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Avatar universal

Did not have enough info about IOLs and fear I made wrong decision

(apologies if this appears twice but my original question seems to have disappeared.)

I had cataract surgery with a monofocal IOL set for near vision put in my right eye last Tuesday. The surgery for the left eye is scheduled in a week and a half. When I met with the ophthalmologist for the initial consultation, he asked questions about my lifestyle, what kind of vision I would want, etc. but he did not mention anything at all about premium IOLS. I believed my choice was either monofocal for distance or near. I learned too late that I am a candidate for multifocal or EDOF and that the doctor is very conservative. I don't think he even offers these to his patients but others in his practice do. He has an excellent reputation btw but maybe just hasn't kept up with the innovations. Putting aside the fact that I am not feeling great about the doctor, what are my options now for my left eye that would increase my range of vision without going full monovision (which I have never tried)? Could I choose an EDOF like Vivity for my left eye or try mini-monovision with contacts first and then do that with the monofocal? I am feeling pretty despondent about this and also disappointed in myself for not knowing more about the lenses. I am usually an avid researcher especially when it's a decision that will impact the rest of my life. Any guidance is appreciated.
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Avatar universal
Hi Juliegk:

Sorry to respond so late, but I felt I needed to. How have things panned out for you? I hope you are happy with the outcome of your cataract surgery. I am just sharing my experience in the hope of making you feel better about your journey.

I have mini-monovision with single focus lenses in each eye. My astigmatism prevents me from having "perfect" vision.

I researched IOL choices extensively. My surgeon said that I was not a candidate for the EDOF or multi-focal lenses because of my irregular astigmatism (uncorrectable by toric lens). One optometrist I saw declared that he thought I was a candidate for the EDOF lens based on his  evaluation of my astigmatism. When I shared these findings with my surgeon, she stated that I would have decreased aquity with EDOF lenses. For my line of work (nighttime driving and very fine print reading) she did not want that for me--and she was right! I know that she was conservative in her recommendations, but she wanted the best outcome for me. My biggest gripe was that she didn't discuss the pros and cons of the lens options, so that I could understand her reasoning. Her answer was  a consistent: "You're not a good candidate for that." After much back and forth, she finally did explain: she explained the physics and calculations behind her decision. (Using the best lay terms she could). She also considered my personality, and how she expected my brain to interact with the new lens. She came to her conclusions by applying her years of training and abundant experience There was no way for her to explain all of this to the likes of me.  I relied on her genius to find the right solution for me, and I'm glad I did.

After thought: Now that I see what those light adjustable lenses can do, I would have liked to consider those because of my astigmatism. But technology is always improving....maybe I can get my bionic lens in 10 years time...

I hope you are as pleased with your final result as I am with mine!
Helpful - 2
Cocobean, thank you so much for responding. I do think it's an issue when doctors cannot or will not explain all the options and possible outcomes about procedures.  It is their jobs to know how to translate medical concepts at a lay person level unless of course they only want to treat other doctors! I have not had the other eye done. Just not looking forward to another appointment with another surgeon. Thanks again for sharing. So, do you have closeup and intermediate vision now?
It seems it must be 8 weeks since your right eye cataract surgery. Have you had an accurate measurement done of where this eye ended up at the 6 week mark or longer? That would be very helpful in determining what your options may be.

One possible one may be the Rayner EMV lens. It is somewhat unique in that it has a bit of boost in vision to the "left" side (distance side) of the peak vision point. If you are forced to put in a lens more myopic than -0.5 D to minimize the differential between the eyes, it could save a  bit more of the distance vision.
Hi Juliegk,

I read magazines and newspapers without glasses in good light, but I do increase the images on my computer (125%) for comfort when I work. I also use a magnifier in low light for the small print. I am VERY comfortable and VERY happy with my vision, but I still wear glasses for driving.  (I don't need to according to the DMV.)

I think the choice of mini-monovision with single focus lenses was the best option for me, but I have nothing to compare it to. I REALLY wanted the EDOF based on the advertising! One other positive thing I can say about the single focus lens is that since it has been around for a while, we know that they function well in the long term.

Side note: I haven't gotten my final pair of glasses because I had posterior capsular opacification, and had JAG laser for both eyes. My optometry appointment is next week. I've been using my old glasses to drive.

If you are able to get around with the surgery in one eye for now, I agree with Ron_AKA about assessing how your right eye is doing...I was terrified by all of the stories of people not being able to see the food on their plates or what they were cooking without glasses. But even with my distance eye, I can see the dashboard on my car, and can grab the correct spice from my spice rack.

