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iol to choose

Hi, I have to decide which kind of iol has to be implanted in my eyes and I am in trouble...I have both yes myopic, - 3,75 S -3,75 D, since I was seventeen, now I am 66 years old. I have always worn rigid and semirigid conctact lens, every day, from early morning to night, without problems. Before cataract I needed +1,50/2,00 glasses to read very small characters, wearing them on my contacts. Now I have -7,5 S and -4,5 D. I had 3 different suggestions: 1) monofocal iol to see well at far, 2) monofocal iol -2.50/3.00 in both eyes to have a very good near vision, and 3) the Symfony lens (available here in Italy). I am accostomed to have a very good near vision even without any lens or glass and I am very sensible to colours. I think that the solution n. 2 might be the more "natural" for me, but also the new lens Symfony seems very interesting even if also "complicated". I would like some suggestions. I have to decide in a few days...
Thank you for any help.
30 Responses
Avatar universal
http://www.healio.com/ophthalmology/refractive-surgery/news/online/%7B465bc15c-7381-4aca-b60d-fd3b9970e351%7D/three-month-results-of-european-study-show-good-performance-of-symfony-iol
"Three-month results of European study show good performance of Symfony IOL

May 13, 2015 ...

'Halo and glare were minimal, with 99% of the patients reporting no halo or night glare at all. Patient satisfaction was high. More than 60% were spectacle-free, and 98% said they would recommend the implant to family and friends.'  ...

'Uncorrected visual acuity was 20/20 at both distance and intermediate and 20/32 at near, with a smooth transition between distance and near vision. The defocus curve was a continuum and did not show the classic peaks of conventional diffractive IOLs,' Hugny-Larroque said. "


Avatar universal
The Symfony isn't "complicated' in terms of what it feels like to someone actually wearing it, it just seems like natural vision. The technology it uses may be "complicated" to achieve that effect, but the vision itself isn't complicated.

You mention with #2 the idea of setting your lenses to see in closer without correction (so you need correction for distance). You can also do that with the Symfony as well. The difference is that the Symfony gives you a larger visual range, so you can see closer in than you would with a monofocal, from whatever distance you set it at.  That way perhaps you don't need to set the lens quite as close in to get good near vision. For instance perhaps you might set the Symfony to give you good vision around the house without needing corretion (rather than merely very closeup).


The issue of color perception with IOLs arose on my thread about the Symfony:
http://www.medhelp.org/posts/Eye-Care/my-Symfony-IOL-results-after-cataract-surgery/show/2425258#post_11780883

if you look near the bottom of the page there are links to articles on the topic. Colors with the Symfony should be the same as those with the Tecnis monofocal for instance. The only difference you might have is if you get a different monofocal which is a "blue blocker" and blocks blue light. Cataracts (or even merely the lens in an older person) blocks more blue light than the eye of a young person, so most IOLs would restore your vision to be more like the natural vision of someone younger (except for those "blue blockers" that most surgeons don't seem to think are a good approach).

My vision with the Symfony lenses (set  for distance, I'm almost 20/15 at distance) seems to me like my natural vision was in my early-mid forties or so  when I first started noticing presbyopia and occasionally needing reading correction (when wearing my regular contact lenses I mean to correct high myopia). I see 20/25 at near, but that is with a reading chart held at a best reading distance for me, perhaps 46-47 cm.   I can read the fine print on say an eyedrop bottle without reading glasses (though I need to adjust where I hold it), and I can read my smartphone just fine without needing to worry about where I hold it. I did need reading glasses to thread a needle recently.

However everyone's results will be different depending on the condition of their eyes. Yours may or may not be as good, a small fraction of those with Symfony lenses need reading glasses for near. Posts on the page I started about the Symfony  link to articles   that talk about the results they have seen in studies.

