Toric IOL For the Risk Averse?

[mmmmpppp]

My mom was told by an outstanding surgeon that she would be an excellent candidate for the Acrysof Toric IOL because she has a cataract and astigmatism.  I don't know how much astigmatism.

My mom is EXTREMELY risk averse.  She read in the pamphlet on the Acrysof Toric that some people do not adjust well to the Toric and are not comfortable with them.  Now she is terrified of this IOL.

Given her risk aversion, should she stay with the Toric or go with a standard lens?  If she goes with a standard lens, she will not have the astigmatism corrected surgically.

Thanks in advance.  MedHelp is truly wonderful!

[dordor831]

  I am an artist and use my eyes to make a living. I was told I have cataracts   and astigmatism and was told about toric lenses as a custom option for either seeing close or far away but the toric operation would not allow both to happen. If I chose to see clearly up close, then I would have to still wear
glasses for distance. I am worried about the displacement or dislodging of the toric lens after it is put in place. Since I would be devastated if anything went
wrong after the toric lens surgery, I was wondering if I should just have the cataract surgery and live with astigmatism like I have for 40 years.

[mmmmpppp]

Thanks for following the whole story, JodieJ.  I really appreciate it.

[JodieJ]

I don't know why your mother doesn't wear glasses now.  Perhaps she is mildly farsighted and her astigmatism brings her close to a spherical equivalent of plano.  Or maybe she's just used to less than crisp vision.

Depending on the power of the IOL which is implanted, your mother could be nearsighted, farsighted or something in between post-surgery.  Her refractive error before surgery is not really relevant.  However, most surgeons can get within .5 diopters of their target.  

[mmmmpppp]

Thanks, JodieJ.  Glad to hear it.

You don't by any chance remember how to find the study you mention in another post that compares the Toric lens to LRI?

She seems to have decided on the Toric lens because she trusts this doctor and because she assumed she'd have excellent distance vision without glasses with the standard lens.

The only twinge of doubt I have about it all is that she doesn't wear glasses for distance now.  Could surgery increase her astigmatism, and enough to cross the line into making her need glasses for distance?  I'm puzzled why she doesn't wear them now if that is a significant amount of astigmatism?

[JodieJ]

It now seems like your mother has enough astigmatism to blur her vision at all distances.  If she is used to wearing glasses and doesn't mind wearing them all the time, then getting a toric IOL might be a waste of money.  (Some people think that they look better with glasses than without.  Your mother may be in this group.)  However, if your mother would like to eliminate her dependence on glasses for some activities, a toric IOL might be money well spent.  (BTW, I suspect that Alcon would be interested in knowing that their informational brochure lends itself to the type of misinterpretation you described.)

[mmmmpppp]

The plot thickens!

The .75 Diopters astigmatism in both eyes came from the office of the Dr. whom my mom had been planning to have implant her standard lenses.  The Dr. I called the "outstanding surgeon" (who did an amazing job on my cataract) says that she has 1.8 Diopters astigmatism in her right eye and 2.25 diopters in her left eye.  He also says that her astigmatism is unusually shaped.  I think he said that hers is oriented around a vertical axis where normally they are oriented around a horizontal axis.  As a result, he said, cataract surgery with any lens will increase her astigmatism in each eye by .5 Diopters.

His plan is to implant one Toric correcting for 2.3 Diopters astigmatism and one Toric correcting for 2.75 Diopters.  In other words, since he expects surgery to add .5 Diopters to her astigmatism, he plans to add that .5 Diopters to the correction he plans to set each lens for.  He says that he can control the astigmatism correction of the lens to within .25 Diopters.

He said that about 1% of his patients have rotation occur with the Toric.  Fixing it is a five-minute, relatively low risk surgical procedure performed within 2-3 weeks of the cataract surgery.

The line in the brochure on the Toric lens that upset my mom so much, namely, that some people do not adjust well to the lens and are not comfortable with it, turned out to refer to the Toric contact lens, which was discussed in the same brochure.

[JodieJ]

Your mother has mild astigmatism--probably not enough for a toric IOL without risking over-correction.  (It depends on her corneal measurements.)  You say that there is absolutely no way she'd get a limbal relaxing incision.  Well, the surgeon is going to have to make an incision in order to perform the surgery.  I believe that this incision could be positioned in a way that would reduce/eliminate her astigmatism.  Dr. Hagan has posted information about this previously.  I don't know why one of the doctors hasn't responded to this thread, but you could try re-posting.  

[mmmmpppp]

My doctor hasn't behaved in a sleazy way.  Bausch and Lomb blew me off when I tried to get the FDA study on the Crystalens HD.  Their behavior added an element of foreboding to the whole thing.  

Thanks, JodieJ.  I always learn from your posts.  The latest info is that my mom has -0.75 D of astigmatism in each eye.  There's absolutely no way she'd get an LRI.  It's either a Toric or a standard (most likely) IOL and nothing else (besides her glasses).

So, we are wondering about the brochure remark about some people being uncomfortable with the Toric and wondering what the risks and consequences of rotation are, as well as wondering about any other possible risks.  She'll be asking the Dr., of course, but I'd love to hear from any the great MedHelp group.

