.   Even reading the answers for people with very different issues than me was interesting and enlightening.

Background: I'm a very active 49 year old (tennis, golf, biking) and my job involves daily computer/analysis work.   I wear contacts with a 2.25 prescription in each eye and use reading glasses for computer work and reading.   I have a slight cataract in my right eye- which is also my dominant eye.  I say it's slight as it has noticeably affected my distance vision, but so far has only very mildly impacted my reading abilities.

Few quick questions:
1. My doctor has recommended lens replacement for both eyes.  Should I get my good (left) eye done as well?
2. I have a dendrite in my left eye as a result of a HSV infection in my early teens.  I was told years ago that because of this it disqualified me for laser correction; will this present any issues during cataract surgery?
3. I have floaters in both eyes that I find somewhat distracting (especially playing tennis) will lens replacement make the floaters worse?
4. (loaded question) - based on my information what lens would you recommend?   I spoke with two doctors at the practice I go to and they both had different recommendations-  just curious what you thought.

Thanks again for all your help.


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by JohnHaganMD, Nov 17, 2015
1.  As a generalization your vision and impairment doe not warrant cataract surgery. Our patients complain of medium to large problems with their vision.  You:  I say it's slight as it has noticeably affected my distance vision, but so far has only very mildly impacted my reading abilities.  I say it's slight as it has noticeably affected my distance vision, but so far has only very mildly impacted my reading abilities.
2. Yes it will increase the risk of surgery because steroids are generally used post op and this increase risk of HSV reactivation.
3. Yes makes them more noticeable
4. I'm not going to recommend a lens. Our practice uses Tecnis IOLs.  I wonder if you really need cataract surgery with your seemingly minor complaints.
5. Realize there are very aggressive cataract surgical practices everywhere that try and pressure everyone with even tiny cataracts to have surgery.  CONSIDER A SECOND OPINION

JCH MD

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by dasmith57, Nov 18, 2015
Good Afternoon Dr. Hagen,

A very informative website.  Thanks for addressing the concerns of so many people.

I am a 58 year old female who recently had RLE surgery to eliminate the need for wearing eyeglasses for most of my daily activities except up close reading.  My vision is quite good post op but there is some blurring going on when trying to focus on things in the distance (signs, that sort of thing).

There is a possibility that I may have developed capsule contracture but won't know for sure until a few more weeks.   It was explained to me, I'm not overly concerned as I have healed wonderfully and had a great surgeon.  I hope I am not breaking any of your rules as I am not asking for advice what I want is your opinion and experience with patients who had similar results.

What I would like, are any comments you may have on capsule contracture?

Thanks,  Debbie

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by JohnHaganMD, Nov 18, 2015
RLE=refractive lens exchange. removing a non-cataractous lens and replacing it with an IOL to reduce dependence on glasses.

It's essentially  the same operation as cataract/IOL. The membrane more often than not develops some folds and wrinkles. Most people do not have any visual problems from this an only becomes a problem when the capsule starts to turn cloudy.

JCH MD

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by GallegaGirl, Dec 06, 2015
Hello Dr Hagan,

Thanks for all the interesting information on this site!

I am 61 and have been nearsighted with astigmatism since childhood. I have worn either hard or gas permeable contact lenses since 16 yrs of age. I have recently developed cataracts that have to be removed but don't  want to resort to wearing glasses. My astigmatism is -2.80 and -2.00 and was given the option of toric lenses as monovision or Lasik to correct astigmatism and a month later have multifocal IOL inserted. Would one of these options be better than the other or should I wait for a toric/multifocal lens to be offered in the US?

Thanks for your help!

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by JohnHaganMD, Dec 06, 2015
Given how inefficient, inept and incompetent the FDA is there is no telling when a toric multifocal will be approved. Note that collegin cross-linking for keratoconus has been the standard treatment for almost a decade and still cannot be done in the USA except under investigational protocol you have an idea why the FDA and trial lawyers and the junk lawsuit industry are turning US medical research into a backwater.

If you will go to my home page and step through the posts you will find one on a study comparing multifocal IOLs with mono-focal IOLs and using mini-monovision to reduce glasses dependence.

Are you use to full mono-vision wearing contacts? or did you wear multifocal contact lens.

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by GallegaGirl, Dec 06, 2015
Dr Hagan,

More recently, I wore multifocal contacts lenses. I have worn mono-vision contacts in the past but I had an issue with my dominant eye changing and am worried that this will happen with the IOL lenses. I also worry about Lasik over IOL causing excess glare.

Thanks again!


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by JohnHaganMD, Dec 06, 2015
Frankly if you believe you will see perfect for all things without glasses after surgery you will be very disappointed.  Be sure you understand all your options. With my article and the many posts here you understand there is no 'Best" choice and different people will have different preferences.