One question is exactly how close you wish to be able to see clearly. If you decide  the distance you want your best focus to be at in centimeters, then the number of diopters you want to be myopic would be (100 / distance), e.g. if you want to see best at 50 centimeters that would be (100/ 50)= 2 diopters myopic, i.e. -2D. Or to see well at 1 meter that would be  -1D, 2 meters would be -0.5D This page lists a few examples:

https://www.slackbooks.com/excerpts/67956_3.pdf

That is merely your best focal point, how well you see in closer than that distance depends on the lens you choose. On the page for the Symfony,

http://www.tecnisiol.com/eu/tecnis-symfony-iol.htm

if you click on the "clinical" tab you will see what is called a "defocus" curve for the monofocal and the Symfony. That shows the typical visual quality for  different distances, measured in diopters. So it shows a monofocal maintaining 20/40 vision up through say 1.5D, while the Symfony does so through 2.5D. If you had your vision set to leave you myopic by say 2D (to focus best at 50 cm) that would mean that with a monofocal you'd still see 20/40 up through (2D+1.5D)= 3.5D (which is 28.6 cm) and with the Symfony you'd see 20/40 up through (2D+2.5D) =  4.5D (which is 22.2 cm).

It is hard to get a good idea of what it means to say 20/40 vision, but here is a chart giving the typical sorts of things you can read at near with different quality vision (e.g. medicine bottle vs. newspaper headline vs. book, etc):

http://www.teachingvisuallyimpaired.com/print-comparisons.html



Avatar universal
Since you are in Italy I'll mention another new extended depth of focus lens, the Mini Well from SIFI Medtech, that  I haven't read much about (its doesn't have a toric version, but in a direct message the poster said she doesn't have enough astigmatism to need one). It is made by an Italian company so perhaps surgeons there may have more experience with it (the study   below refers  to Italian surgeons you might check with). The Symfony has had more published studies so it may be a safer bet, but perhaps the Italian surgeons may give you more insight on how this lens compares. I only noticed its existence after my surgery so I hadn't tried contacting anyone to get more information. These are the results from  a study presented at a conference in September (if you search, there are charts on the net that compare visual acuity given in logMar with other measures like 20/20 or 6/6, etc):

http://www.escrs.org/london2014/programme/poster-village-details.asp?id=22298&day=0
"Postoperative refraction was -0.32±0.43 D, and astigmatism was 0.72±0.21 D. UDVA was 0.2 log MAR in 1 eye, and binocular UDVA was above 0.1 logMAR in every patient. DCNVA (40 cm) was 0.12 logMAR in 1 patient, and was above 0.1 logMAR in 19 patients. Spherical aberration was -0.03±0.02 μ within the central 4 mm, and +0.95±0.18 μ within the central 6 mm. Coma levels were similar as with aspheric IOLs. Aberration-based optical quality expressed as Strehl ratio was 0.143±0.075. Contrast sensitivity levels were between those of monofocal IOLs and those of diffractive multifocal IOLs. No patient was using spectacle correction for near reading. No patients reported glare, halos, or photopsias."

They have a product brochure on their website:

http://www.sifimedtech.com/en/category/prodotti/area-chirurgica-prodotti/iolpremium/min-well/
which claims also "no halos and glare", but that may be based only on small studies (or it may mean no different than a monofocal, since even with a monofocal some patients get halos and glare).
Avatar universal
Thank you for the links that I'see sa soon as I have  enough time. The are. A lot of issues which deserve so much attention.
I heard the someone Who has Symfony sees sometimes circles, and I would like to know if it is true.
Rita
Avatar universal
By "circles" I am guessing you mean halos from lights at night. Even people with a monofocal lens can see halos, and the number of people reporting problems with them with the Symfony is comparable to the number with a monofocal. Most people don't see them, and most who do usually see them fade over time and eventually disappear. However that still means that *some* will see them, as with any lens, and they are often going to be the people that post about the lens since they have an issue (while most of the people with great results will never post). That is why doctors depend on studies to know how common things are.

Some people see halos&glare even with their natural lens, e.g. this eyeglass site is pitching reduced halos with their glasses and shows a simulated images:

http://www.zeiss.com/vision-care/en_us/better-vision/products---technologies/i-scription-lenses.html


This book on IOLs has a good description with images of the issue in a chapter by Dr. Chang, its worth looking at since it also includes an artists depiction of the halos they saw and their decline over time. Just an excerpt:

http://tinyurl.com/kj9jwte
"Halos are not necessarily abnormal aspects of human vision. They occur naturally in many people. They can be from refractive effects or diffractive effects (Figure 1). It is common to implant a multifocal IOL in a hyperopic patient who is having refractive lens surgery or presbyopic lens exchange and have that patient comment that the halos with the multifocal IOL are less than with the original natural lens. This almost never happens with a myopic patient. Therein lays an important lesson about the difference between myopic and hyperopic visual systems. Hyperopes commonly have halos as part of their visual experience prior to IOL implantation and are much more forgiving  of them after implantation of a multifocal IOL. Myopes rarely have halos as part of their visual experience and are less tolerant of them after implantation of a multifocal IOL.

