43 years old with cataract - looking for advice

Eye care
1

First off, sorry for the length of this. I have to make a big decision and am looking for some advice, I’m 43 with prior lasik (4 years ago). I developed a cataract in my left (non-dominant eye). I didn’t get diagnosed for well over a year because I (foolishly) just thought my eye was changing and would need to have lasik performed again, so I wasn’t in a rush (my right eye, which is the dominant eye, is perfect although presumably will also develop a cataract).

So now I need to decide what IOL to get for my cataract eye (non-dominant). I’m not touching my right eye until absolutely necessary (but should consider it in whatever decision I make).

My goal is glasses independence. I know in order to achieve this, I will have to make a trade-off somewhere. Cataract or not, I can easily see myself looking into surgical presbyopia solutions in the future if my reading vision degraded sufficiently to need glasses. Having to wear contacts since I was 15 and only being free of this for a few years, I’m very eager to avoid glasses of any kind.

I am aware of many of the trade-offs with a panoptix but think I might be a good candidate to deal with them. The current state of the eye with the cataract is that everything more than 5 inches away from my face is completely out-of-focus (it has been this way for almost a year). Also, due to the cataract, I have considerable glare/halos in that eye. My right eye (dominant) is perfect (with a small age-related burgeoning blurriness at near vision; I’m starting to zoom the text on my phone). Despite both of my eyes being as different from each other as two eyes can be, I tolerate the glare/halos just fine, and don’t experience headaches, dizziness, or queasiness of any kind. I can drive at night and in any weather conditions. I can live my life fine. Even with the downsides of the panoptix, surely it would be a huge improvement over my current experience with the eye, right? For example, I’d gladly keep the glare/halos from my cataract if only the vision at all distances was clear. I should note that when the time comes to deal with my dominant eye, I would not opt for a second panoptix. I would likely choose a monofocal set for distance (if I’m happy with the intermediate/near vision of the panoptix) or a vivity set to distance (if I feel like I’d want slightly better clarity in the intermediate +.

The only other option I’d consider would be blended vision. I could consider a vivity in the non-dominant eye (the one I’ve got the cataract in) and then possibly go for another vivty in the dominant eye when needed. My other question would be, is it possible to get excellent vision at all distances (far, intermediate, near) with blended vision suing two vivity lens? Lets say I had a vivity in my right dominant eye right now set to distance. Would it be possible to set another vivty in the left non-dominant eye to get excellent intermediate AND excellent near vision without creating a dead zone or a zone of poor/degraded vision between the two eyes? What I’m say is, with vivty blended vision, would I be able to achieve excellent vision at all distances?

Thanks for reading this. I’m just nervous and want to make the best decision. There’s so much to consider.

2

Something I read in an article the other day was that multifocals may not be the safest bet for younger people simply because you may still have 40+ years ahead of you and you never know what kind of ocular pathology you may develop later in life. If you end up with Glaucoma in your late 50s for instance or macular degeneration in your 70s a multifocal would be contraindicated. I think the safest bet might be Vivity with a slightly near target (since it’s your non-dominant eye… maybe second minus)

3

You have a couple of issues that require consideration. First is that you are younger, and second that you have had prior Lasik surgery. Some surgeons will not do a MF lens like the PanOptix with someone with prior Lasik. One reason is that MF lenses have issues with with halos, flare, spider webs, and loss of contrast sensitivity. These can be aggravated by the damage to the cornea from the Lasik. MF lenses are also sensitive to how well centered the lens is in the eye. Since you are younger there will be lots of time for the lens to decenter. If that happens with a MF lens there is no good way to fix it.
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The Vivity EFOF lens would have less risk than a MF lens, but there is still some risk of halos. And yes you could do mini-monovision with Vivity lenses, but there is really not much advantage to doing it. You will not get good reading vision with the Vivity unless you offset the near eye by -1.0 D, and some surgeons may not want to do that. You can get similar results by using a monofocal and offsetting the near eye to -1.5 D. All considered that is probably a lower risk option. With the near eye at -1.5 D and the distance eye at -0.25 D there will be no weak vision distance at the intermediate range.
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Normally when mini-monovision is done the non-dominant eye is chosen for the near eye, but it does not have to be done that way. Some even believe that the reverse, crossed monovision, is better. So, basically you could do your left eye now with a monofocal set at -1.5 D for close, or at -0.25 D for distance, and then later when the right eye is done, then choose the complement for it. It is somewht arbitrary. I have crossed monovision and it works for me.
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As for lenses if you choose the monofocal route, then you may want to consider the B+L enVista. It is a neutral asphericity lens that is claimed to be more tolerant of less than perfect eyes, and the lens not being perfectly positioned. Zero or close to zero asphericity lenses like the Tecnis 1 and Clareon may give very slight better vision in perfect eyes, but the enVista probably does better in the less than perfect eye. It also has a wider depth of focus which helps in a mini-monovision configuration.
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Last, prior Lasik makes it harder to measure your eyes and accurately predict the power required to hit your desired target. Something you may want to consider is the Alcon ORA System, if your surgeon uses it, and recommends it. It does a final measurement of the eye during the cataract surgery after the natural lens is removed. It is claimed to give more accurate results. @karbonbee here had excellent results with it, and as I recall @karin08666 not quite so good. Something to discuss with the surgeon.
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4

I have macular degeneration and my doctor would not allow Vivity. Only a basic monofocal and Eyhance.