JCH MD

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by Beevv, Dec 28, 2015
Thank you for the wealth of wisdom here and your valuable time. I am 52 and a a high myope -12/-13 and have had TWO cryolaser vitrectomy rs in the left eye and retinal detatcent laser in the right.  the poor left eye has a lot of scar tissue, and was described as a mess by my second surgeon. These ops were in 2009 and I was told I would need cataract op in 2010 but it was up to me when to have it. I have not realised that it will be harder if left longer and I still have not gone back. Reading your article has prompted me to do so, but I am concerned about the risks of the op and any extra complications of having left it so long. Does the later stage of the cataract affect the type of procedure or suitability of lens? Also they mentioned that as I was so myopic they may actually not put any lens in.  Would this be more or less risky in terms of macular and retinal deterioration in the future ?
I do not wear any glasses at the moment but dependent on gas permeable contacts for over 30 years. Would I be able to wear them after the cataract op (diff prescription obviously) and should I stop wearing them for some time before the op (even tho would be hard) as I read the post about them changing the shape of the cornea.
Thanks in advance for reply !

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by Beevv, Dec 28, 2015
PS the first vitrectomy failed and so was redone 6 weeks later. Three and a half hours of eye surgery put me off eye ops a bit I think!

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by JohnHaganMD, Dec 28, 2015
Waiting only increase the risk of surgery if the lens of the eye turns red/black (a so called cata-rock) or the lens swells and turns right (mature or ripe cataract). Even then with modern techniques the risks are still small.   Your GP contact lens will interfere with the measurements for determining IOL power and you may need to go without the contacts for several weeks till your cornea curvature readings stablize. Even if it should be determined that your IOL power needed is zero "called plano" you would do best by having an IOL with power zero put it. It helps stabilize the vitreous  and would reduce the risk of retinal detachment and macular edema.

Also you understand that after one eye is "fixed" the two will be wildly out of balance and that the second eye will need to be done 3-6 weeks after the first.

On my patients with history of RD or high risk for RD I have them see their retina surgeon and get okay for the cataract surgery. Then I have them see the retina surgeon 7-10 days post operative for a repeat retina exam by the retina surgeon.

JCH MD

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by excaptain, Jan 06, 2016
Hi Dr. Hagan,

I just wanted to follow up on my promise to report when I had the surgery. I had it 2 days ago, general anesthesia. Everything went well. It's only 2 days post op and I can see as clearly as I did before the cataract (20/20). Amazing!!!! What a life-changing experience. The doctor did a spectacular job. She also go the final refraction target correct. I think it is about -2.25 or -2.5 give-or-take (based on the distance of optimal reading focus of about 40 cm). Fantastic! Exactly what I wanted and what you had suggested. Thank you so much Dr. Hagan - I am extremely pleased. I can read a book or the computer without glasses, distance vision is like before (with glasses) and amazingly even intermediate vision is pretty good (I can read the computer screen from about 80 cm away wearing my -2.0 distance glasses - I didn't think I would be able to do that!). There was no post-operative discomfort at all and I can't feel the IOL (which is still amazing to me).  Of course there is an element of luck here but the most important thing was my surgeon, Dr. Carolyn Anderson from Langley, B.C.. What a brilliant surgeon and the best doctor I have ever met. Apart from being extremely skilled, she has impeccable "bedside manners" when communicating with patients and she is a wonderful person. Highly recommended if anyone is looking for a cataract surgeon. Also, the Alcon lens (SN60WF 21.0 D), as I had hoped, has excellent color and brightness matching with my other eye. Virtually indistinguishable color and brightness from my natural lens. Whoever thought of tinting the lens at Alcon is a genius.

Anyways, thanks again Dr. Hagan, your help was invaluable. What a wonderful profession you have!

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by JohnHaganMD, Jan 06, 2016
Very happy and pleased for you. I have been in medicine long enough to witness extraordinary changes in cataract surgery and it is so much safer and faster healing than in the distant past. Thanks for the follow up.

JCH MD

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by Momahicks, Jan 13, 2016
Dear Dr Hagen - I had Lasik surgery performed ten years ago and was very satisfied with the results. I have recently developed difficulty in my right eye. Having had no problems with my eyes until this time I had not visited my opthalmologyst until now. I was told at the office that my records had been purged from their system because I had not been there for so long. After my eye exam I was told that I had developed cataracts in both eyes with the right eye being the worst. The Dr seemed to downplay the complications that he would have in calculating the lense needed without my pre Lasik measurments and recommended a basic single focus lens implant along with the Femtosecond laser to treat my cataract and correct a moderate amount of astigmatism. I went home and did some research about cataract surgery after Lasik and discovered what a shot in the dark it is to calculate the correct lens without my pre Lasik measurements. What is your experience with post Lasik cataract surgery? Can this be performed with any predictable rate of success? Do I have any other options? Can you recommend a good opthalmologyst in the triangle area of NC with whom I can get a second opinion?

