Avatar universal

Cataract Surgery and IOL Choices (The Newly Appoved Symfony vs. Monofocals)

I am a 59 year old male and was just diagnosed with cataracts in both eyes by my Opthamologist/Surgeon earlier this week.  I have to go for a dilation next week where he will also go through the "Cataract Consultation".  I should mention that I have Diabetes but it is currently under control (A1C, 6.9%).  He said that I don't appear to have any retina issues due to the Diabetes (although he needs the dilation to really take a good look inside).

He gave me a quick rundown about what can be chosen but it was brief and he said he would go into it at the full consultation.  Also, I didn't know anything about the IOL choices or procedures then.  Since Monday though I have read *a lot* about it (especially on this site) and feel I now have a very good idea about this entire topic.

I even went to see my optician whose judgement and experience I trust to ask him what he sees "after the fact" in terms of success, glasses, etc.  He said if he had to give an overall impression it would be that most people that were used to wearing glasses for many years...and I am in that category...could not get used to going eyeglass-less for some of the time and needing reading glasses for some of the time.  They just found it easier to keep glasses on their head...just like they always have done.  For example, he himself is a -2 with good intermediate and close vision.  He would opt to get an IOL that would essentially keep that the same and simply wear his progressive glasses always on...just as he has done for many years.

I believe I am a -4 with a +2 for near vision but am not positive (I don't even profess to know what the numbers all mean anyway).  I know I have some astigmatism but I have no idea how much or in what eye.

I think that covers the introduction of my question.  What I am looking for is some advice as to whether or not monofocals or Symphony would be the best choice.  I know the Symfony was approved by the FDA last month and from everything I've read, they are a really great alternative to monofocals.  As far as I'm concerned, I would not choose multifocals at all due to the glare, halos, aberrations, and bad low light contrast.  I also don't think I could handle monovision, or at least to any great extent.

I should mention that I am currently out of work and really do not want to spend the money for premium IOLs but will do so if the Symfony IOLs really do offer so much more...and I am believing that they do.

I am NOT averse to wearing glasses after surgery so please keep that in mind.  That means that if I need them to correct astigmatism or reading...then I'll get progressive glasses.

I would like to have great distance vision (for day and night driving) and especially intermediate to watch TV (about 10 to 12 feet away).  I use my cellphone a lot so I would hate to lose that close vision I have now (6 or 7 inches away) but again, if I need glasses...so be it.  But all that being said, if I could go glass-less some of the time as an option, that would be great.

So I am wondering if getting Technis monofocals would be "OK" or if I should go all out and get the Symfony.  Again I've read that the Symfony IOLs are the greatest thing since sliced bread for far and intermediate vision...and maybe even for near vision.

I am sure all your comments will be helpful.  I would especially also like to hear any long-term ramifications from the Diabetes and how it might affect things down the line.  Same for the astigmatism.

Thank you in advance for all your help!
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177275 tn?1511755244
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I am currently considering IOLs. I am strongly farsighted with astigmatism. I wear two different pairs of progressives for distance and computer work. I am 53, healthy with clear eyes and no laser surgery but I cannot function without glasses. 3 years ago I had surgery  correction for strabismus and have adjusted to this by now.

Recently I had hearing loss so now I wear RIC Hearing aids which hangover my ears. I find this highly annoying with glasses and would like to be able to be without glasses most of the time.

I have been told by 2 docs that I am on the edge of what Laser can do for me. and 2 docs have suggested IOLs. After an analysis, one surgeon recently suggested I have like Tecnis Toric Aspheric IOLs in both eyes. he said that for my lifestyle they would give me the clearest vision but I would have to wear glasses for near vision.

I have not paid them anything and they still have to do secondary testing. He thought the other types were better for retired people.

I have been reading about Symfony and all the paid consultants seem to think that it is equivalent to monofocals but with better range. Yet, Dr. Hagen appears to disagree with this.

Alternatively, there appear to be a lot of interesting devices in the pipeline that look promising for offering full accommodation with clear vision and that makes me wonder if I should wait for something new to come along or look in other countries.

Price is not an issue for me, I just want to make the best choice.
To answer your question we need some additional information: 1.  What is your age 2. What is your current glasses RX and your best corrected vision with it  3. Confirm you have cataracts and that your surgery is cataract surgery for reduced vision as opposed to "clear lens extraction" where a non-cataract lens is replaced with an IOL to reduce thickness of glasses.

and read this as a primer for your research:  http://www.medhelp.org/user_journals/show/1648102/Consider-ALL-the-Options-Before-Your-Cataract-Surgery-Working-Through-Whats-Best-For-You
Since you say you have "clear eyes" that seems to imply you have no cataract. Its  best to be cautious about the idea of a lens exchange because despite a very high level of safety, someone winds up being the "statistic". Some doctors urge people to not take any risks. However life has risks,  and small risks are hard to assess, especially ones that accumulate over time. There is e.g. if you don't get surgery  a slight increased risk of accidents from driving with progressive glasses vs. having good vision without glasses (e.g. via multifocal contacts or premium  IOLs) due to the smaller visual field and the potential delayed reaction time needing to  move eye and/or head to look through the right part of the lens.