Because halos are normal after any type of IOL implantation, the important question to ask is not, "Do you have halos?" but rather, "Are the halos bothersome?" Every IOL ever studied has some incidence of halos reported after implantation. Researchers have been known to brag about the IOL they use having a less than 5% incidence of halos. "

Dr. Chang writes about multifocal halos on his website also (and remember the Symfony is more like a monofocal):

http://www.changcataract.com/los-altos/cataract-center/frequent-questions-about-multifocal-lens-implants.htm
"Depending upon the size of your pupils you may see halos, which appear as a glow around lights at night. These halos are different from, and much less problematic than those caused by cataracts. They relate to viewing distant lights through both the near and far focusing zones of the lens. They do not obscure the vision, but rather can create a distracting ghost image. Fortunately, these halos become less noticeable and distracting over time as the brain learns to selectively ignore them through a process called neuroadaptation. This is the same process that allows us to ignore background noise, such as traffic sounds or an air conditioning fan. Another analogy would be the temporary distraction of wearing earrings, jewelry, or a seatbelt for the first time. As these sensations become more familiar over time, we become less aware of them. How quickly this adjustment occurs varies for different individuals. However, experience has shown that neuroadaptation is a gradual process and that suppression of the nighttime ghost images continues to improve throughout the course of the first year.  

Even a standard lens implant can produce some halos at night, but they are more evident with a multifocal lens implant. This is because the pupil dilates in the dark allowing more light to enter the interior of the eyeball and to scatter off of the peripheral parts of the lens implant. Halos are always very noticeable during the first 24 hours after surgery when your pupil is still dilated. Do not be alarmed by this temporary artificial situation. The first generation multifocal lens implant that was introduced in the late 1990’s produced very prominent halos that were difficult for many patients to adapt to. The newest multifocal lenses have been successfully re-engineered so as to significantly reduce the halo effect compared to the earlier model.  "

And the Symfony is supposed to be more like a monofocal in terms of the incidence of problematic halos.


Avatar universal
Good news about the halos. By "circles" I do not mean halos from lights at night; I mean (I'll try to explain)  the concentric circles within the lens, i.e. the circles that constitute the structure of the lens. I read that someone (speaking about a trifocal iol) was seeing, in particular situations of light, one of the three circles, and this was a bothering side effect.
Avatar universal
I'm not sure when/why he would be seeing these, other than as halos at night, which can take the form of concentric circles. I am one of those infrequent people that sees halos  from lights at night with the Symfony (concentric circles corresponding to rings on the lens)  but I'm not bothered by them since they are so light,  translucent, I see through/past them. I have no issues with glare, and overall my night vision is better than I can ever remember (even before multifocal contacts and then cataract which might have impacted night vision, it often seemed like my night vision wasn't as good as others).


Avatar universal
I understand that when he was looking at something, (not at night) for instance a book, he saw the book as through a circle; ie one of the three circles that delimit the three concentric zones of the trifocal. This was one of the bugs of this kind of lens. I think that it is similar to what happens to me sometimes when wearing my contacts (not multifocal): I see the bordeline of my stiff lens fluctuating when there are particular situations of light, and if I pay attention to it.
I 'll have my visit with the surgeon in a few days. He suggested me first iol set for far, but I fear I need glasses for near and also for Intermediate. Then he suggested Symfony saying that I'd use glasses for near (+1,00/1,50). Another surgeon told me "only monofocal, don't use multifocal, Symfony is a kind of multifocal, you should be never satisfied with it".  Now I return to the first, a little bit informed, also thanks to what you wrote, but I am so much anxious...
Avatar universal
I had cataract surgery 3 weeks ago and had the Tecnis 2.75D MF IOL implanted.  I just posted my experience which might be of interest to you.  

