That's a tough one. I advocate cataract surgery in both eyes (understanding that the only indication in the left eye is the difference between the eyes caused by the first surgery). In the hands of a good surgeon, your risk to the left eye is minimal. Of course this would mean needing reading glasses at a very young age (unless you chose monovision or mini-monovision). Phakic lenses are terrible and much higher risk for complications than regular cataract surgery. Contact lenses themselves are not without risk.
I would go for distance correction or slight nearsightedness in the right eye and try the contact lens solution in the left eye. If you have issues with that, you can always opt for cataract surgery (clear lens exchange) in the left eye. This is just my opinion though so think through it for yourself.
I would do cataratct surgery in both eyes since you will need it in the other eye at some point too
This is a tough call given that contacts haven't worked well for you.
That said, I agree with the prior comment that I'd probably have the RE cataract surgery and target a refraction that's what you ultimately want from the cataract surgery (i.e. without regard for how it aligns with the LE).
You don't have to target 20/20 distance refraction; some people who do mostly close work on the computer or reading and who don't mind wearing glasses for distance vision will choose a nearsighted target range such as -2 to -3D It's up to your choice, your lifestyle and for you and your surgeon to decide together.
After the surgery (or even before, if you want to try ahead of time) maybe you can try Restasis, punctal plugs and/or other methods of addressing your dry eye problem to see if you can tolerate a contact lens in the LE for a greater percentage of the day. If so, it would be much easier to deal with the refractive 'gap' between the two eyes.
If not, you will have to decide between an ICL (I know something about them and appreciate your concerns in that area; they are not risk-free) or doing early cataract surgery (clear lens exchange) in the LE to bring it close to or match up with the RE.
As an aside, a friend had your situation and opted for an ICL in eye #2 after cataract surgery in the first eye. She was very happy with the results and had no complications, but 10 years later now faces cataract surgery in eye #2 which is complicated by the presence of the ICL which needs to be removed during the cataract procedure.
Good luck with your decision making process.
Thanks everyone for your thoughts -- I appreciate it! Dr. Vosoghi, good point on how even contact lenses are not without risk.
Flossy93, my understanding is that given how myopic I am, addressing the myopia in my RE is sort of an "all or nothing" prospect (so even if I were to choose to target -2 or -3 in my RE, I wouldn't be able to wear glasses afterwards because there would still be a big gap between that and my LE prescription).
I'm concerned about doing the LE cataract surgery early because my understanding is that the cataract surgery increases the risk of retinal detachment significantly in someone as myopic as me.
I am also wondering about doing optional limbal relaxing incisions for astigmatism in my RE during this cataract surgery. Does anyone have thoughts on the pros and cons for this?
The best thing to do is to have BOTH eyes done...even though you other eye's cataract hasn't progressed as fast as the one you are having done...this way, your eyes will be in SYNCH....
Then it's just a matter of deciding whether you want to go with 20/20 for both eyes and wear readers for close, or as an alternative, consider mini monovision and have them make your other eye at about -1.0 diopters or so (full monovision can be very tough to adjust to)...
Also, if you have significant astigmatism, you'd be better off paying the difference and get TORIC monofocal lenses...that is what i have....
Also, i had both eyes done even though, like you, my other cataract had not progressed that much at the time i had my first eye done...
You'd need to do the other eye eventually anyway, so why put yourself through all this...GET BOTH EYES DONE NOW...
The risk of a detachment will be there today or in 10 years. The most important thing is to find an experienced surgeon, and discuss with him/her your concern about potential retina detachment and any mitigating techniques that can be used.
You should also investigate 'laser' cataract surgery vs the traditional method. There are many posts on this topic in this forum. Basically the laser approach involves softening/cutting the cataract with targeted laser energy, which reduces the amount of ultrasound energy needed to loosen and remove the cataract from the capsular bag. Dispersing ultrasound energy inside the eye has the potential to increase risk of detachment, although many high myopes have had traditional cataract surgery with no issues.
The same laser system can also be used to do limbal relaxing incisions w/ results shown to the doctor in real time. For significant astigmatism or for more predictable results, though, I think toric IOLs are supposed to be better - although there is still a small risk of them rotating after implantation.