I delayed cataract surgery   a  couple of years (since one eye remained 20/20 correctible)  in hopes of a better lens, since there was talk about better next generation accommodating lenses coming out, but almost 2 years postop they still aren't approved anywhere (though one of them is trying for approval in Europe now). I've been surprised that the limited clinical trial data I'd seen so far hadn't indicated that much of a jump compared to existing lenses, I check out of curiosity, but hadn't for a few months.

One problem with accommodating lenses is that they depend on the eye to change focus and therefore they can only be fully tested when placed inside someone's eye.  It seems to make sense to be a  bit cautious of being an early adopter of a new accommodating lens until it has been on the market a while. The Synchrony accommodating lens showed promise originally, but isn't being used anymore since a decent minority of patients had problems.

Static lenses can have most attributes well tested on an optical bench outside the eye, even if clinical trials are needed to calibrate what visual acuity the results translate into and assess things like halos they can't test for outside the eye.  With an accommodating lens you need to test in the eye to see how well the eye gets it to change focus, and to see if any movement of the lens causes problems for the eye over time (e.g. like a cotton t-shirt that might feel fine when you put it on, but chafe your arms after running in it), and to be sure the lens continues to accommodate over time, etc.

Deciding whether to go for an IOL is somewhat like deciding when to upgrade computers or cell phones. There is always a better option on the horizon, but in the meantime you live with your current situation. I'm unsure there are any major leaps coming within a few years, though there are some EDOF lenses that might be an incremental improvement over the Symfony (there isn't enough data to be sure yet), and there are some newer trifocals that might be better than existing ones but it isn't clear yet from the limited data I'd seen.

Unfortunately the FDA is known for being overly cautious and keeping us a number of years behind the rest of the world in terms of IOL technology. There are many companies with IOLs abroad, like trifocals, that haven't even bothered trying to get them approved in the US, so it is worth keeping an eye on whats going on outside the US if thats an option for you.  The Symfony is from an American company, but it was approved in Europe a couple of years before it was approved in the US.

Although I went abroad for the Symfony before it was approved here,  I almost went for a trifocal. Some people would prefer the better near of a trifocal if they are willing to risk a slightly higher risk of halos&glare and possibly a tiny bit lower quality intermediate.

The Symfony has been out long enough that there are lots of studies on the lens based on thousands of paitents which confirm the results the "paid consultants" as you put it talk about. (e.g. checking the abstracts at the big ASCRS and ESCRS conferences, as well as looking at the clinical trial data).

Although data is the best thing to explore, here is one surgeon (not an AMO consultant) who posted his  experience with implanting the Symfony for a year:

and his comments on getting premium lenses:

177275 tn?1511755244
Thanks for your observations.
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Avatar universal
Thanks for posting your success story even though it is hard for you to post right now.  You sound very happy w/results so far!   Congratulations and best wishes for the other eye.  
I haven't checked your earlier posts in quite some time to see why you were (or weren't) considering toric.
I am not ready for the surgery at this point but find it very useful to continue my research to keep learning.
Thanks, and enjoy.  
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Hello teller4...I know that my posts are quit voluminous but they are all in this thread and worth reading to see how my decision evolved.

I read a lot if other threads too and certainly info from other Internet sites.

I will say that Dr. Hagan's advice had a lot of of influence on my decision for a number of reasons, not the least of which was costs.  However, the advice from Software Developer was also invaluable and well worth thinking about.  It's not an easy decision really and I changed my mind a lot before I settled on non-laser and standard monofocals.
Glad things worked out well for you.

Avatar universal
FYI - the procedure itself is painless.  I had the laser and I think it improves your odds of coming out 20/20.  However, with my dominant eye retina detachment, I most likely have lost that.  As RD can be a side effect, be sure to be on top of it and insist on being seen if something strange happens to your vision. I am same age and have had glasses since kindergarten.  I have a selection of reading glasses in various strengths and  safety bifocal sunglasses.  All were inexpensive and useable.  They may try and sell you progressives as soon as they can because insurances covers it.  You may want to wait a while.
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Thank you for commenting Billy.  Although I would hope for good distance vision, I doubt I will get it because of the astigmatism.  Like you, I am used to glasses.

I am not completely positive that they were up selling the laser and tonics but that was certainly part of the equation, especially for laser.

