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Astigmatism Options?

Hello folks,
I'm a 66 year old male with blurred vision in my left eye, due to cataract. I also have an immature cataract in my right (dominant ) eye. I absolutely do not want to address the RE until the cataract becomes problematic. I have worn glasses for over 55 years and really have no problem with glasses dependence after surgery. However, the idea of reduced glasses dependence is certainly attractive. I have been examined by two surgeons, and both have recommended toric lenses. One stated that I have much more astigmatism than can be corrected with LRI. My current refraction is: OD sphere -2.50, cyl +1.75, axis 010. OS sphere -1.00, cyl +2.00, axis 180. I am reluctant to incur the added expense ( $2500 in my area), plus the risk of a second surgery to rotate the lens, not knowing how many years until I need surgery on the RE. I'm searching for options. How much reduction in  astigmatism can realistically be expected with LRI? How much residual astigmatism is considered non-problematic for most people? Is LRI or LASIK an option at a later date, after both eyes have been implanted? I would greatly appreciate your input on this.
4 Responses
177275 tn?1511755244
Start out by reading this carefully:  https://www.medhelp.org/user_journals/show/841991/Consider-ALL-the-Options-Before-Your-Cataract-Surgery-Working-Through-Whats-Best-For-You

LRI= limbal relaxing incision. The problem is that LRI is hand cut by the surgeon and is inexact like the old RK surgery.  So it varies according to the surgeons skill, experience and what kind of karma is in the air that day.  Toric IOLs are good optics and a highly skilled surgeon needs to do a second procedure to improve alignment only about 1.1% of the time.  That is a better % that LRI.   If you don't mind glasses and don't want extra expense or risk just go with monofocal and put the astigmatism correction in the glasses you will still need post surgery.  My wife was faced with same option and she opted out of toric IOLs.
20 Comments
Thank you Dr Hagan!
I have read the article multiple times. Very concise and easily understood by the lay person. Needed a few reads to fully absorb the wealth of information ( a sign of my age, perhaps). I am extremely risk-averse where my eyesight is concerned. I have completely ruled out multifocal lenses after reading the many horror stories on this site. I will most likely end up making the same decision your wife made. As far as the expense of the toric is concerned, I would only be upset (laughing as I write this) if I were to die before my other eye requires surgery, thereby gaining no degree of glasses independence in return for my $2500 investment. Haha.

Have a great day!
Not sure where you live but that is more than twice as expensive as our practice charges for upgrade to toric.
I have called several ophthalmologists in the area.  The going rate for toric upgrade seems to range from $2150 to $2500. Add $600 - $700 for multifocal, and another $600 - $700 for laser with ORA. There is a lingering question in my mind about these high volume LASIK and cataract practices: If I go with the standard surgery and monofocal iol, will I receive the same quality care as the person spending $3500/eye out of pocket? I really don't want to be in the whack 'em and stack 'em group. I do understand the amount Medicare pays for this is an insult, and that's a very unfortunate situation.
The high power/high volume practices are set up so the moment you enter you are made to feel the standard monofocal IOL with small incision surgery is substandard. Often they give financial incentives to their staff if they can talk people into pouring more out of pocket money into 'premium' upgrades.  I posted this recently but I have a patient from a local "upgrade mill" where he spend $6000/eye  with what he said was a guarentee he would not need glasses for anything. He paid for everything,  mutltifocal IOL, femtosecond laser, astigmatism correction, ORA technology.   He needed glasses for many things and was very unhappy about the quality of his night vision.  Nothing I could do for him.  Also posted when my wife had surgery we didn't pay for any upgrades and she is very happy.   That's all I'm going to say,  your money.  I would not pay for any of that if I were having surgery on myself.  
Thank you for your candor, Doctor.
On a different note:  I have read a few posts where the patient's post surgery refractive error was significantly different than what was targeted. 1 - 1.5d as opposed to the expected +/-0.5 diopter. It was explained that this was the result of the iol sitting farther forward in the capsular bag than was anticipated by the surgeon. Is this a fairly common occurrence? In the case of a toric lens, does this phenomenon affect the cylinder refraction as well? Or, is the cylinder only affected by a circumferential rotation of the lens?
The standard IOL formula work well for normal eyes. For eyes much longer or shorter than normal, eyes with corneal disease, previous RK, trauma, weak zonules (pseudoexfoliation), operative complications they are less exact.  In a normal eye with greater than +/- 0.75 deviation from expected measurement errors are probably more likely the cause.
@rh52 like you are going to do, I only had cataract surgery on my left eye, the right eye only has a baby cataract thus far and I will do nothing with it unless necessary. I went with a monofocal IOL set in approximate parity with my non-surgical right eye, with distance correction continuing to be provided by RGP contacts or glasses as I've done since the 1970's.
I checked with our practice today for cost of toric IOL over what insurance allows $1100.
Hello MrPresley,
If I decide to go with toric lens, I want to target -1.25 or -1.50 for my left eye, so my eyes still work well together. Then if or when my right (dominant) eye requires surgery, I will target near plano. If I decide against the toric lenses, I will probably do exactly what you have done, as I will always need glasses for the astigmatism correction.