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by JohnHaganMD, Jan 13, 2016
There are so many patients that have had LASIK that have had cataract surgery and their original measurements are not available (also RK patients) that there are formula for picking an IOL.  While the range of error is not as narrow as eyes with no previous surgery (+ or - 0.50 diopter) it is no where like "just making a guess".  It would be a good idea on the first eye to  not shoot for 0.00 at distance since if you are undercorrected it would leave the eye farsighted and there is no distance that is clear without glasses.  If you want to get a second opinion you may need to have the second consultant run another set of measurements on your eye to compare with the first set.  AND get your eyes examined yearly from now on. I do not personally know anyone in that area.

JCH MD



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by Urs111, Feb 01, 2016
Hi Dr Hagan ,
           very Informative Article am so glad I found this site . I am a 35 year old female . I am highly myopic LE -11.75 & RE -11.5 . I had a Vitrectomy done on the RE in July 2011 for Macular Pucker following which I had Cetral Scotoma . I have now developed a cataract in my RE . Have been advised to get it operated but the main issue would be the Vision Imbalance following IOL in only one eye & i am unable to wear contacts for long periods due to Dry Eyes .  Lasik is not possible due to insufficient corneal thickness . I have tried the following  
Wearing glasses with -11.75 prescription in the LE and -2 in the RE and contacts with prescription -9.00 In the LE and am ok with this . Am hoping to wear contacts for as long as possible and at times when am unable to wear the contacts would opts for glasses .  My question to you is ... Would my post op vision with IOL be similar to my Current vision with contacts ? If so can I mabe get by with the different pres glasses ? Am used to monovision due to Central scotoma in RE would it help me to tolerate the imbalance better ? Do you have any other solution ? Am not wiling to get the LE operated since it is my only good eye left and LASIK or ICL does pose the risk of Retinal Detachment and with my high Myopia am already at greater Risk .
Thanks .

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by Urs111, Feb 01, 2016
Hi Dr Hagan ,
           very Informative Article am so glad I found this site . I am a 35 year old female . I am highly myopic LE -11.75 & RE -11.5 . I had a Vitrectomy done on the RE in July 2011 for Macular Pucker following which I had Cetral Scotoma . I have now developed a cataract in my RE . Have been advised to get it operated but the main issue would be the Vision Imbalance following IOL in only one eye & i am unable to wear contacts for long periods due to Dry Eyes .  Lasik is not possible due to insufficient corneal thickness . I have tried the following  
Wearing glasses with -11.75 prescription in the LE and -2 in the RE and contacts with prescription -9.00 In the LE and am ok with this . Am hoping to wear contacts for as long as possible and at times when am unable to wear the contacts would opts for glasses .  My question to you is ... Would my post op vision with IOL be similar to my Current vision with contacts ? If so can I mabe get by with the different pres glasses ? Am used to monovision due to Central scotoma in RE would it help me to tolerate the imbalance better ? Do you have any other solution ? Am not wiling to get the LE operated since it is my only good eye left and LASIK or ICL does pose the risk of Retinal Detachment and with my high Myopia am already at greater Risk .
Thanks .

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by JohnHaganMD, Feb 01, 2016
First and foremost I would be sure the vision in the RE is bad enough that you really need surgery. If you can "get by" then you may want to wait a while as there is no easy solution.  To answer your question wearing glasses AND contacts does not simulate what it would be like with just IOL  for a couple of reasons 1. you're still looking through contacts and 2 the optical system of glasses and contacts is not like an IOL in the eye. Image size is totally different.

You are 35 and already have dry eyes and reduced contact lens wearing time. That will only get worse over time.   You might seek out the finest refractive surgery/cataract surgeon you can get to on a regular basis and ask for their opinion.

JCH MD

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by Urs111, Feb 01, 2016
Hi Dr Hagan , Thank You so very much for the prompt reply .... I cannot avoid surgery by more than a year and in any case even after 2 or 5 years would have to face the same problems .
Was thinking of getting the surgery done but leaving the same high myopic number in the RE i.e . Aim for a post op number of -11 in the RE which would then match my LE number of -11.75 .  I have no problems with wearing specks for the rest of my life . And do not wish to get rid of it for cosmetic purposes .
Is this according to you a feasible solution and if not would you please give me the reasons why is this not an option ?
Also other than vision improvement is there any other advantage of reducing the myopia post cataract surgery i.e does it improve my eyes by reducing strain on it ?
Thanks

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by JohnHaganMD, Feb 02, 2016
I would suggest you re-read my article again. I've done over 12,000 cataract surgeries and managed after surgery probably twice that number. I have never had a patient put an IOL in their eye to leave it -11.00  In fact the largest planned post operative refractive error I've ever seen, or agreed to leave a patient is -3.00.