I am sorry about the retinal detachment.  I hear that this surgery can increase that possibility and I think I also read that if you are diabetic (I am) that it might be even more likely.
Avatar universal
I had IOL's for distance.  I also wore glasses my entire life and did not mind .  When I was finished, I could drive and do most things without glasses.  Arms length and closer was iffy depending on lighting and type.  Retina detached in my dominant eye and I may get 90 percent back.  I agree that they really try the up sell.
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177275 tn?1511755244
Okay I'm sure readers will find them informative and interesting
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177275 tn?1511755244
Good luck
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Thank you Dr. Hagan.  I will be documenting my results after each surgery assuming there are no issues in my Pre-Op screenings at the hospital where the surgery will be performed or at my primary physician's Pre-Op clearance.
177275 tn?1511755244
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177275 tn?1511755244
Hope all ends well.
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Thank you Dr. Hagan
177275 tn?1511755244
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177275 tn?1511755244
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177275 tn?1511755244
1. The benefits of femtosecond laser are not proven in controlled studies and in the first 50 cases the complication rate is higher. This is an unnecessary expense for most people.
2. If you are use to glasses, want the least chance of complication and the least expense go traditional. You can choose mini-monofocal distance bias or mini-monofocal near bias and be able to do many things without glasses. For best vision both eyes and every possible distance you will need progressive multifocal glasses which are a whole lot less expensive than all the "up-charges" being pushed on you.
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Avatar universal
I ended up -.5 in my right eye and +.5 in my right eye, with some remaining astigmatism in both eyes, residual distortion from an epiretinal membrane in my left eye, and a big honking floater in my right eye from the posterior vitreous detachment in my right eye that closely followed the cataract surgery.  This is the second time I've had to get used to progressive glasses, and it took a couple of weeks, but I'm dealing fine now at all distances with these very thin glasses.  Vision is clear and stereoscopic for the first time in a year and a half.   The bonus is that the cheap progressives I ordered from zenni ******* are just as good as the expensive (even after vision insurance) ones I got from my eye doctor's office - I'm going to buy several pairs.  I'm happy - the floater is the only thing that sometimes bugs me, but given where I've been, I've had a great result.
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Avatar universal
I was diagnosed with a perforated eye on Tuesday 2nd August 2016. I can't have an op for it and have been put on antibiotic drops and also oral antibiotics. I go back to see the Consultant on 18th August. We are due to go to Tenerife on 16th September is it going to be alright for me to fly?

Kathy Richmond
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I do not know what that term means to you but a perforated eye means trauma to the eye with something like a knife, or stick or BB pellet penetrating the eye.  You will need to ask your eye surgeon that question.
Avatar universal
Why not? Just curious.
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This is the problem with all multifocal IOLs including symphony which you should be willing to increased risks before you plop down the money: 1. They are more expensive 2. The complication rate is higher (more moving parts) 3. The optics are not as good as aspherical and night vision glare and dysphotopsia is higher 4. Glasses are often needed for many thing 5. The rate of explant and IOL exchange is higher than monofocal 6. There is tremendous pressure from ophthalmologists and otometrists to "upsell" these "premium" IOLs due to continued lowering of Medicare and private insurance payments for standard cataract/IOL surgery. A cataract/IOL surgery and 3 months of care costs one-half to one-third what a dental crown costs in metropolitan areas.
Avatar universal
I really wanted multifocal IOLs after years of wearing multifocal contacts, but after a series of  serious retinal issues they were not for me. I ended up with standard IOLs in both eyes set for distance - one unfortunately a little over corrected, one a little under. I'm very, very happy to have great vision back with a pair of light progressive glasses. Would I have paid extra for Symfony had they been available over the last year? Maybe. But life is great anyway.
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By over-corrected I assume you mean that it's too strong a lens?  How does that affect your vision?  Do the progressives really bring it all together?  As I mentioned in my original post, I do not mind wearing glasses but I'd love to not need them sometimes.
I've seen you post only an "=" sign before Dr. Hagan.  What does it mean?  Correct?  Ditto?
Means I've read the post to there and need make no further comment
177275 tn?1511755244
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Thank you for replying.  As I mentioned, I've read alot since Monday and your article was one I read with great interest.  And I read it twice as I saw you advise someone else!
So if you have additional questions please feel free to post
Oh and the Symphony IOL is not the greatest thing since sliced bread.
Well, one of the questions is what would do think about my optician's observations?  Specifically about under-correcting rather than going all out for perfect distance vision.  Again, he noted that most people were unhappy that they needed glasses sometimes when they spent their lives always knowing where they were...on their faces.

Also, what are the ramifications of Diabetes?  Now and for the long-term?  With either monofocals or Symfony?