http://www.medhelp.org/posts/Eye-Care/Tecnis-275D-MF-IOL-Experience/show/2597910
Avatar universal
I read your experience. It was very useful.
Tomorrow  I'll ask my surgeon also about your iols. I think that the choice he will suggest will be Symfony....
Avatar universal
If you go with the Symfony, report back your results.  
Avatar universal
The surgeon suggested a monofocal set -2,50/3,00, to have a very good near vision, or Symfony. He did not have a good experience with Mini Well.
I have chosen Symfony. Next week I'll have operation.
Avatar universal
I had my operation five days ago. Now I have the first eye done, the left one, with Symfony implanted. I had asked for Mini Well, but the surgeon told me that he did not have good results with them, so I confirmed my choice for Symfony. I have a good vision far, good intermediate, but I must wear glasses (+1,50/2,00) to write for instance now. I don't know if the situation will be better when I have also the right eye done. I fear I have to forget my near vision... But I can see the trees all around me, and the leaves, and the windows of my neighbor with their small particulars. I am worried for the glares I saw yesterday night looking at the lights of the cars. They were very large and not transparent, so that it was Necessary to look away. I hope it will get better!
1 Comments
Symfony only have 1.5 diopter depth of focus, which means the near vision is not good as we need 3 diopter depth to get near vision. Miniwell or INFO from SAV-IOL will give you all and better distance, intermedia and near vision. US surgeons got no access to Miniwell and INFO from SAV-IOL.
Avatar universal
re: "but I must wear glasses (+1,50/2,00) to write for instance now."

Your eye is still healing from the surgery (which may cause some visual glitches) and getting used to having a new lens, my near vision was poor for a couple of days before it became good. (and with multifocals it can take a number of weeks/months for the best near vision to come in, which may be true with some patients with the Symfony as well). Many people with any type of lens   experience some visual glitches the first few days after surgery, so I wouldn't worry yet about glare and night vision. Most studies that talk about things like night vision issues are referring to the results at least 1 month or often 3 months postop.

In addition of course with your other eye not being operated on yet it won't have good near vision in that eye, and the difference in near vision between the two might lead you to do better with correction until you do. The brain can deal with some visual difference between the two eyes (like in monovision) but it may take a little time to adapt to. If your left eye doesn't have enough near vision, the can target the right one to be a little myopic, monovision.

I am suspecting unfortunately that you may have wound up being hyperopic, farsighted, in that eye, which would reduce how much near vision you get while still leaving good distance&intermediate. I'd suggest at your next postop (usually 1 week) you see what they say your prescription(/refraction) is, and what your vision is in that eye by itself.

The prescription unfortunately can vary the first few weeks until the lens fully heals into place. Usually they don't even consider prescribing new glasses until 1 month postop if the prescription seems stable (sometimes a few weeks more than that).

In terms of glare, part of what might be going on is after the lens clouded by a cataract has been removed, more light can enter the eye. Most people after cataract surgery (especially if they had both eyes done around the same time) comment on how much brighter the world is at first. I had to turn my monitor brightness way down.  It may be that at night the lights will seem brighter at first until you get used to the difference (and that the difference between your eyes may also be confusing your visual system if one eye is seeing it more brightly than the other).

Avatar universal
I have already had my first postop check. The surgeon sayd that my left eye was able to read small characters wearing +1.50 lens. For the right eye an equal Symfony was ordered, as the surgeon suggested same correction in the two eyes. Furthermore I understand by him that Symfony iols cannot be set up even a little myopic. I think that at the end of the story I have to wear 1/1.50 glasses for near vision. Anyhow I thank you for telling me that your night vision became better with the passing of time and I'll wait some weeks hoping the same for me.

1 Comments
That is because symphony only got 1.5 diopter depth, that's why they promote mini mono vision, Miniwell or INFO from SAV-IOL will give you all distance vision.
Avatar universal
re: "was able to read small characters wearing +1.50 lens"

The question is what your prescription is. I'm suspecting there is a very good chance the lens power they used was wrong, that they left you farsighted, which takes away your near vision. Though as I said it is possible that may be off since:

re: "first postop check"

Usually that is the day after surgery, and the eye is still very much recovering from surgery and the measurements may change and improve quite a bit.

re: "suggested the same correction in the two eyes"

If possible a tiny bit of monovision, making he 2nd eye a bit myopic,  is often used to get a little bit more near.

re: "understand by him that the Symfony iols cannot be set up even a little myopic"

They have studied mini(/micro)-monovision for this len. I suspect I've read everything on the net about this lens, and a number of surgeons talk about  doing a slight bit of monovision, and no source I have seen says there is anything wrong with having one eye be a bit myopic. If your first eye is farsighted, even if trying to get the 2nd eye to be plano (neither myopic nor hyperopic), it is best to aim to err on the side of making the next eye a little myopic worst case rather than hyperopic again.

