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I need help deciding if Toric IOLs are a good value for my situation.

I require prism correction, as well as correction for myopia, astigmatism, and presbyopia. I currently wear progressives.  History; early in life I was able to clearly focus on objects within 3" of my eye with little to no effort. I offer this as some indicator of the scope of my myopia.  I do not have my current prescription, but will report back with it tomorrow, if that would help with any advice. I have worn glasses for 56 of my 66 years. Therefore my goal is not to eliminate them.  I have resigned myself to wearing them till I die.
  
Given the level of my myopia, I also have been able most of my life to get by without wearing glasses for close in to intermediate range work.  Which I would define as from 6 inches to 4 feet. And which I greatly prefer now, when working from 18" to 4'.

My surgeon has told me most people choose distance correction in their IOLs as opposed to near.  He also has told me that my prism problem will require wearing glasses for correction even after my cataracts are removed and new IOLs are inserted.  Because I am bothered more with wearing my progressives for near work now, (feels like I'm in a tunnel) and have little to no complaints about their functionality for distance vision, I'm considering having the close or intermediate IOLs implanted.  As I age further I anticipate less distance requirement and more close to intermediate for computer, hobbies, and and reading work.

My question is, if I choose close or intermediate IOLs WITHOUT astigmatism correction, and accept wearing 'reader' single vision glasses for astigmatism and prism (if needed) for close and intermediate, with a SEPARATE pair of single vision glasses to correct for astigmatism, prism, and distance, will I be creating a condition which will be difficult for an optometrist to correct for?  OR will choosing Toric IOLs dramatically reduce the complexity of creating glasses?  I should add the cost for the Toric IOLs is considerable, but if creating glasses with prism, distance and astigmatism correction is going to be very difficult, it may be worth it.  
2 Responses
177275 tn?1511755244
1.  I must have your glasses RX
2. Read this carefully  LINK  https://www.medhelp.org/user_journals/show/1648102/Consider-ALL-the-Options-Before-Your-Cataract-Surgery-Working-Through-Whats-Best-For-You--2019-2020-Update
3. I think you have been given bad advice.  Most patients that are myopic and have read all their life without glasses are miserable if eyes set for distance both or one distance and one intermediate.  I have done over 12,000 cat/IOLs and NEVER had a patient happy. In fact if a patient insists on distance and has read without glasses I would get a second opinion or refer him to another surgeon.  I wear progressives but read and do all my computer without glasses. If I ever need Cat/IOL I want to be able to read without glasses and use computer.

Post when you have RX and have read the article.
1 Comments
OK, her it is
OD Sphere -0.75 Cylinder -1.25  Axis 178 Vert Prism 0.5u  Hori Prism (blank) Add +2.50  Seg Ht (blank)
OS Sphere -0.25  Cylinder -1.25  Axis 179 Vert Prism 1.0d  Hori Prism  1BO      Add +2.50   Seg Ht (blank)
Lens Type Progressive
No other notes

I REALLY appreciate your help!!!!
177275 tn?1511755244
First of all distance vision is defined as 20 feet/6 meters or farther. So if you have perfect distance vision (an you will not without having toric intraocular lens (IOLs) you would not see clearly at 10 ft or 15 ft for instance to watch TV. You would need progressive multifocal IOLS all the time   One of the most important things is do you see double at distance without glasses?  PLEASE ANSWER  And also confirm you do NOT see double at near/intermediate without glasses.  Most people that have prism glasses have double vision without glasses.  You have a SMALL amount of prism. I wonder why it was put in in the first place. Did you have double vision at distance one time?

The astigmatism in your glasses works against you at distance but helps you read without glasses.   If you want your best vision without glasses at distance and near you will need to consider toric lens (astigmatism correcting).   Or you would need to consider astigmatism correction cornea surgery post operative. Toric is usually best, fastest and least expensive option.

I hope you read my article. First you need to ask do you really need cataract surgery at this point? If you do you should consider your vision for everything you need to do and want to do a BIG problem BAD ENOUGH to warrant surgery. If you are not at that point, ask yourself why you are considering surgery.

If you are at that point first know most surgeons recommend setting the non-dominant eye for reading and giving the dominant eye better distance vision. One way to address your problem is to do the first eye and target something like -1.00 post op refractive error (remember this would require a toric IOL).  Let that eye heal (4 weeks) decide at that point in the second eye whether you want to see better at distance or near. If you are happy with your near vision without glasses the 2nd eye could be targeted for -0.25  if you want better near vision the second eye could be targeted at about -2.00          REMEMBER if all else fails and you are left with more myopia than you want (near vision without glasses) that can be corrected with LASIK but if you want better vision LASIK cannot ADD myopia.

I would also suggest, since you seem a thoughtful person, that you get a second opinion from another cataract/IOL/refractive surgeon.