And finally, why aren't the Symfony IOLs the greatest thing since sliced bread...as compared to monofocals?
Most premium IOLs are for those who don't wish to be wearing glasses, since a monofocal is the lowest risk option in terms of having great distance vision (even if the Symfony isn't far behind). You say you aren't "averse" to wearing glasses afterwards, which suggests that you would prefer not to. Although your optician suggests many people who are used to wearing glasses find it hard to adapt to not wearing them, its up to you to make the call regarding how much of an issue that is for you. If you don't mind glasses, and money is an issue, you might wish to stick with a monofocal.  Of course the optician's viewpoint may be skewed because he may not see the people that are happy without glasses after surgery with a premium lens.

In terms of undercorrecting, I suspect it  depends on whether you ever find it useful or convenient to take off your glasses to take advantage of your nearer vision the way some low myopes do.  Some of them like that ability and so they wish to retain some myopia after surgery. In my case I was highly myopic so I wore contacts/glasses every waking moment and so I had no desire to remain myopic afterwards.

That said it depends on your visual needs, when you'd prefer to wear glasses if needed. If most of your visual needs are intermediate and near, and you don't mind wearing glasses for distance, it may be convenient to set your eyes for intermediate. If you use a lot of really close  near vision, even if you went with the Symfony you might benefit from setting it at intermediate to get more near.

Although a premium lens costs extra,  if your insurance doesn't cover progressive eyeglasses, you might wish to factor in the savings from potentially not needing progressive glasses in the future (though after surgery you wouldn't likely need new ones often since the add wouldn't be changing), vs. the cost of over the counter readers (or even prescription readers that aren't progressive are going to be cheaper than good progressives).

No IOL is perfect, there are always tradeoffs. You mention wishing good vision at everything from 6 inches to distance, and unfortunately there isn't an IOL yet that will give that full range  of vision without tradeoffs. There are trifocals only available outside the US that may come the closest to providing that full range, but which have the risk of halos and where intermediate vision may not be quite as good as distance&near.

I tend to describe the experience I have with Symfony IOLs as like having early presbyopia,   it doesn't provide as much near as a trifocal or higher add bifocal. You do notice some reduction in near vision even if you can get away without readers for most things. A minority of people need readers with the Symfony for reading, though most will need them occasionally for say threading a needle or other really near fine vision tasks. In my case I have no trouble using a smartphone using normal fonts, but I don't hold it at 6 inches (though its at a comfortable distance, perhaps 15 inches, I don't recall what I measured before and don't have ruler handy).  A tiny bit of monovision, micro-monovision, will give some more near vision with the Symfony without much impact on distance or stereopsis. (for various reasons I didn't get that, though I might consider a laser tweak to get there, it hasn't been something I've felt a need to do).

Although the European studies consistently showed that the Symfony was comparable in contrast sensitivity to monofocals, the FDA trials seem to indicate a slight reduction.  I hadn't explored the issue, but the reduction seems to be minor since it wasn't picked up before in other studies. I don't know whether  its enough for patients to notice even if the tests show it, its not something thats noticeably impacted me as far as I can tell. (but everyone is different). The risk of halos is low and  seems to fall within the range of monofocals, perhaps higher than the better monofocals (like the Tecnis)  but lower than data I'd seem for other common monofocals like Alcon.

As far as I can tell, my distance vision is better than I can remember it being with contacts or glasses in the past, including night vision overall. That said, I did wear multifocal contacts before I had cataract issues (which reduce contrast sensitivity and have some reduction in low light vision)  so my memory may be flawed since it had been a while since I had single vision contacts or wore glasses much.  I did find someone else about my age with the Crystalens (which is a single focus lens, even if it supposedly accommodates) who seems to see a reduction in near vision with even a slight reduction in light (e.g. holding something to cast a shadow over the near eye chart), but the same experiment didn't alter my low light vision at all.

Thank you for your reply Software Developer.

Let me clarify my initial long-winded post.

When I say I am not averse to wearing glasses, I mean that I've been wearing glasses for 48 of my 59 years.  I am used to always wearing them and therefore never lose them!  So if I need some type of glasses afterwards...so be it.

However that being said let me say that I use my progressives when using my cell phone or reading....when the distance is approximately 12 inches..  What I love though, is that I can take off my progressives for distances of 6 inches for either close reading (cell phone, book,detailed work).  I would prefer not to lose that ability because it seems comfortable.

Will I definitely lose that 6 inch vision with the Symfony?  I know ill lose it with monofocals.

And one more thing, as I mentioned I have some astigmatism.  I don't know how much or in which eyes or both.  I would rather fix that with eyeglasses rather than getting the toric Symfonys.  The reason...I am too worried that it has to be placed perfectly and that it might move as well.

That actually leads me to a separate question.  Can you rub your eyes after surgery heals?  I mean everyone rubs their eyes font they?  Your eyes tear when you cut onions, allergies, itches.