Your cornea on the LE is not likely too thin to have some sort of refractive surgery. What is true is that it is not at all likely that lasik could be done to leave you 0.00 post op. However by during a surface refractive procedure (PRK) it might be possible to correct 6 to 7 diopters of myopia  that is it might reduce your myopia to about -5.75 to -6.75  The chance of making your dry eyes worse would be less with surface PRK than flap lasik.   You could then target your RE to about -3.00 and you would only have about 3 diopters difference between the two eyes and you might manage that with glasses or glasses and a contact on one eye.  Down the road when the LE develops a cataract you could target that eye for 0.00 that would be full monofocal or you could go -1.25 which would be mini-monofocal with near bias.

As i said I would never put an IOL in an eye to plan on leaving it -11.00

JCH MD

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by Urs111, Feb 03, 2016
Hi Dr Hagan , Thank You for your opinion . That is the exact opinion expressed by my doctor . Am trying to convince him otherwise . The LE cornea has some inherent weakness due to which LASIK or any other op on the Cornea was ruled out . He is of the opinion that if I were to perform LASIK I would definitely require a corneal transplant in 3- 5 years . Also I am unwilling to perform any sort of surgery on the LE due to the very reason stated by you that all surgeries carry risk .
However if in the future I were to develop a cataract in the LE , I would def try to go Plano or as close to Plano as possible in that eye and wear contact for as long as possible in the RE . If Contacts pose a problem I would also be open to any or all further surgeries in the RE , such as the piggy back IOL .

My only question is does leaving behind the high number in RE cause any harm to the RE , I.e does it put more strain on it ?
Thanks .

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by JohnHaganMD, Feb 03, 2016
No it just makes it much more difficult to see, the image size is much smaller, the night vision worse and the vision without glasses not functional.

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by SaKaLa9, Feb 03, 2016
I hate being a whiner, because compared to my previous situation, my eyes are awesome. I am a lifelong serious reader however, over 1000 books just since I started using my Kindle. It is a paperwhite, which I think is backlit.

My eyes are about 14 and 13 and I have cataracts. I had surgery on the weaker left eye 2 weeks ago and received a  Tecnis multifocal ZKB00 +7D +2.75D lens. I have great distance and mid vision. I also can see the small print on my Apple watch (black background, white letters) when I hold it at arms length! Weirdly though, I cannot read my Kindle(white background, black letters), even with a larger print adjustment. If I put the maximum contrast on it, i can see the letters, but with dark shadows behind, reading is a strain.  I also can see the newspaper, but need longer arms to read it comfortably.  

I had to delay my other eye surgery because I fell due to my currently very discrepant eyesight and had a mild concussion. I now am wondering if the other eye could possibly be corrected in a way that would improve my near vision. Also, do you know why I can see my watch so well and yet not read? Thank you so much Dr. Hagan.

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by JohnHaganMD, Feb 03, 2016
It would help if you had your uncorrected vision in the LE and what 'over-refraction works best.  If you have good distance vision and mid-range vision but not reading vision (say about 20 inches away) It means you must be slightly over-corrected for distance (small amount of hyperopia) or if correctly focused for distance that you need more than the average amount of reading power for near.  This might occur because of the position of the IOL within your eye or you might have a big pupil that does not help you focus well at near.

When you get the other eye done the surgeon can discuss with you intentionally leaving that eye under-corrected at distance say -0.75 to help you with your very close vision.  You might see what effect a +1.00 or +0.75 reading glass has on the ability of your LE to read at near.

Your observations about the watch and Kindle   must be apples to apples   done at same distance and same size print/letters. If that is the case then the white letters on black background is giving your greater contrast sensitivity and is easier to read.

JCH MD



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by Urs111, Feb 04, 2016
Hi Dr Hagan , Thank You so very much for taking the time and patience in answering all of my questions and clearing all doubts .

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by JohnHaganMD, Feb 05, 2016
Happy to help. Best of luck and good fortune.

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by unhappy_camper2, Feb 08, 2016
Hi Dr. Hagan:
Thank you for this article.  I wish I had found it before my cataract surgery.  I had prednisone-induced cataracts for years, and had to have them removed when I could no longer read the DMV eye chart.  My dentist recommended an ophthalmologist that was in a research group he was in and said she was top-notch, so I went with her.  I was near-sighted with astigmatism and had to wear glasses 40 some-odd years prior.  I left the lens decision to her.  She said my vision was -12 in the left eye and -14 in the right and she picked the AMO Tecnis Toric IOL (L ZCT 2,25 + 5.5, R ZCT 3.00 + 7.5) to correct far-vision (I have read your article and every post and I still don't understand my prescription or why the refractive error should not be 0.00).  The ophthalmologist told me if I chose far I would have to use reading glasses to read and work on the computer, which I thought would be fine.  My problem is I wasn't told I would not be able to see anything up close.  I couldn't even read with 3.25 reading glasses.  I kept telling the doctor everything was blurry from my nose out to about three feet, and she kept telling me it would clear as my eyes healed.  I told her I needed to get glasses in order to see anything up close and she kept telling me she didn't think I would.  I gave it a full three months and then she told me my eyes were completely healed so my close vision would not clear.  I then went to my optometrist and got fitted for progressive lenses (I had worn them before).  When I got my glasses, I still couldn't see up close (like to cut my fingernails or thread a needle), so my optometrist increased the near power, but not as much as I needed because he said it would blur my intermediate vision (he told me I needed a four to read).  So even with progressives my near-vision is not clear.  If I had known I would never be able to see clearly up close again, I would have chosen the IOL to correct my near vision, as I assume progressive lenses would be able to correct the far vision.  Is this a wrong assumption?  I have tried wearing reading glasses on top of my progressives which helps but isn't very practical.  Is there anything else I can do other than more surgery to clear my near vision?        