Cocobean2 Thanks for responding. Your comments are instructive and nothing like having been through surgery to share insights.   Would you please post after you have your next visit and have your final pair of glasses and have had them for a week or so.  I believe it would be very helpful for those following this discussion. And not to see pedantic it is YAG laser.
Dr. Hagan:
Of course, I will share my experiences after I get my final glasses. Thank you for correcting my misspelling of the YAG laser. That could have lead to a lot of confusion!

Avatar universal
My thoughts would be:

1. Wait 6 weeks for the first eye to fully heal and then get a refraction (eyeglass prescription) done by an optometrist to see where you actually landed for refraction.
2. If you are happy with the reading vision then you may want to consider using this eye as the near eye in a mini-monovision configuration. The normal target for the near eye is -1.5 D.
3. It is best do a trial with a contact lens in your unoperated eye first. You will want to use a contact that will correct this eye to plano, and also correct any astigmatism. I find Costco is a good place to trial contacts.
4. If you are happy with the vision you get with simulated mini-monovision then you may want to consider doing it with an IOL in your second eye. What IOL did you get in your first eye? A standard monofocal like the Tecnis 1, Clareon, or B+L enVista should be fine. If astigmatism (cylinder) is predicted to be 0.75 D or more, you may want to consider a toric to get the best possible vision without eyeglasses.
5. You probably want to have a conversation with the surgeon about the outcome from the first eye compared to what the target was. The surgeon should be able to adjust the calculation for the second eye based on the first eye, if they are reasonably similar. Using the same lens would also likely improve the accuracy on the second eye.
Helpful - 1
Hi Ron, Thank you for your response. It appears Dr. Hagen agrees with your comments. The lens in my right eye is a Clareon and after about 10 days the refraction in my right eye is -2.50   Since it is greater than the -1.50 you recommend, does that mean I cannot do mini-monovision?
I would wait the full six weeks and get a refraction that you can depend on to be stable. And you could hope the myopia reduces some. Having -2.5 D in the near eye would be full monovision, not mini-monovision. The surgeon I went to says he has done up to -3.0 D, but that I think is not very popular any longer.

First you could try it with a contact in your non operated eye to give you plano distance vision to see what you think of it. Things I would look for are a loss of of some vision in the intermediate distance, and perhaps some loss of depth perception. But you could find it acceptable and after a contact trial you could go ahead with it.

Another option would be to do a -1.0 D in the other eye (that could be simulated with a contact as well). This would reduce the anisometropia to 1.50 D, but would not give full distance vision. You may get 20/40 if you are lucky and that may be enough for a driver's license without glasses. But, it is not going to be good distance vision.

Keep in mind that with any degree of monovision you can always get progressive glasses that will correct both eyes to plano.
The unoperated eye has a cataract so wearing a contact lens on it will not give you a full appreciation of what the post op vision will be.   Most people that are myopic and are use to having good reading/computer vision without glasses are usually not happy unless they can do that post operative.  As I have recommended earlier I would suggest getting second opinion. Your original surgeon should have discussed premium IOLs and  have told you what the post operative refractive error was being targeted.  The last comment about the light adjusted lens is that your vision can be tuned post surgery in the eye with LAL.  
Yes, if the cataract in the unoperated eye is significant, that can limit what one can determine from a contact lens trial of monovision. I went from having my first eye surgery done, and then a gap of 18 months or so before the second eye was done. During that time I wore a contact to simulate mini-monovision. It was helpful in determining what mini-monovision was like though.

I was myopic prior to surgery and at times do miss the ability to take glasses off and have kind of an up close super vision. But, I am essentially eyeglasses free now and I enjoy that much more. For me it was a good tradeoff.
If your eye stablizes at -2.50 and you have good vision at near, if you tried for best distance vision (20 ft or further) withou glasses (target 0.00 ) then you would be doing Full monovision not mini-monovision. If someone has not done this before with a contact lens it is often difficult to get used to.  Had you had a light adjust lens (LAL) you would be able to 'tune' the refraction post operatively.  
233488 tn?1310693103
This is rough calculation but your residual uncorrected refractive error in operated eye is about -2.00 +/- 0.5 diopters.  What was the 'target' post op refractive error you and your surgeon chose for your monofocial IOL?    