I thank you in advance for your reply.
Ok, so you do take advantage of your myopia through taking off your glasses. Unfortunately to get the same sort of benefit you have now you'd likely need to be left almost as myopic as you are now with any IOL since:

re: "definitely lose that 6 inch vision with the Symfony"

You can convert a distance into a lens power diopter measurement by -(100 / distance-in-centimeters) so that 6 inches means a focus at about -6.6 diopters or so.  Although the results of lens studies are just averages, some lucky people wind up with better results, the odds are no one would get vision up that close with any lens set for distance, any lens would need to be set to leave you nearsighted to some degree to get that close in.  Unfortunately the number of diopters it takes to get just a little bit closer rises rapidly. You would have to get lenses set to leave you very myopic to be able to get distance that close up, perhaps with an eye set to be -4 myopic (focusing best at 25 cm) you might get useable 20/30 vision at 6 inches (based on average results) with the Symfony. (you'd have to be perhaps -5 or so with a monofocal).

With the Symfony you do get a wider range of vision than with a monfocal (regardless of where you target the best focal point), but not as near as you'd want. If halos weren't a concern for you then I'd suggest a high add bifocal as something to consider, perhaps with some monovision on top of it.

I read my smartphone at a more typical distance I think for those who aren't nearsighted when reading it.

If you don't have much astigmatism, they tend to  correct that with an incision rather than a toric lens.  Surgeons vary on how much astigmatism they prefer to correct with a lens vs. an incision. A small amount of astigmatism doesn't impact vision too much so glasses might not be required for some distances afterwards.  If you needed glasses afterwards for astigmatism and wore progressives, it isn't clear if the Symfony gives too much benefit. Overall they have good luck with toric lenses, and can reposition them if they do rotate after surgery. I hadn't checked on the statistics regarding that in detail since I didn't have much astigmatism and didn't need a toric lens.

After surgery heals then rubbing your eye is no different than beforehand as far as I'm aware, I don't recall hearing any cautions about that.  Rubbing your eyes is more problematic for those wearing contacts, so from decades of wearing them perhaps I don't tend to ever rub my eyes. (I can vaguely remember doing so when young before contacts, which is why I'm thinking I changed behavior after getting them). Wiping them to clear allergies or sweat or whatever else is different.
Yikes!  So to save my 6" vision I'd have to get lenses that would make my distance vision as bad or worse than it is now?  I definitely don't want that.  I want distance and intermediate (TV, computer, eating, food prep).

So it seems that I can get that with the Symfony but would most likely need reading glasses...or I could get cheaper (and better optics) monofocals, set for distance and then need progressives for intermediate and close vision.

I don't think I want monovision.  And well leave the astigmatism out of the equation for now.

Again, I have my cataract consultation on Thursday so I'll need to hear what he says.

It's a lot to consider and I appreciate all your help so far.
As I said, the problem is that the closer in you get, the more diopters it takes to move the focal point inwards a given distance. 0 diopters focuses at inifinity, 1 diopter at 1 meter, 2 diopters at 0.5 meters, 3 diopters at 33.3 cm, 4 diopters at 25 cm, 5 diopters at 20 cm, etc. That is why getting an added diopter at intermediate/far-near can make a noticeable difference in the inches/centimeters extra you get, but it doesn't help as  much at really near.

Actually most people with the Symfony don't need reading glasses for typical reading distances,  only for really near vision like the 6" you are talking about which is nearer than most people read at. There is no guarantee though, some people are the unlucky "statistic" that needs readers even at typical distances. It can help to get  a tiny bit of micromonovision, like -0.5D, doesn't have much impact on distance vision since the lens gives decent vision a little bit further out from where it is focused so the -0.5D eye still helps with distance vision The Symfony manufacturer page has information about micro-monovision  on the "clinical" tab:


It also doesn't have much impact on stereopsis since for most of the visual range both eyes are being used, except for very near.
Your last comment was very helpful Software Developer.  It matches what I reported earlier that my optician (my eyeglass guy, not my ophthalmologist/surgeon) told me.  To repeat it, he said that he is a -2 and does great with his progressives.  He would prefer to remain there in the event he needed cataract surgery.  However I think he is basing his decision on simple monofocals and not on the Symfony IOLs.  I don't think he really even understands the difference as he is an "eyeglass guy".  Still I understand his point of view.  He likes his very near vision.

For myself, cost is an issue for me and it will have to play a big part in my decision.  That being said, I am willing to raid my retirement funds to pay the additional costs for the Symfony IOLs if I feel they are worth it to me and of course after I hear what my surgeon says on Thursday during the consultation after my dilation and including a discussion about my astigmatism.

Right now, I feel that they may be worth it to me.  The website you referenced really shows some great stats.  Of course...it's Tecnis' site so they are going to spin things their way as much as possible.