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by JohnHaganMD, Feb 08, 2016
You would need to give me your glasses prescription including your reading add and your vision with and without the glasses at distance and near.

If your far away vision (20 ft or further) is good (say 20/20 to 20/25) with or without glasses then there is no logical reading why you should not be able to read at near and intermediate with progressive bifocals.

So if you can find that information I would be happy to try and help you.

JCH MD

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by unhappy_camper2, Feb 10, 2016
Hi Dr. Hagan:
Thank you for taking time to help me.  My IOL enables me to see 20/25 far vision in both eyes.  Near vision L 20/70 R 20/200.  My eye surgeon told me most people don't get results that good.  Without glasses, I can drive, but I can't see the dash board or read labels, or see more than a blur up close).  My progressives are R+0.75 sphere -1.25 cylinder 063 axis add power +2.75.    L+0.75  sphere -0.75 cylinder 104 axis add power +2.75.  With these progressives my far vision is 20/20 both eyes and near 20/25 both eyes.  My problem is near vision seems to be measured ONLY to reading distance (about 18 inches), not for anything closer.  I like to do hand sewing, and I can't see well enough to thread a needle (or cut my fingernails etc.) with or without glasses.  I used to be able to do that stuff without my glasses.  My optometrist told me I need +4 reading glasses (which I assume is why I can see better if I put my +3.25 readers on top of my progressives which gives me  +4).  He told me he couldn't give me a +4 power in my progressives or it would make my intermediate vision blurry.  Why is that?  After surgery, my refractive error is +.25 -.75 in both eyes.  This doesn't make sense to me as I would think you would want 0.00 - doesn't 0.00 mean you need no correction and would be able to see from your nose outward?  

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by JohnHaganMD, Feb 10, 2016
I don't know what your refractive error was before surgery but you can algebraically subtract the post op from the pre op and that is what you was corrected by your surgery. The ZCT 225 corrects 2.25 diopters of astigmatism and you still have 1.25 and the ZCT 300 corrects 3 diopters of astigmatism and you have 0.75 remaining.  If you were shooting for best distance correction (20 feet or more) without glasses (often not the best choice as my article outlines) then the 'perfect" RX would be 0.00  no sphere and no astigmatism (cylinder).  So your post op Rx is off some but its not an exact science.  Most patients are happier if they have some residual myopia a typical "happy RX" for many people is 0.00 in the dominant eye and -1.25 in the non-dominant eye. We try and never leave an eye hyperopia or farsighted because no distance is entirely clear without the glasses. Your 'spherical equivalent" in the RE is about zero but the LE is hyperopic.  If you want to know what the spherical equivalent is read about it on wikipedia but it might be though of as the "average" refractive error of the sphere and cylinder.

I think your optom is WRONG.  If you wear progressive bifocals your intermediate vision does not have to suffer by going to a stronger reading segment (referred to as reading 'add')   Most companies that make progressive bifocals offer them routinely up to +3.50 add.  Sometimes a +4.00 is not available or may be available at increased cost. You would have to check with the optician.  Most people after cataract surgery use about a +3.25 add in a progressive. since you do smaller work at closer distance you would need more "add".  Another problem is if you have a very large frame it moves the most magnified portion at the very bottom of the lens down and away from you and its often hard to look through that part. Sometimes a small frame which moved the most magnified part up higher works best.  Other options would be to use magnifier loupes, illuminated magnifying glasses like you will see in craft stores and craft catalogs.

I don not know what you mean with this: After surgery, my refractive error is +.25 -.75 in both eyes.  That is not your refractive error. It is your progressive RX which you list in line 3.     And your thinking is wrong. If you have a RX of 0.00 in both eyes and a monofocal or toric IOL it means your vision is not perfectly clear till you are 20 feet or more from what you are looking at. At that distance the light rays enter your eye parallel and the IOL and cornea focus them properly. But as things get closer the light rays are diverging and need a lens system to focus clearly and that RX changes as the distance changes.

I'm thinking you got your glasses from the Optom. Most opticians will remake a lens one time without extra charge within the first 30 days. (our optical its 60 days).  The Optom may charge the extra price for a +3.75 or +4.00 but you shouldn't have to pay for two completely different lens.  Have the Optom (or you) keep the lens you have now and put the new RX with higher add in and see how you do. If you don't like they can always stick the old lens back in.  In very rare cases people sometimes have to get two pair one for everyday (like you have now) and one with the much stronger add for fine detail work, crafts, sewing, etc.