What was your refractie error in both eyes prior to surgery *(glasses distance correction)?
Helpful - 1
My surgeon did not discuss a target refractive error, unfortunately. The comment was made that I would have what I always had - the ability to read up close. I did not want to lose that but did not realize I could have possibly had that plus intermediate and distance. I am seeing my optometrist tomorrow and will ask him about the refractive error in both eyes prior to the surgery. What is the best outcome I could hope from this? I am in Dallas and trying to find someone who offers the LAL that you recommend. I greatly appreciate your time.
We have a surgeon in our practice with an international reputation. He knows all the leading surgeons across the US. I will ask him to recommend a couple in Dallas. The best outcome it that you are happier after the second operation. That you can read with the first eye, see the computer and a TV 10-12 feet away out of the second and have 'acceptable vision at greater than 20 feet without glasses. And that with glasses you have 20/20 at distance if just for driving or with progressive multifocal glasses can see great with both eyes at all distances.
Dr. Hagan, that would be a welcome outcome for my vision. I look forward to your colleague's recommendations for surgeons in the Dallas area - it's a big area so anywhere in the DFW metro area would work.
This website has been wonky for years. Posts are lost, not posted. This is whom my colleague suggested in DFW.  
Jeffrey Whitman, MD
Key-Whitman Eye Centers
Dallas, TX

Thank you, Dr. Hagan. I will post after my visit with Dr. Whitman. His practice is very popular so it may be a couple of months.
When you call to make an appointment tell them you are a referral from Dr. John Doane (MD) of Kansas City, MO    Might spead things up
233488 tn?1310693103
The first thing I would suggest is that you post-pone your surgery on the second eye. Even with small incision/no stitch it takes about 4-5 weeks for the post op vision to stablize.  In the meantime I would suggest you do research on the Light Adjusted Lens (LAL).  Our practice has switched to it as our premium lens. It can be adjusted post operatively and it corrects astigmatism. It  is relatively new and all surgeons do not do this surgery. Many surgeons that dont do premium upgrades do not mention them to patients but that is becoming standard of care to present all options.    LINK  https://www.rxsight.com/us         I have been doing this forum for a long time. Generally it is the best plan NOT to do the second eye till you are happy with the first eye. Often the person ends up unhappy with both eyes.
Helpful - 1
Thank you, Dr. Hagan. It is very kind of you to share your expertise. I discovered this forum in the middle of the night last night since I am not sleeping well due to what I view as a mistake I made that will last a lifetime. I appreciate your help.
Don't dispair. But as i said don't rush into the second eye. When you don't have your glasses on in your operated eye. What is the distance that is clear ? reading  computer   tv  distance (greater than 20 ft)
I postponed the second surgery. It was something I wanted to do, but felt intimidated about cancelling such a big procedure. Your recommendation gave me the push I needed to do it. Thank you for that.

The farthest distance I can see clearly and comfortably with unaided eye with new IOL:  
Phone or book: 15 inches reading
Computer: 18 inches without increasing font.
TV that is 55":  standing in front of it - I can read the captions from 3.5 feet.

This website not infrequently loses responses. Just lost mine. What post-operative uncorrected refractive error did you and your surgeon pick?  If you can see book at 15 inches your post op refractive erroe is about -2.00 +/- 0.50 diopter.   So your vision as you describe would be spot on if you had asked to read without glasses.  What were you and surgeon hoping for with the monfocal IOL?       What was your glasses prescription for distance before surgery.?  
I just saw my optometrist and surgeon in the past two days. My right eye with the Clareon monofocal is now between 2.25 and 2.50.

My px before surgery - optometrist says it was 2.25 in both eyes. Surgeon says it was 3.00 in right eye.

Now that the right eye is a done deal, do you think my right eye was overcorrected for the purposes of mini-monovision? Should I even try with the contacts to see how I adjust?

The optometrist gave me two contacts to try in my left eye to improve distance vision, a 1.25 and a 2.50.

Ideally, I would like to come out of this with near vision and computer vision and wear contacts or glasses for driving. I think that is the best I can hope for.

Thank you for any guidance you can provide.
Lens designation in diopters start with a plus + or minus -   I suspect that you are myopic or nearsighted and your glasses for distance and you could read without them at near. If plus then you were hyperopic and there should be an Add for reading  or the last possibility is your distance vision was good and you used these for reading.  Please confirm so  can give you the best possible answer.

You are correct, I am myopic.
Your near vision would seem similiar to what it was befoe the cataract and before the surgery (since it seems your post op refractive error is about -2.50)  If you do full mono then the distance from 20 ft and further but the TV will still be blurry and you will have to have to move your head some when switching between keyboard and monitor. Or you could go mini-monofocal with near bias and aim for about -1.00     Wearing the -2.50 contact would approximate full monofocal and the -1.25 mini-mono near bias

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