I would like to thank you again for all your comments.  They, along with Dr. Hagan's, have been tremendously helpful in what has been a crash course in "Everything Cataract"!
The stats on the Tecnis site match what I've seen in other articles and studies on the net (I tend to do periodic searches for new articles on it, and check the ASCRS and ESCRS conferences.. partly curious if as an early adopter I made the right bet based on early studies, and since others ask questions and I wish to be sure its still a good choice). There is a new article that just went online with a surgeon discussing the results from the study for FDA approval:


A related article in the current issue of that publication talks about the issue of night vision with multifocals, and the difference with the Symfony:

I had the consultation with my Ophthalmologist/Surgeon this morning.  I trust his opinion and he essentially told me the following:

1) I have a Class 3 cataract in each eye (or is it category?).  He certainly can remove it with normal phocoemulsification (sp.) but given that I am diabetic which means there can be healing issues, that the femtolaser is gentler and requires less healing.  My take is that it is also less traumatic in general in terms of breakup and suctioning which means it's better all around for the surrounding tissues.

2) I have astigmatism in both eyes and he recommends a toric.  I asked him about the dislodgement and placement issues and he said he has only had one move on him where he had to go in and readjust.  If I choose the toric, he said I will only need OTC readers for close work. If I choose the non-toric monofocals, I will definitely need glases.

3) I mentioned the Symfony.  He said the rep was actually in his office on Tuesday telling him all about it.  He doesn't care about what is written on the internet about the lenses, he prefers to have his only experience to really know how good they are.  He is very obsessive in measurements and results etc. and only will believe what his experience shows.  That said, he told me that he would love to put in the Symfonys so that he can see the results for himself.  He said that they won't be available until September sometime.

4) Costs...well here is the problem.  I am out of work and would rather not pay but let's face it.  You only do this once and at 69, I don't want to make a mistake by being cheap.  Here are his fees:

a) Non-Laser/Traditional IOLs - $0

b} Laser/Traditional - $1500/eye

c) Non-Laser/Toric - $1700/eye

d) Laser/Toric - $2500/eye

He does not know what the Symfonys would cost but he said to probably add $500 per eye for each of the above and hope that it's less.

I should mention that he uses the Alcon monofocals and toric lenses.  He doesn't use the Tecnis because the program he needs to use to do the calculations is much harder to use than Alcon's.  I am not sure how I feel about that.

I trust this guy as I have been going to him for years.  I know how he is, very thorough and obsessive.  He doesn't do a million procedures a year (like some others where I live).  He does about 8 or so on the days he operates which is not everyday.  I think it's once a week or so.

Anyway, this is the story.  On Monday I go back for the rest of the measurements and then will schedule the surgery.  He does them two weeks apart.

I'll give him my final decision then.
Correction...I am 59....not 69 as I wrote in my last comment.  Maybe I just *feel* 69??
Having a cataract atypically young can make you feel older, I know when I had a problem cataract at 49 it made me aware of getting older. A few years later  I feel younger since my vision is more like early presbyopia in mid-early 40s (though finally getting back to jogging as much as   I did then helps also :-) ). I know cash flow issues can make thinking of this as a long term investment problematic, otherwise you might think of it as the cost being effectively like $X per year for the rest of your life for more convenient vision.  In my case after having worn correction all my life, I really liked the idea of being able to go the rest of it without needing to worry about correction most of the time, if say an emergency happened and I need to run out of the house, or in future decades if I ever have temporary physical impairments or hospital stays making dealing with correction less easy, etc.

You don't mention what level of astigmatism you have, surgeons differ regarding the level they choose to go for a toric and when they prefer to use incisions. Make sure they used a modern state of the art scanner that does a good job of measuring total corneal astigmatism, including posterior astigmatism. They used to measure only anterior astigmatism, thinking posterior was always too minor to worry about, but then data showed it could often be enough to make a difference. I don't know how up to date surgeons tend to be on the issue, if they already had otherwise good scanners, or if the costs are low enough they tend to all be up to date.

One issue with laser surgery is that if you go for it, to be sure the surgeon has gotten past the learning curve using the laser  (I've seen various figures of 100-150 perhaps). I was personally considered investing in a premium lens to be more important than laser cataract surgery, but your situation is different, I hadn't explored whether there is any proven benefit in the case of diabetics.

I don't know offhand if this article:


was about the study I recall seeing fairly recently regarding the results based on surgical volume (I don't see a date on this article offhand, and I only took a few seconds to search). The data is several years old, but it suggests complication rates may be lower with surgeons doing over 1000 surgeries a year. It discusses complicating factors, but obviously you figure practice helps. High volume surgeons presumably also are more likely to have encountered any rare complications beforehand (ones not due to surgical error) which makes it more likely they are prepared to deal with it.