JCH MD

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by JohnHaganMD, Feb 10, 2016
NOTE: I called the lens "no line bifocals"  that is technically incorrect as is "no line trifocals"  they technically should be called a progressive multifocal but the former terms will never go away so I used them. Only with LINED bifocals and trifocals do you need to have concern about losing intermediate vision if the reading vision is made stronger.

JCH MD

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by unhappy_camper2, Feb 12, 2016
Hi Dr. Hagan:
That you for giving me answers I haven't been able to get from my ophthalmologist or optician.  This has been really discouraging to me - I couldn't figure out why I couldn't get the vision I want after surgery using progressives.  I have been going to this optometrist for over thirty years and never had a problem before.  

It seems to me that I needed a different refractive error after cataract surgery to get the close vision I desire.  I'm not sure if the ophthalmologist tried for a specific refraction error, or it just ended up that way.  The ophthalmologist was the one that told me most people don't get that good of results with cataract surgery.  It was the ophthalmologist's office that told me my refractive error after surgery was +.25 -.75 in both eyes - this was not the doctor, but the technician so she must have been wrong - does this matter?  The technicians seem to think that it's not important to see any closer than reading.  

Yes, I got my progressives from the optometrist (they are supposed to correct all three fields of vision), but I already had him remake them because of the same problem of not being able to see up close (closer than reading vision).  The second office visit was when he told me he couldn't give me the +4 that I needed for up close without making my intermediate vision blurry.  They are small frames (actually frameless), as I have a small face and have always needed a small frame.  The optometrist tells me the only way I will be able to see clearly up close is to buy separate reading glasses with a R +4.0 sphere -1.25 cylinder 063 axis L +4.00 sphere -0.75 cylinder 104 axis.  The technician tells me she has three pair of glasses, one for everyday, one for computer, and one for reading.  They seem to think that's the way it is, and I thought that was plain wrong.  I don't really want to have several pair of glasses lying around and having to get the "right" one for whatever it is I'm doing.  I  was beginning to think that the whole profession doesn't think seeing any closer than reading is important.

So now, I will have to decide whether to go somewhere else to get different progressives, or call the optometrist and see if I can work something out as they want to charge me again to make different lenses.  Thanks for clarifying things for me.

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by JohnHaganMD, Feb 12, 2016
Yes good luck. As I said usually adds on progressives to +3.50 are no problem, some companies offer +3.75 or +4.00 at an extra charge.

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by unhappy_camper2, Feb 18, 2016
Hi Dr. Hagan:

I searched and found that Nikon makes a +4 add lens, so I called my optometrist about it and was told that the Varilux lens (which is what I have) was better than the Nikon and that I also need a polycarbonate lens.  I got polycarbonate when I was extremely myopic, because they were lightweight, but I wonder if I really need them now.  I understand they are more impact-resistant and have UV protection, so maybe it's worth getting them.  From my searching, it looks like Trivex may be even better than polycarbonate for its better optical quality and suitability for drill mounting (I have frameless progressives that would be considered "no line trifocals" not "no line bifocals").  The technician at my optometrist's office tells me you can't get +4.00 add with polycarbonate without distorting the intermediate vision (or with Trivex, or Free-Form).  Does this make sense to you?  It's really hard to find info about +4 power in a progressive (whether it can be done without blurring intermediate vision).

I still don't understand the refractive error.  I thought that was simply the amount of myopia, astigmatism, or presbyopia - why isn't my refractive error the same as my prescription?

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by JohnHaganMD, Feb 18, 2016
1. No line bifocal and no line trifocal are both incorrect terms and both are the same type of lens. The correct term would be no line progressive or multifocal. However no line BF and no TF will never go away and are only thing some people understand.  The reading "add" is not part of your basic refractive error that is this distance (> 20 ft) RX.  Most adds after cataract surgery are +3.00 to +3.50
2. Your refractive error and your DISTANCE glasses RX are one in the same.
3. With your new smaller post op refractive error polycarbanate would not be necessary.
4. I don't know anything about Trivex our opticians handle those.
5. Is your optom going to re-do your present glasses at a reduced or no cost. If so you may need to keep putting up with all the run-around you're getting. If so a plastic varilux with +4 add and UV blocker and scratch resistant coat without anti-reflective might be a good option. If your optom is going to charge you a whole new set of lens you might just want to get your RX and go elsewhere for the glasses.





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by unhappy_camper2, Feb 18, 2016
Hi Dr. Hagan:

Why would I not want anti-reflective?  The glasses I have now are Crizal.  I spoke to the technician again today and asked her to the talk to the optometrist again because she insists that I can't get the +4 add without distorting my intermediate vision (that is what the optometrist told me also).  Is that true with the polycarbonate lens?  In the meantime, I found two places online that I can get +4 add in a progressive lens (FramesDirect.com for $329 and GlassesUSA.com for $287 - I paid $523 for the ones I have now, plus I added transitions for an additional $112 when I had the glasses remade (but I didn't know they don't work inside a car).  I am waiting for a call back from the optometrist's office.