I'm hoping that you didn't understand him correctly. If that is what he claimed, that would indicate he doesn't know what he is talking about and you should consult another surgeon.
1 Comments
Mono vision because symphony only provide 1.5 diopter depth of focus, not like Miniwell or INFO from SAV-IOL which give you 3 diopter depth.
Avatar universal
What do you mean with "a bit myopic"? I think that -1, -1.50 could be enough to "compensate", balance the other eye hyperopic. I'll try to talk about this target with the surgeon. I hope to solve the thing.
Avatar universal
re: " I think that -1, -1.50 could be enough to "compensate", balance the other eye hyperopic."

Yup, that is the micro/mini-monovision I was mentioning, those are a "bit myopic", a bit nearsighted. Usually with the Symfony they do 1D or  less, the Symfony page (if you click on the clinical tab) shows the results of a small bit of monovision:

http://www.tecnisiol.com/eu/tecnis-symfony-iol.htm

however you may decide you want a bit more. The thing to do is to find out what the prescription is like on your first eye, if it is truly farsighted (vs. perhaps just merely still recovering from surgery), and then what sort of add you need to do with that to see the size print you want to see at a comfortable distance. That should guide how nearsighted you want the second eye.
1 Comments
Go for 3 diopter EDOF lens, you don't need mini mono vision, symphony only give you 1.5 diopter depth.
Avatar universal
They measured my left eye, and I have 10/10 far, so I am not hyperopic (if I understand well). The surgeon showed me how My sight could be with -1.00, -0.50 either looking at far and reading very small characters. He told me that it's possible to implant in the right eye, on the base of the prescription they already made and that is quite the same of the left, a lens 'a little bit lower which allows me to see the size print I want to see at a comfortable distance. I can choice the add to do this.
Avatar universal
Actually with this IOL you can be a bit hyperopic (even say +1.5) and still have 10/10 far.  
Avatar universal
So it could be better to ask for a little bit (-1.00/1.50) myopic eye to balance the other either it is hyperopic or not. In this case I could not only read and use the computer, but also handle the very small objects I use for my hobby.
Avatar universal
I don't know how long you are waiting before the other eye. Again its possible that you are merely still recovering from surgery and your near vision in the operated eye will get better.  If the eye looks like it is recovered well enough to get a good sense of vision, you can use it to estimate where you might want the other eye. You could look at what the prescription for that eye is, if it is say +0.50, then look at whatever strength lens you need to see the print you'd like to see, say +1.50. Then do (reading-add - prescription) so in this example  +1.50 - (+0.50) = 1, and that is how myopic you want your other eye to be able to read that well, i.e. -1.  There is a limit to how much monovision you want to do since it reduces 3D vision, but -1 or even a bit higher is tolerated by most people (if the vision in your other eye is good enough, you might consider a contact lens trial).

Unfortunately the quality of vision people get with an IOL varies with each person. Although most people don't need glasses for anything with the Symfony (except perhaps very rarely for a rare close up task), a  minority of people do need to  wear reading correction with the Symfony. Usually people focus on getting the eyes set right to handle the majority of their tasks well, even if they do occasionally need   glasses.
Avatar universal
I  had my second eye operated five days ago. The near vision of the first eye is getting better, and the near vision of the second is even better, also because it is a little bit myopic. I'll have my visit in two days and I'll know how is the situation. Halos and glares are shining. I hope it's too early.
Avatar universal
I had my last visit of this year two days ago and the next will be next year.
I have good vision in the left eye, the right eye is a little bit myopic. I was so much satisfied of my far and near vision, but a lot of flying objects and filaments (of the corpus vitreous they told me) are seriously disturbing me.
I always have had a lot of them, with and without contacts, but now I have one of them in the right eye, since two days, that is obscuring a large part of my vision. They prescribed me some integrators, telling me that probably I'll obtain no results. Do you have any suggestion?
Thank you in advance.
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