You might wish to check around on fees, since I gather they can vary greatly, I don't know if you have many options within whatever your driving distance is (after surgery usually btw you'll need someone else to get you home since they usually sedate you enough that driving isn't an option, and in most cases the eye is patched, though apparently some don't patch the eye these days). In some cities the media (local magazine or newspaper) publish  best doctor lists based on who doctors would go to for treatment since they can better assess their peers in various specialties (hopefully) than lay people. Actually the laser/toric cost is getting to the point where for 2 eyes it might be about the same or cheaper to  to fly to Prague  and get it done, even including travel expenses for a week (and with an added $500/eye on top of that, it definitely would be).

I'd imagine that Alcon lenses aren't much different than Tecnis lenses to implant so I'm sure a surgeon can do it, I don't know whether any slight differences are enough that you'd prefer a surgeon with more experience with Tecnis or not, that wasn't an issue I had to check on.
re: "He doesn't care about what is written on the internet about the lenses, he prefers to have his only experience to really know how good they are."

Surgeons should be taking their cues from evaluating study results, with appropriate evaluation of potential flaws in studies such as small sample sizes. Long ago science, including science based medical doctors, realized that anecdotal evidence and personal experience can be misleading if nothing else due to random chance when dealing with a small sample size since perhaps the patients you had were atypical. When there are limited or small studies available on something, a  doctor can use his personal experience to "sanity check" whether there are signs a study might be flawed. However a surgeon   needs to keep in perspective that their own personal "study" can also be flawed, and potentially biased if they don't carefully track every factor.. including those they don't see.

Unfortunately some doctors seem to have less of a grounding in a science based approach to medicine than you'd expect (e.g. see the ScienceBasedMedicine.org blog which often focuses on the worst of quackery, but addresses the issue of scientific thinking in medicine and doctor training  in general in some posts). That said, its unfortunately true that many IOL studies seem to be surprisingly small, so ideally of course the results should be confirmed with multiple studies, and fortunately there are many studies on the Symfony now. Unfortunately there aren't as many head to head comparisons between different premium lenses, or between different monofocals,  as would be useful for patients since those sorts of studies are more useful than comparing different lenses by looking at  results from 2 different studies (the demographics of patients, surgical results, and questions asked of patients may vary between studies, among other factors).
In terms of measuring the astigmatism, I know he uses multiple methods to measure it and he brought out a color coded map of it which looked a lot like those weather radar maps you see.  You know, red and yellow mean severe storms and blue and green means much less.  He did tell me that all of the measurements agreed (he is obsessive about this) so I am confident in his decision as to what would be required to correct the astigmatism, either with a toric or eyeglasses.  I don't have the numbers though.

As for your other comments about referring to studies as opposed to his own experiences, or at least putting his experiences in its proper place, I do agree with you and it does bother me to an extent.  However, as you said, the studies out there are small and therefore might not have any more weight than his experiences.

I also am keeping in mind what Dr. Hagan always reiterates and that is that monofocals are still the safer choice compared to any of the premium IOLs, despite the claims made by Symfony and anecdotal experiences such as yours.  You need to keep in mind though that I do not have an immovable need to be eyeglass-free.

In terms of laser vs. non-laser, I think that Dr. Hagan is right.  I do not believe it makes a huge difference and it laser has its minuses as well as positives.  And adding $1500 per eye (with monofocals only), It does seem to be an unnecessary expense.  So I am leaning toward leaving lasers in science-fiction movies, where they definitely are a positive.

So that leaves me with deciding to be my surgeon's first Symfony patient or simply getting monofocals.  As I mentioned, the added cost of toric IOLs with traditional surgery will be $1700 per eye but he mentioned that could be up to $500 more bringing the cost per eye to up to $2200 per eye.  So a $4200 expense to me.  That's a lot of money to *hope for* great results and like Dr. Hagan says...maybe have more complications despite the results that you, and others, have had.

I'll continue to research over the weekend and pray a lot to help me make the final decision.
I had my final measurements today.  I chose the phcoemulsification with the standard monofocals.  The doctor was fine with my choices but did reiterate that I would definitely still need glasses afterwards to correct for astigmatism and reading.  I knew that going in and my eyes will be somewhat better in terms of uncorrected vision.

My right eye is scheduled for August 29th and my left eye is scheduled for September 9th.
As I promised, I want to document my surgery and results as information for everyone.

This entry pertains to the first surgery on my right eye.  As a reminder, I declined laser surgery and toric lenses.  Partly because I am out of work and couldn't afford them and also partly from the great advice from Dr. Hagan.

I had my right eye done yesterday, August 31st.  I was nervous but it was easier than I thought it would be.  I was somewhat in a twilight state but I could hear everything going on.  I couldn't see anything though.  Sort of a blank white and then gray color.  Then the put on the gauze and shield and of course I saw nothing.  The procedure took  40 minutes from start to finish.  I thought it was less as I was silently praying the rosary which usually takes me about 20 minutes.

