Appointment yesterday: thoughts and your insights appreciated

Eye care
1

so had my first opthamology appointment in 15 months yesterday with a chicago suburban doctor who has loads of experience and all good online reviews as far as i looked. im in no hurry to get this done as i continue to gather data from this forum and other sites. all the info i have gleaned really helped me yesterday in my interaction with the doctor.

so the details:
-he gave me a bunch of time to ask one question after another. patiently answered them all. did not have a condescending attitude.

-he pretty much sounded like he only used the eyehance lens for the monofocal option. im pretty sure he also does premium but i have no interest in them. when i asked about the clareon and envista, he said good things about them but i would need to pay extra for them since he works in different facilities for surgery. i did not quite understand but i assume his familiarity with eyehance was a selling point.

-he was fairly adamant plano and -1.75 were the best targets for “monovision”. i asked if this was not a bit much and overdoing it with a slight edof lens and he said almost all his patients had been satisfied. i told him i had been pretty happy at the -1.25 with contacts. i think he would do what i want if i push it. its out of pocket and he is not cheap.

-he seemed a little uninterested when i mentioned the targeting -.25 to avoid a hyperopic outcome. this bothered me a little.

-he thought 2 weeks between eyes was enough. i expressed my interest in 5 weeks.

-we did a couple of experiments where i walked around the office and front door with the adjusted amounts of refraction on a portable phoropter to see if i could " tolerate Monovision" which i thought was kind of silly and for show.

Now as a self taught student of psychology and neuroscience ( im pretty obsessed with it), from the visit with the doc, i realize his goal was to get people out of glasses, thus the wide gap of -1.75 on an edof lens, an overkill if one is ok with glasses. but that is HIS goal not mine. i want clarity, some depth of focus, and glasses to tune up when i need to. the quick turnaround tome for the second lens was his belief that the time between is a hassle and so get it done. i disagree since i do believe you guys on getting a final result in 5 weeks is worth the hassle.

and does a slight edof affect visual acuity with glasses? and is he using eyehance because they are more expensive ($3499 each eye) out of MY pocket?

i liked the doctor but he has been doing this for decades and i know he adjusts his consultation based on the patient. and a more informed patient is a more difficult one as we will not always agree with the suggestions.

so i am happy to get any insights from y’all. i may just bite the bullet and see if there are any local clareon/envista surgeons and fork out more money for another opinion.

what a clusterfuck compared to ANY other surgery out there. the patient has GOT TO BE completely informed unless they are an 80 year old who will benefit from any choice the doctor makes for them.

thx
dan

2

I do think -1.75 is a bit much and yes, some surgeons have a strong preference for plano while others have a strong preference for first minus… but those numbers are theoretical. Once you have an IOL Master scan done and the IOL calculation sheet for instance, if your dominant eye has predictions of +0.14 and -0.20 he would surely choose the minus power. But if the sheet said +0.04 and -0.30 he would choose the +0.04 whereas other surgeons would choose -0.30. That may just be his own bias or it could be that because you are doing monovision he wants the best chance at nailing plano in your one distance eye. And maybe he has a history of nailing his targets so he has confidence in that approach. Also I suppose you could say that when we are debating differences of a quarter diopter, we are, to some degree, splitting hairs. And the outcome can vary by as much as half a diopter above or below target anyway. . I would insist on 5-6 weeks between the surgeries.

3

Attempting EDOF with monovision for $3499 out of pocket each eye? Simply use Vivity. There is possible loss of CS in either approach to extend range of vision. Chance of visual effects and problems post surgery seem similar for both, based on reports here and in the literature.

4

I have a theory that when they target "plano" they build in the margins to keep you from going farsighted. I could be wrong.

What was your prescription (sph and cyl)?

Do you have insurance (Medicare or other)?

5

For what it's worth, I had a consultation with a cataract surgeon in PA within the last year who suggested Eyhance lenses. The cost at that time in that practice and if I remember correctly was in the range of $1800. Definitely less than $2000 per eye.

6

I don't think I can tell you anything you don't already know. They are your eyes, and your goals are the ones that matter. You should consider the doctor's advice, and then inform him what you want for lenses, timing, and refraction. If the doctor is uncooperative or too expensive, he's probably not the best one for you.

Regarding Eyhance, all these lenses involve tradeoffs. My impression is Eyhance differs only slightly from standard lenses in both favorable and unfavorable effects. The price seems high. I would agree with your considering Clareon or enVista. Doctors do get volume discounts on their preferred lenses, and tend to recommend or require them.