Be sure to have a thorough dilated pupil retina exam before the surgery. The retina specialist should be told you are having cataract surgery, and should check the peripheral retina carefully to make sure there is no sign of abnormally thinning, pending detachment or any slight tear. If there is any anomaly it can be 'tacked down' with a laser in the office, ahead of the cataract surgery. This will further help mitigate the risk to your retina from the surgical manipulation of the eye.
My comment about the slight negative target refraction was more to do with your preference after surgery, not as a way to reduce the 'gap' between the two eyes. Some patients who have been nearsighted a long time prefer to target slight nearsightedness, so they don't need reading glasses for reading/computer, as long as they're willing to wear glasses for distance vision for driving, playing golf, etc.
It does sound like the 'default' selection for IOL power is 20/20, with progressive glasses for computer use and reading. Or a blended approach where one eye (usually the dominant one) is set to 20/20 and the other is slightly undercorrected like -1 to -1.5D ('mini-monovision'). You can try contacts to simulate this effect before surgery if you want to see what it's like. Dr. Hagan has written a good blog post about deciding on the right lens and vision scheme during cataract surgery.
By the way, i had a pretty high amount of astigmatism and the toric does a really excellent job of correcting it (i have the acrysof toric lenses) and while not quite as nearsighted as you are, i was about -6.5 in both my eyes prior to the surgeries...
Now that I'm 4 weeks+ out from my surgery, I thought I'd report back on what I decided to do, as well as results! I opted to correct the myopia completely in my RE and did go with a monofocal lens set for distance. I also opted for astigmatic keratotamy during the surgery, to correct for astigmatism in my RE. The surgery went very smoothly, thankfully. I'm loving being able to see clearly out of my RE again!! I do wear a contact lens on my LE about 12-14 hours a day now. My eyes do get fairly dry and uncomfortable especially toward the end of the day after staring at the computer at work, but am using eyedrops and have also gotten a humidifer in my office to help. I'm also exploring other types of contact lens that might be more breathable in my LE.
What's really great is that I do not really need reading glasses since I've adjusted to using my LE for reading, and both eyes work well together for computer as well. I'm still planning to get some light reading glasses with correction for RE only, for fine-tuning purposes, and to see if I'm comfortable reading or doing computer work while wearing the reading glasses if I choose to have my contact off in my LE.
I also am able to do more than I thought I would with my contact lens off (i.e., using my RE only). I can watch TV comfortably, do things around the house (that don't require me to see detail up close), wash dishes, etc. I also go on workouts (powerwalking/running in my neighborhood) with my contact lens off in the mornings before work.
I also have patched off the right side of my old eyeglasses so when I wake up in the mornings and don't have my contact lens in yet, I can read messages on my phone with my glasses on, for example. This is not comfortable for longer periods of use, however.
I'm continuing to adjust to having lost the ability to see up close in my RE, but the monofocal lens has worked out really well for me. I was worried about halos and issues seeing at night with the multifocal lens, and have had no issues in that regard with the monofocal lens.
Thanks to all for your thoughtful advice!
Thank you for the thoughtful comments about your cataract surgery experience. It's so great to hear that your RE vision turned out so well. If you can cope with the LE for a while until that surgery is 'covered' in terms of the cataract being ripe enough to be removed under medical insurance, great. If not, at least you bought yourself a little time to decide what to do in the LE.
Re contacts for your LE, investigating various drops, Restasis, plugs, etc to help the dryness are all good ideas. I also read somewhere recently that sleeping under a fan or working where there is a breeze or fan (from an A/C duct or a fan) can exacerbate dry eye problems. Just FYI; I have dry eyes and wear contacts too so I am always looking for possible solutions. The humidifier is a great idea.
I encourage you to try various contacts til you find one that works and that is 'breathable' to help preserve the health of your cornea. With astigmatism there can be trouble finding toric contacts at the higher prescription ranges, but until you've worked your way through them all it's worth continuing to try. My sister (a -8.5D w/ astigmatism) just found a lens she likes after 4 tries with other variations, so keep at it. And congratulations again on the successful surgery!
A related discussion, Cataract Sx & Lens