This morning, September 1st, I saw the surgeon less than 24 hours later.  I could not believe the difference.  I now have 20/30 uncorrected vision for distance.  I no longer have close vision in that eye which I knew would be the case since I opted for monofocals, despite the fact that I wear progressives and have some astigmatism.  I can only type this on my cell phone because my left eye still can see close without glasses.

My surgeon said that the pressure was a bit high...30.  He relieved the pressure and it came down to 11.

I cannot believe the colors through my right eye now.  They are vibrant.  Whites are white and not dingy yellow.  All colors pop.  I am watching TV now and can easily see news crawls with no issues.  My brain is already integrating my "new" eye with my "bad" eye even without glasses for that bad eye.

I do think that when I get the left eye done next Friday, September 9th I will have a lot of difficulties reading and using my cellphone.  Perhaps a cheap pair of drugstore glasses will do the trick until my surgeon feels it's time to give me a prescription for my new progressive lenses.

Since I haven't had my new eye at night yet I don't know how my vision will be.  My hope is that since I have the simple monofocal lens, that the optics will be superior and that I'll have great night vision.

So again, from my surgery yesterday and the early results today, I am very pleased.  I will be posting more results and certainly results after my second surgery next Friday.  My next Post-op appointment is next Thursday so I'll probably post my results after that.

I've been praying to Saint Lucy, the patron saint of vision and so far she has answered my prayers.  I've just finished thanking her while enjoying a celebratory cigar in the backyard while looking at all the green grass and blue skies.  Who knew the sky wasn't gray and the grass wasn't yellow??!!
re: "Perhaps a cheap pair of drugstore glasses will do"

It likely should. Since you've had one eye done, a day or two  before the other surgery you could select readers that work for that eye for whatever distance you need, to be sure you can function well enough after surgery on the 2nd eye.  It may save you some hassle.

In my case the near vision for the Symfony seemed to go  in and out for a day or two after surgery before it settled in permanently (I don't know if thats typical during the initial recovery). I had the 2nd eye done  the next day, a couple of hours after the bandage came off the first. So the first eye's vision was still fluctuating while I had a patch on the 2nd eye the day of its surgery.   I hadn't been prepared beforehand, so  I had to hunt for a temporary pair of readers to deal with phone&computer, while of course not being able to see near well to read the tags on the glasses to see their reading add or their price.   .. and with a patch on one eye.
As promised, I am posting the results of my second eye surgery.  You can read my post above about the first eye which took place on August 31st.  Again, I had Alcon monofocal implants, non-toric despite my astigmatism.  It was due to costs and wanting to get the best optics.

I had the second surgery done nine days later...this past Friday, Sept. 9th.

The surgery went well but I was more awake.  My doctor apparently thought I was too much out of it during the first eye and was concerned about sleep apnea.  I don't have that but I am a big guy and probably snore.  Either way, I wasn't a basket case and was a model patient.... meaning I didn't move!

The next day (Saturday) the patch was removed and his quick check showed that I have 20/40 in the left eye.  I should mention that was the same as my right eye but as of one week after that first eye...it was close to 20/20.  I am hoping the left eye catches up.

In general my far vision is wonderful!  I haven't seen so well or such vibrant colors in many, many years.  I couldn't ask for better distance-wise.

So here are the downsides.  You knew they were coming right?

I am mourning the loss of my near vision.  I always needed progressives for the computer and reading about 12 to 14 inches.  However, I used to have great close vision without correction at about 5 inches.  It was always great.  Well that's gone.  I do have a pair of 2.75 cheapreaders and that gives me great vision about 13 inches away.  Any closer and all goes blurry again.  If anyone has a suggestion I'd love to hear it.  Would a higher number cheater help?  Or even exist?

The other issue is that I have rays coming off headlights and streetlights at night.  These are NOT starbursts but one ray.  The right eye is almost horizontal and the left eye is about 45°.  So the two make an "X".  I mentioned this to my doctor and he said it was most likely due to my astigmatism and so I might need glasses for night driving.  I don't mind that as long as it REALLY gets rid of the rays.

So all in all, I am loving my new eyes despite my cons.  It's wonderful to sit in the backyard enjoying an early morning cigar and coffee and be able to see a red cardinal deep in the shade at the center of a huge oak tree behind my house....with or without glasses.
Many visual artifacts people have initially following surgery, whether they are halos, starbursts, or something else, do go away in the first few weeks/months. Most studies on IOLs report results only after the first 3 or 6 months or so to avoid that initial period where more people temporarily have them. In addition, residual astigmatism might be correctable with an incision in the doctors office (some do it at the slit lamp).

Higher add power readers exist, you can check around online, or perhaps at one of the doctors visits you can get them to give you a prescription for higher add glasses. For occasional near use a low cost online glasses store might be good enough for what would replace cheap readers (even if some might be skeptical of the quality of online cheap glasses for things like driving). Perhaps a bifocal or progressive pair targeted at a near range.
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