7

I see some issues in what you are reporting. Comments: . 1. Eyhance would not be my first choice for a monofocal but it certainly is OK. I would not pay extra for it over another monofocal. I would pick Clareon and enVista over the Ehyance. 2. Targeting -1.75 D for near is a bit much. Yes, I think it would be tolerable if you targeted a more conventional -1.50 D and there was a miss to -1.75 D. When he says plano for the distance eye that is fine if you end up there, but is risky to target exactly plano. The standard approach is to target -0.25 D to have some margin of safety from going far sighted (positive) with a miss. Not being willing to target -0.25 is a bit of a red flag. 3. A second red flag was only allowing 2 weeks between surgeries. This indicates he is not interested in what the accurate outcome of the first eye is, before he does the second eye. It indicates he will not adjust his calculation to suit your particular eyes. 4. Best practice is to do the distance eye first with a target of -0.25 D and then give it 5 weeks minimum to heal so you can get an accurate refraction of the outcome. If at that point the eye is -0.25 D then you could consider -1.75 D in the second eye and respect the guideline not to exceed 1.5 D between the eyes. And if it turns out as plano then -1.50 D as a target would be safer. 5. $3500 per eye seems way out of line from what prices are like around here. I would expect more like $1500 per eye for a monofocal. You may want to try to get a reference from B+L on who in your area uses the enVista. And the same with Alcon to find who would do a Clareon lens. . All in all I think I would pass on this surgeon. Ideally you want a surgeon that is doing things correctly without you having to tell them to do it correctly.

8
  1. Best practice is to do the distance eye first with a target of -0.25 D and then give it 5 weeks minimum to heal so you can get an accurate refraction of the outcome. If at that point the eye is -0.25 D then you could consider -1.75 D in the second eye and respect the guideline not to exceed 1.5 D between the eyes. And if it turns out as plano then -1.50 D as a target would be safer.

If we are to presume doing one eye, see the result, and then do the second eye with data learned from the first, it would seem to me to better to do the near eye first. I think we agree that hitting the mark with near is less critical than hitting the mark precisely for the far eye.

I think 1.75 sounds ideal. I know you are not in agreement with that. That is good.

9

The reason for doing the distance eye first is that it allows you a period of time with one eye corrected for distance with an IOL that will have no accommodation. You can use standard over the counter readers with this eye to simulate -1.25 D, -1.5 D, and -1.75 D vision without any accommodation. If you do the near eye first you lose the opportunity to do this test, because the near vision ship has already sailed. Targeting distance vision is easy. Most everyone wants 20/20 vision there. . I think the graphs at the link below provide the best information on mini-monovision options and what the impacts are of chosing different amounts of myopia in the near eye. I studied the graphs to death and even added my own lines by interpolating between the -1.0 and -1.5 D and decided that -1.25 D would be the best trade off considering the overall combined visual acuity across the distance range, and also the loss of stereoacuity with higher amounts of myopia. However when I did the test above with readers after my first eye was done with an IOL for distance, I found that -1.25 D was not enough for the reading vision I wanted, and at that point changed my mind to target -1.50 D, which matches the conclusion of this study. . https://www.semanticscholar.org/paper/Optimal-amount-of-anisometropia-for-pseudophakic-Hayashi-Yoshida/dd8837a9151a536759f195a18d4fa94a0fbf0f90

10

Sorry, I forget your particular circumstances -- are you too young for Medicare? Eyhance is considered a monofocal by Medicare and doctors can't charge extra for it . At $3,500 an eye, I'd be tempted to at least see what LAL would be in your area. There is a forum for eye surgeons only that used to be open for us peons to browse (they've since locked it down to members only), and there were some posts by surgeons who said their practice was making Eyhance their standard monofocal. . I'm with others, from what I've read here and other resources, I wouldn't agree to a target of plano but would want the slight safety factor of targeting -.25. Refractive surprise is one of my biggest concerns. . Your appointment sounds better than my first one. I got a "I'm God. I'll do what's best, and you'll love it" surgeon. Which is why I'm seeing another in January. Good luck to us on finding someone who suits.

11

im too young fir medicare. he wants 7000 per eye for lal. chicago is an expensive city, im sure that plays into.

12

the wait to the surgery varies so much between doctors. i found a surgeon who did clareon and charged closer to 2000 per eye but that was a 1-2+year wait. there are doctors here with the best reps who have a 4-6 month wait just for an appt!

the guy i saw yesterday could get me in soon. i guess its like the airlines. the sooner you choose, the cheaper it gets.

im getting in touch with alcon and b&l to see you uses their lens in the area..if i have to spend another $250 i will have to...

13

$7,000 for LAL sounds good - if it includes the follow-up care/treatments.

14

$7K per eye ($14,000) sounds good?

15

it might be more...i cant afford it anyway

16

Metro Chicago and the surrounding area have many cataract surgeons. There are also numerous medical centers there with ophthalmology depts. Surely you can find someone cheaper and better. Where I live my city has a Christian Outreach Ministry. If you are low income, they can arrange to find surgeons to do surgeries without charge. I know people who have had neurosurgery and orthopedic surgeries.

There many churches in Chicago. Try asking some of the big ones, like the Catholic Archdiocese of Chicago. Be persistent. You may have to spend hours on the phone or the Internet, but keep at it.

17

I've seen $10k per eye. That's all-in, fully out-of-pocket (not net of a Medicare or insurance allowance). It's expensive, but that is the going rate for LAL.

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i realize that, everything takes time. thanx for input!

19

i use Eyhance too. it a good lens for me.

Now waiting for my second eye appointment.

But I think $3500 per eye is on the high side But I think you can get the ops will be short right?

Some doctors need wait for up to 4 months before ops but they charge cheaper.

20

I've seen $10k per eye

Wow. That's expensive.