Thanks again for all the time you have spent answering my questions.  I have had a hard time believing I needed a separate pair of glasses for the up-close vision (like threading a needle).  I never needed two pair of glasses before.

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by JohnHaganMD, Feb 19, 2016
Anti-reflective is expensive, hard to keep clean, and not at all durable. More than half the people that try then dislike them and do not get again. I really dislike AR and don't get in my glasses unless the manufacturer only offers the lens I want in AR.

If you want to fork out the money for AR or if you have no choice and it only comes in AR its your money

The opticians/optometrists and some opthalmologists. It's a very expensive upgrade and greatly adds to profit margin on glasses.  

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by JohnHaganMD, Feb 19, 2016
Anti-reflective is expensive, hard to keep clean, and not at all durable. More than half the people that try then dislike them and do not get again. I really dislike AR and don't get in my glasses unless the manufacturer only offers the lens I want in AR.

If you want to fork out the money for AR or if you have no choice and it only comes in AR its your money

The opticians/optometrists and some opthalmologists. It's a very expensive upgrade and greatly adds to profit margin on glasses.  

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by JohnHaganMD, Feb 19, 2016
Anti-reflective is expensive, hard to keep clean, and not at all durable. More than half the people that try then dislike them and do not get again. I really dislike AR and don't get in my glasses unless the manufacturer only offers the lens I want in AR.

If you want to fork out the money for AR or if you have no choice and it only comes in AR its your money

The opticians/optometrists and some opthalmologists. It's a very expensive upgrade and greatly adds to profit margin on glasses.  

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by unhappy_camper2, Feb 19, 2016
Hi Dr. Hagan:

The technician from my optometrist's office called today and said the optometrist says intermediate vision will be clear with +4 add power, but I won't be able to see an intermediate distance as far away as I do now (she said the dashboard in my car would probably not be as clear as it is now, nor anything further than that - until 20 feet). I asked how is that clear?  She said if I can find someone who can guarantee otherwise, I should have them make the glasses, but she thinks I will be disappointed.  My optometrist will remake the glasses if I want to try it but I will have to pay for them again.  She said their lab will not make rimless glasses unless they are made with polycarbonate because the plastic easily breaks around the drill holes.  She said they could remake the glasses using Varilux plastic, but they will still cost $277 for the lens plus $140 for anti-reflective (saying I should get it as it reduces glare, includes UV protection, and two year scratch warranty) plus the cost for a frame (unless I bring in a rimmed frame).  

I told the technician I have been told that I could get a +4 add power without any intermediate vision distortion (I didn't say from whom), but she still insists they are correct.  I told her I was very upset and I would go elsewhere if I decide to try it.  I told her they should have explained all this to me BEFORE I got the glasses.  I never expected to have to deal with this as I've never had this issue before.  I also wish progressives weren't so expensive, because I don't really want to shell out another big chunk of money.  It cost $4200 for my intraocular lens in addition to the cost of the progressives.  I live in California and EVERYTHING is more expensive here.  I'll probably just live with it and put my +3.25 reading glasses on top of my progressives when I want to do close-up work.  I am really disgusted.  

Thanks for all the time you have spent on me!

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by JohnHaganMD, Feb 19, 2016
or you can buy a magnifying loupe over your glasses like you can get in a crafts or hobby store. Or you can Google Magnifying Loupes and see what types of magnifiers can be worn over glasses or you can just wear two pair your progressives and +3.25 (or other power) magnifier.

My daughter lives in California I know how expensive things are there twice as much as here in Kansas city

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by SuziQ0614, May 05, 2016
Hello, Dr Hagan. I am 66, have cataracts caused by long-term use of prednisone. My left eye was operated on this past September 2015, an Alcon AcrySof IOL with yellow tint was used, which I am told filters out blue light. Now my right eye must also be done but the facility now uses Bausch & Lomb enVista IOL which is NOT tinted. Will this cause any issues, 2 different lenses with one filtering out blue light and the other not? I would appreciate your help.  Thank you.

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by JohnHaganMD, May 05, 2016
this is a generalization but most people do not notice any problems or difference in tinting. This is a common situation. There have been one maybe two postings of people that if they compare eyes notice slight tint changes but not with both eyes open. These two people were like artists.

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by JohnHaganMD, May 05, 2016
this is a generalization but most people do not notice any problems or difference in tinting. This is a common situation. There have been one maybe two postings of people that if they compare eyes notice slight tint changes but not with both eyes open. These two people were like artists.

177275 tn?1438375244
by JohnHaganMD, May 05, 2016
this is a generalization but most people do not notice any problems or difference in tinting. This is a common situation. There have been one maybe two postings of people that if they compare eyes notice slight tint changes but not with both eyes open. These two people were like artists.