5

Go with a monofocal. If near and intermediate vision is important to you, you might consider the Eyhance. The Envista that Ron referenced is fine, but depending on where you live, you may have difficulty finding a surgeon who uses it. Try to get at least two opinions from a cataract surgeon who is fellowship trained in Cornea\Anterior segment surgery.

6

Yes probably a good decision. I think Vivity is borderline in terms of using it in eyes with some degree pathology. Some surgeons will think it’s ok depending on what the issue is and how bad it is and how stable it is and your age etc… others will be more conservative and play it safe with a monofocal. Which is probably wise.

7

I have macular degeneration and my doctor would not allow Vivity. Only a basic monofocal and Eyhance.

8

True! I need to get this reply to aaron which is where I thought I sent it!

9

Thank you all for your help!! This is all very new to me and the more I look into things the more confused I get. I’m really unprepared as I didn’t think I’d have to worry about a decision like this for another 30 years.

Okay, I’ll scrap the plans for a panoptix. All of thew points you made were enough to scare me off of it.

I’m curious about a few more things.

My desired outcome is glasses independence with as clear as possible vision at far/intermediate/near (no weak spots in between). Lets say I go for mini-monivision/blended vision to achieve that. I feel I’d tolerate that well because prior to lasik I had very weak eyes for distance but would often wear a distance correcting contact in one eye for a week and then switch eyes the following week. I did this because wearing contacts in both eyes all the time took a toll my eyes but I hated wearing glasses. So I have years of experience dealing with two eyes that are extremely off from each other with no issues. Even right now, my left eye is completely out of focus while my right eye is perfect. No issues with tolerance.

Would a vivty in my non-dominant eye (the eye with the cataract) not be a better choice to have excellent intermediate and near vision in an eventual minimonovision/blended vision scenario vs a monofocal set to near? Then when my right eye goes, get either a monofocal or vivty set to distance? Theoretically, I’d be covered with clear vision at all distances between near and far, right?

My concern with mini-monovision with two monofocals (and please correct me if I’m off base here), would be that I’d have a weak spot between near and far. Wouldn’t intermediate vision suffer? I use a desktop computer for work; poor intermediate vision would be a bummer.

10

The nice thing about a lens like Vivity is that it doesn’t split the light into 3 distinct zones, it spreads it all out over a wider focus area than a monofocal. So there are no weak spots. But the range isn’t as wide as a multifocal and the near vision is not nearly as strong. But I think you could get by with it. You don’t need 20/20 near for reading. 20/32 is good enough. I’d maybe set Vivity for second minus (so whatever target is 2 steps away from the closest target to plano) and then take it from there. Your distance won’t be perfect but the second eye will make up for that. The second eye you’d probably do first minus.

11

Actually I think more light is effectively split with the Vivity than the PanOptix. Overall I think the contrast sensitivity loss across the depth of focus is higher with the Vivity than the PanOptix.

12

It will ultimately come down to a personal choice. But get more opinions from other cataract surgeons. It will be an extra expense but it will be worth it.

13

The contrast loss may be higher with Vivity but it does not split light

14

“Splitting” may not be the precise term, but if you look at a contrast sensitivity (MTF) curve for the Vivity compared to the monofocal, it is almost cut in half at the 0.0 position, and squished out to the right so it is more than double the monofocal at -1.0 D and much higher at -1.75 D. There is only so much light, and you can’t have it all everywhere.

15

If you search Vivity Extends Light there is a link that says Vivity stretches and shifts light.

16

i dont have personal experience with vivity but i have to agree with this. the stretching light and edof is concept that leads to not having good vision at any distance for some. with symfony there was always that missing sharp vision for me.

if there was a good way to know how much near you would get with monofocal that should be the first choice. if that falls too short for your liking of intermediate and close and if you dont like how much near and reduced distance you get with a -1.5 contact in that plano iol eye you should seriously consider a trifocal in the other eye.

17

Thanks again for the comments; I appreciate it! You’ve all give me a lot to consider.

If I decided to do a mini-mono or blended vision, I’m wondering about some different scenarios:

  1. What would a monofocal need to be set at to get near vision comparable to a panpotix in my non-dominant eye?
  2. If I used a vivity instead of the monofocal, what would that need to be set at in order to get near vision comparable to the panoptix? How much distance vision would that cost me?
    3)Would monovison with a monofocal lens set to near and the other set to far require glasses for clear intermediate vision? If so, would there be any overlap of clear vision between both eyes?
  3. If I used a vivity in the non-dominant eye, set to lose some distance but gain more clear vision would a monofocal set to distance in the dominant eye cover all zones? Would there be any clearvision overlap with the vivity?
18

Thanks again for the comments; I appreciate it! You’ve all give me a lot to consider.

If I decided to do a mini-mono or blended vision, I’m wondering about some different scenarios:

What would a monofocal need to be set at to get near vision comparable to a panpotix in my non-dominant eye?
If I used a vivity instead of the monofocal, what would that need to be set at in order to get near vision comparable to the panoptix? How much distance vision would that cost me?

3)Would monovison with a monofocal lens set to near and the other set to far require glasses for clear intermediate vision? If so, would there be any overlap of clear vision between both eyes?
If I used a vivity in the non-dominant eye, set to lose some distance but gain more clear vision would a monofocal set to distance in the dominant eye cover all zones? Would there be any clearvision overlap with the vivity?
19
  1. my panoptix card says +2.17 ADD and +3.25 ADD.
20

sorry you are having to go through this at 43. i was 41 when this started for me 6 years ago. only now am i seeing some light at the end of the tunnel. good luck on what you decide to do.