4 Comments
Again, thanks you for taking the time to respond.  I did read you article before I put up the first post.  My doctor has been watching my eyes for over 8 years now.  I am a type 2 diabetic, and am relatively well controlled. My AIC is in the mid to high 7's.  My work demands a lot of desk time in front of a computer, and I have not forced myself to get to the gym.  I also have had a issue from 20 years ago with some orthopedic work on a crushed heel bone, which developed osteomyelitis.  The infection was cured, but I developed a sinus in the ankle area which caused a surgical incision to never heal.  My primary care doc talked me into wound care, they cleaned it our, put me on linezoid for 9 weeks and after three, started me on hyperbaric for 40 sessions as the linezoid was not clearing up what was left of the staff (not MRSA, though that was the original infection along with pseudomonas).  The hyperbaric played heck with my vision for about three months afterward.  

My ophthalmologist had told me I had cataracts, but they were progressing VERY slowly.  The hyperbaric evidently accelerated that cataract growth.  When I asked my wound care specialist about it, she told me, "Ya, hyperbaric can do that"  Guess that was better than losing my foot.

I have a constant haze in my vision now, and require considerably more light to see than I did before this situation.  

As for the double vision, my optometrist said he was not going to correct it completely because he didn't want my muscles to lose tome by not working against the problem.  I'm not sure what percentage he corrected for, therefore what you see on the prescription is not what I really have.  

During my eye exams, one of the tests has a device, that when looked into, has a small house on a horizon, with a red flashing light in the house.  I am to stare at the house, and they take some measurement.  I described it so you might know the instrument. What ever it is, my right eye sees the horizon at eye level, and at a true horizontal. The left eye sees the house lower by about 1/2" and the horizon tilting down to the right at about a 8 to 10 degree angle below horizontal.    

I do see double at distance, without my glasses.   Even with them, I have to make sure they are set correctly on my face, or I see double images.  

When I am reading or using a computer, without my glasses, without much effort at all, I can correct for the prism by thinking about it. I suppose I am forcing my muscles to correct for it.  If I purposefully relax my eye muscles, then I also have double vision in close, with one image lower and tilted down to the right.

As for focus doing those same tasks, my right eye focuses pretty well.  I'd estimate 20/30 or better (based on what I remember from the small chart lines markings) My left eye is pretty bad without glasses when reading.  It does not change based on distance to the object.  I presume that's the astigmatism.  

I did not follow you on this paragraph.  "The astigmatism in your glasses works against you at distance but helps you read without glasses.   If you want your best vision without glasses at distance and near you will need to consider toric lens (astigmatism correcting).   Or you would need to consider astigmatism correction cornea surgery post operative. Toric is usually best, fastest and least expensive option. "

I have no problem with wearing glasses for distance.  I do have some issues with single vision distance lenses when I drive, due to the instrument panel is very fuzzy.  Given I can handle single vision glasses for distance work, I fully concur with your advice about having the IOLs set for near , as opposed to distance.  I would prefer to wear glasses for distance.  

Are there lenses available which would be reversed from a typical progressive? IE, the top set to correct for my distance needs and the lower portion set to no correction (since my IOLs would take care of that)  My current complaint with progressives is the very limited near vision area and having to hunt for the 'sweet' spot.  

My last concern is trying to understand if putting correction for astigmatism, prism, and distance vision all into one lens may be more than can be reasonably done.  It seems they must have done this now, but I've never been really satisfied with results.  My lack of satisfaction with the current situation where the lens' have to correct for distance, close in, astigmatism, and prism might be due to the limits physics sets for us; maybe I'm just asking too much.  

So to sum up my question, would getting the Toric lens be advised since I do not want to wear glasses for close (and hopefully intermediate work,) but am willing to wear them for distance viewing. Obviously I'd prefer to save the cash, but if the Toric lenses are recommend in my situation, then I will cover the money.



A great deal of this depends on your surgeons experience. Most cataract surgeons do well with "plain vanilla" surgery. That is standard cataract surgery with a spherical IOL.    After that things like toric IOLs,  LASIK, femtosecond laser, etc. require extra training and a lot of experience. You might ask your surgeon about his/her experience with toric IOLs, ask whether the surgeon has extra training in cornea/refractive surgery, ask if they can do LASIK post op to tune up your results if needed. I still think it would be worth the time and expense of seeking out the best second opinion in your area (a cataract/IOL/cornea/refractive surgeon) and get opinion about  1 needing surgery 2. toric or non-toric,  3 target post surgery refractive error.     If you are operated on by a highly trained, highly experienced surgeon with excellent results in toric (astigmatic) IOLs and and you have reasonable financial means for most people the toric IOL would be a good investment. This is a generalization as we cannot give individual recommendations having not examined you.
I understand and greatly appreciate you taking the time to walk me through this.  I'll report back on another opinion and keep the group updated on my decision and how it goes.
Thank you. As I said in the articles, the time to make these decisions are prior to the surgery.
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177275 tn?1511755244
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