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by SuziQ0614, May 05, 2016
Thank you! I was a little concerned when they told me. I  feel better now.
Bless you.

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by JohnHaganMD, May 05, 2016
Best of luck

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by violet_t, May 06, 2016
Dear Dr Hagan, I'm from Bulgaria and here nobody explain or does a proper counseling.  I'm a 35 year old woman and I have pan uveitis in both eyes sine 15 years. Before 6 years my eyes developed cataract. I've been nearsighted since I was 13 years old and I have astigmatism in both eyes. I have undergone surgery in my LE and now i'm farsighted with this eye. My problem like above is I wasn't told I would not  be able to see anything up close. I'm satisfied with my far vision, but now I think it was a bad decision, because i don't have detailed vision and that is not ok for me. I'm going to make the second surgery on my RE and I don't won't to lose my near sight. My eyes are
RE =c -3,5 dsph=0,4
LE= c +0,75 dsph= -1,0 dcyl 010=0,6
What do you think is the best option for me, i want to read without glasses? Is -1,5 good for me? I want to be able to see my face up close and my fingernails. And Do you think a Toric lens is a good option ? I have EnVista in my LE and for the RE the doctors sets for Acrysof or CT Asphina. I 've read that glistenings are present in the majority of  patients with Acrysof lenses. Is that a problem?
Sorry for my bad English.
Thank you so much!

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by JohnHaganMD, May 06, 2016
What is your vision with your present glasses. What do you take for your pan-uveitis? Is there a specific name to this uveitis? Glistenings are not a problem. Silicone lens is a problem given your retina uveitis. Acrylic better choice.

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by violet_t, May 06, 2016
My glasses are RE -3 D and -1,5 left eye, I need them for computer and driving. I see very good with my right eye, little cloudy duo cataract. The uveitis affected the front, middle and back - the peripheral retina of both eyes. RE pupil doesn't react to light. My iris had part artrophic area. It was bad because it was difficult to overcome the inflammation. I was treated with corticosteroid pill and injection, also in the eyes, antibiotics and eye drops. They think it's autoimmune problem.
Now my both eyes are calm but not fully ok, I think it's normal with this disease and the eyes are affected.  Frequently I have pain in both eyes but I read a lot :).
Thank you for your response!

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by JohnHaganMD, May 06, 2016


Re-read my article again especially the segments on full monofocal and mini-monofocal distance or near bias.

Your surgeons intentionally or unintentionally set your LE for full distance correction. Without getting into the optics the spherical equivalent of your glasses correction is +0.25  so this is almost perfect for seeing without glasses further than 20 feet (6 meters).

You should have been told this especially since most myopic people (like me also) like to read without glasses and are use to doing this even if they wore bifocals before surgery.

You evidently have not had your glasses changed since surgery since your LE does not have the RX you listed for the LE that you made in the first post. (+0.75 -1.00 axis 010)

If you opt for -1.50 in your    LE   you will be using only one eye at a time without glasses. The only way to make both eyes work at the same time and for all different distances will be progressive no line bifocals.  WIthout glasses being -1.50  you likely will be able ONLY in your RE (the one to be operated on) to see yourself in a mirror, see the computer screen and read large print in good light. It will not look like what it looks like now because you now have -3.00 which gives much larger magnification but shorter focal point.   If you go with what you have not -3.00 that is full monofocal and you will lose your intermedicate vision and glasses may be difficult to adjust to.

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by violet_t, May 06, 2016

Thank you for your opinion Dr. Hagan. It was intentionally set like this :( . They told me I will have good near vision, not perfect but good. And then I was in chock. I can't do my eyebrows or oder things that require near vision and it's not comfortable doing with glasses. I see very good at Far distance with my left eye but I need glasses duo astigmatism. What I wrote in the first post it's how is my vision now, the second is my glasses made  after the surgery. The mini or full  mono vision it's not a practice here and I do read  and search a lot and that's  how I come to this. I was thinking I can save the good near vision of my RE but I cannot.  I know I will only see with one eye in one distance at time, like it's in the moment, but for my case is the best option I think.
Thank you so very much for your time and quick responses.

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by JohnHaganMD, May 06, 2016
Well your best bet is to explain to your surgeons your disappointment and your wishes for the second eye so you won't be shocked again after the second eye is done. i don't know what opportunity you have for second opinions from different eye surgeons but if you can get one by all means do so. If your doctors told you you would have good near vision after the first eye was done out of that eye then they badly miscalculated the measurements needed to pick and IOL and they should be repeated again on the second eye.   Their IOL error is somewhere about 1.5 dioptors and that is more than 3 times the acceptable error that is acceptable.



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by violet_t, May 07, 2016
Yes, I will seek for another opinion! Thank you, you have helped me a lot!

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by JohnHaganMD, May 07, 2016
best of luck, the more you research and study your options the luckier you will get

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