Dr Hagan, thank you for checking into that. My 86 year old mom lives in a rural area in southeast Wyoming. She has had two very successful cataract surgeries and two successful glaucoma surgeries, all performed by a small market doctor in western Nebraska, and all with virtually no out of pocket cost. She thinks I should go there for my surgery.  She truly believes he is a fantastic doctor. I am seriously considering it. As yet, I have not contacted his office to see if they offer toric lenses, but if they do, I would bet the cost is a lot less than here in Las Vegas where people come (doctors included ) to seek their fortune.
For reference, my right eye Tecnis toric monofocal cost above that of a regular monofocal IOL was about $1300 in my area of southern California, 1.5 years ago.  I didn't get any other extras like femtolaser and ORA which would have brought to the total extra cost  closer to $3000.
I went to three different eye surgeons for opinions on cataract surgery a couple years ago and the cost of toric and multifocal IOLs varied quite a bit, so be sure to get multiple quotes from several doctors.
Thank you NightHawkGuy,
Perhaps I have just not yet found the right surgeon. I have seen three surgeons and called a few others for pricing. The lowest quote for toric upgrade was $2150 with no laser and no ORA. I am surprised at what what you paid, as California is reputedly one of the most expensive states in the nation for most everything.
I looked up the cost data for my right eye cataract surgery with Tecnis toric monofocal IOL and the extra cost for the toric IOL was broken down as: $540 for IOL cost and $793 for surgeon toric IOL procedure = $1333 total I had to pay in advance.  The rest of the surgery charges went thru insurance and got billed later, I ended up paying about 10% co-insurance so under $400 total including surgeon fees, biometry, anesthesia service, rx eyedrops, etc.
Compare that which what a patient told me today.  He is spending $5400 out of pocket on a dental implant.
One more question, if you don't mind Dr Hagan, then I will stop bothering you. I have read in this forum and elsewhere that the placement of the phaco incision along the steep axis of an astigmatic cornea can reduce the astigmatism by up to .5 diopter. Would this also reduce the risk of surgically induced irregular astigmatism in comparison to an alternate location?
When I began my career almost all incisions were at 12 oclock, reduced with the rule astigmatism and the surgeon sat at the patient's head.   Starting in the late 90's the surgeon moved to the side, the incision to 9 o'clock towards the ear side and reduced 'against the rule astigmatism.   Most surgeons don't fee comfortable operating anywhere by laterally now so very few place the incision in the steep axis.  Because toric IOLs and laser astigmatic surgery is available that is no longer consider a modern way of reducing astigmatism unless the person has against the rule astigmatism.
Very interesting piece of history, Doctor! I believe my astigmatism is against the rule (OS axis @ 180, OD axis @ 010). It is fascinating, to me, that all of this, and probably dozens of other factors, must be accounted for in the planning of a cataract surgery. Iol power and orientation are just the tip of the iceberg. Couple that with the myriad of possible pre-existing defects and diseases of the eye, and it is no small wonder that some people do not get the outcome they were hoping for. My heart goes out to those people and to the physicians that, then, must help them adjust to, and cope with their new visual reality. I am not a risk taker. I believe, for me, the best course is to keep it as simple as possible, and opt for a high quality monofocal iol. I will be a happy camper if I end up with adequate CORRECTED vision, with a minimum of complications. Thank you, Doctor for helping us work through the process of choosing!
I also want to find a good surgeon who is NOT performing 30 surgeries in a single day. I'm just not comfortable with that.
If I remember correctly the surgeon who did my cataract removal spent about 15-20 minutes of OR time.  Generally there was a queue of 4-5 patients staged for their procedures outside of the OR. My wife had it done in both of her eyes a month or two apart and it seemed about the same then. She had a different surgeon than I did but it was at the same practice.
To know with or against the rule astigmatism it would be necessary to know if a plus or minus sign in front of the cylinder power.  If it's PLUS you have against the rule, if its negative you have with the rule.   Our surgeons do 10-11 cases on their surgery day.
Avatar universal
I had multifocal lenses and I would not recommend them. Like you I have worn glasses for many years and the idea of being glasses free seemed worth the risk, of still needing glasses. I think these lenses are being oversold and do not deliver what they promise. Do not even think about having them unless you are desperate to be glasses free and even then accept that you might need glasses. I do not have sharp vision at any distance, although far distance is acceptable. I cannot read all the text on TV and reading is impossible without glasses. After the first operation on my left eye I could read N8 unaided and a few months later my sight had deteriorated and is now N18.  I have a new pair of varifocal glasses and I have been using this type for years. I bought them in October last year, but I have increasing difficulty reading for any length of time. Text is clear to start with and then I have difficulty focusing. I have just ordered a pair of reading glasses to see if this solves the problem.  Another factor is that I always had reactor light lenses so effectively had sun protection all the time.  If you end up glasses free, consider that you might still want to wear sunglasses much of the time when outdoors.
2 Comments
at_239,
Thank you for your input. I am sorry to hear of your less than happy experience. After receiving an education from reading this forum, I now fully understand that very few people with artificial lenses become glasses free. I would like to be able to do things around home without glasses. However, when I'm out and about, I think I would much rather have them on my face than in my pocket. For me, it would be much more annoying to always be reaching for glasses, than to wear them full time.
Comments are helpful. Remind anyone reading the time to do this research on cost, type IOL, add ons,  desired post op uncorrected refractive error is BEFORE surgery.
Avatar universal
Dr. Hagan - why were you not able to help the patient who had the multi-focal and upgrades? Could you not do a lens exchange?
Avatar universal
Hello, RH!  I'm a few days late to the discussion, but I recently had cataract surgery for one eye (the other is fine) and went with Alcon AcrySofIQ.  I've also worn glasses all my life and although the idea of not needing them any longer was AWESOME, I did not want to have surgery on the other eye when there was no need to do so.  I'm happy with the decision I made.  I went with near vision (to match the other eye of course) and wear some pretty spiffy new glasses.  
3 Comments
thanks for sharing your experience
Thank you!
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