[JodieJ]

Alcon's toric IOL is a monofocal (not a multifocal/accommodating) lens.  If it is targeted for distance vision, it can potentially eliminate astigmatism and provide excellent distance vision.  This might enable someone with significant astigmatism (and refractive error) before cataract surgery to drive, watch movies, and participate in sports without glasses or contacts.  S/he would, of course, still need to wear glasses for intermediate and near vision tasks.

Who would benefit most from a toric IOL?  Probably someone with significant astigmatism who wanted to minimize his/her dependence on glasses, especially those who wanted a (modified) monovision correction.  Someone who is comfortable wearing glasses after cataract surgery might better spend their money on something else.  

[LynneAV]

The picture that is forming in my head could well be wrong, but I have the impression that some cataract eye centers want to hint that the patient might not have to wear glasses after cataract surgery if they opt for enhancements like the toric IOL. They can't say that outright, though, so instead they repeat "You will still have to wear glasses!" even though you didn't ask that and in fact have repeated over and over that you are used to wearing glasses and don't mind them.

So, the patient keeps wondering what the heck is the advantage to additional cost and risk if she still has to wear glasses no matter what? I am guessing that perhaps there is some outside chance that purchasing the toric IOL would free a patient from glasses and thus make the risk worthwhile (perhaps) ... but since nobody can come out and say that, I think they are hoping you will pick up on a silent "wink wink." The person who was recommending a toric IOL to me seemed (it was a phone conversation, so I could not read body language) dismissive and defensive about it, "everybody loves it" kind of answer when I asked about any complications. This is the weirdest and most indirect thing I've ever experienced with medical care, have to tell you!  This is more like buying a used car than making a vital medical decision that will probably affect your quality of life for the rest of your life.

[mmmmpppp]

Thanks LyynAV.

I'm so grateful for the patient perspectives, but I'm disappointed that no doctor replied.

Still wondering:

1)  why my mom's brochure on the Acrysof IOL says that some people are not comfortable with it and do not adjust well, and

2)  how many patients need to return to have rotation corrected surgically?

[LynneAV]

Thanks ... I'm thinking I will pass. I think I am also "risk averse."

[Harold14370]

Lynne,

All I remember from the video was that the toric has to be aligned to the correct axis in order to correct your astigmatism, and it can move after the original operation. Then they would have to go back in and realign it.

[LynneAV]

Harold, do you remember *anything* about the additional risk of the toric IOL?  I am having a hard time finding the previous discussion of toric lenses and I keep going round and round finding the same two posts when I use the search (probably because of my cataract, lol, my eyesight is really annoying at the present).

[Harold14370]

I have no idea what the risk would be. They showed me a video that covered the risks of the cataract operation as well as the additional risk of toric. It was nothing more than a laundry list of things that "could" happen. As far as I knew, the risk of the cataract surgery could have been anywhere from 1 in a million of anything going wrong, to having a 50-50 chance of getting out alive. They seem to want to keep that info close to the vest. Some informed consent, eh? I had to more or less drag out of them some idea of the risk of surgery. I wasn't very interested in the toric, though.

[JodieJ]

It's my understanding that no option guarantees a perfect correction of astigmatism.  In one study I read, limbal relaxing incisions did a better job with mild astigmatism, and the Alcon toric IOL did better with moderate to severe astigmatism.  Not all surgeons are adept at performing LRIs (or implanting toric IOLs.)  Your mother should bring the brochure to her next appointment with her surgeon and ask him/her about the risks.  If she doesn't mind wearing glasses after surgery, she might not want to pay several thousand dollars to correct her astigmatism.  (At the time I had cataract surgery, Alcon's toric IOL was very new, and it did not come in the power I needed.)

[mmmmpppp]

Oops, just realized what a dumb question, "do you have the Toric?" was.  Sorry.

Do you have an IOL?

[mmmmpppp]

Thanks, JodieJ.

In another post, Dr. Hagan says (I believe) that the Toric IOL is a lower risk and/or more effective treatment for astigmatism than the limbal relaxing incisions.  I also thought that I had read that there is a significant unpredictability with the limbal relaxing incisions.  But no matter how effective, my mom has never wnated to have her astigmatism addressed surgically and won't start now.

Do you have the Toric?

Sorry to harp, but just to keep the question alive:  Any idea why her brochure says that some people do not adjust well and are not comfortable withwith the Toric?  Any idea how many need to return for a surgical follow-up (or wish they could have a surgical follow-up)?

[JodieJ]

Limbal relaxing incisions can also correct mild to moderate astigmatism.  Some surgeons don't charge for this procedure.  It worked out well for me.

When I had cataract surgery in September 2006, Alcon's toric IOL was very new, and the additional fee per eye was $500.  It's hard to believe that the charges have increased more than 300% in under 3 years.

[mmmmpppp]

Thanks for replying.

Any idea what percentage need the 2nd operation?

I haven't found anything that makes sense of the brochure comment that some people do not adjust well to the Toric and are not comfortable with them.

[Harold14370]

I declined the toric lens. I figured I would be wearing glasses full time anyway, due to the need for reading and intermediate range correction. When would I not want to be able to read the display on my watch or cell phone, or read packages on store shelves when I go shopping?

As it turned out, they miscalculated the spherical correction by 0.75 diopters in each eye, so I wouldn't have had perfect uncorrected distance vision anyway.

The toric would have cost an extra 1800 per eye, not covered by insurance. The risk of getting the toric would have been the possibility of the toric rotating out of alignment, and needing another operation to realign, with the attendant risk that goes with any eye operation.