Confused and delaying cataract surgery

Eye care
1

This is my 1st time posting. I have been delaying cataract surgery for over a year. I am nearsighted.
My current prescription: RT -2.75 with +.75 astigmatism 112 Axis and LT -3.00 with +.75 astigmatism 164 Axis. The cataract is worse in my left eye than my right eye. I had been leaning towards the LAL IOL but now I am not sure. If someone could explain to me: if the ophthalmologist targets my current prescription using monofocal IOLs, will I see the same intermediate and distance that I do now? Or will intermediate and distance be blurrier with monofocal IOLs? I want to maintain my nearsighted eyesight. I don’t mind wearing single focus glasses to watch TV or drive. I have not adjusted to progressive lenses in the past – though I have not tried progressives for a long time. I am a bookkeeper. Right now I have my computer screen 16’’-18” away and the paperwork I read about the same distance. My calculator readout is large enough to read. I am 73 years old, and I would like to continue working.

I have read all of the post on the LAL cataract surgeries. Thank you to all who post.

RxSight Adjustable Lens to correct positive dysphotopsia?
2

The LAL is basically a monofocal. The advantage of it is the accuracy of hitting the desired target for refraction. It is of most use in doing mini-monovision where one eye is targeted to plano (0.0 D) to see distance and the other eye with mild myopia (-1.5 D) to see near. The idea is to be eyeglasses free. It works best when you can hit the specific targets. . In your case you want to remain myopic and be able to read without glasses. That is relatively easier. Yes, you could use LAL and refine the setting of them to get exactly -2.5 D for example in both eyes. But, if you went with standard monofocals and they come out as say -2.75 D in one eye and -2.25 D in the other, you would have very similar vision and perhaps even better near vision. Both of your eyes are not exactly the same now, and there is no good reason or benefit for them to be exactly the same for very good near vision. So my thoughts would be to go with monofocals and make sure you schedule at least 6 weeks between eyes. At the 6 week or longer mark get an eye exam and find out how accurate the surgeon was in hitting the target you desire. Then if there is a miss, adjustments can be made for the second eye to ensure a good combined outcome. In short with your desires it is probably not necessary to spend the extra $$ on the LAL. Standard monofocals should be fine. . To answer your question about whether a monofocal IOL that is targeted to -2.75 D is the same as your natural eye at -2.75 D. The answer is basically yes. Perhaps not exactly, but for all practical purposes, yes. Without the cataract you will notice a significant improvement in vision clarity and colour brightness. . One thing you should ask about is the need for a toric lens. Ask the surgeon what the predicted astigmatism will be in each eye when a standard monofocal is used. If it is greater than 0.75 D then you will likely benefit from a toric if you value eyeglasses free vision with your near target. If you plan to always wear glasses then there is no need to spend the extra on a toric. Eyeglasses will correct the astigmatism.

3

Ron gave you excellent advice. Depending on what your cataract surgeon uses, you could use a Clareon monofocal, a Tecnis 1 monofocal or the Eyhance monofocal, all of which are excellent. And so is the enVista, but depending on where you are, it is not as common as lenses made by Alcon or Johnson and Johnson.

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your pre-cataract prescription is somewhat similar to mine. at 72 your pupils will be relatively smaller giving you good range of focus. while i would recommend starting with clareon monofocal with myopia between -0.5 and -0.75 and then decide what to do with second eye based on the results. but due to small pupil here i am tempted to tell you to get clareon vivity first at -0.5 to -0.75. check if you get any night time artifacts and the near and then decide on another vivity or clareon.

or go with clareon monofocal with myopia between -0.5 and -0.75 and if you are unhappy with the near and intermediate with it get a panoptix in the second eye.

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If you are concerned about getting the best accuracy with a standard monofocal while targeting myopia as you plan, there are a couple of IOL power calculation formulas that tend to be more accurate when targeting myopia instead of plano. They are: . Barrett Universal II Hill-RBF 3.0 . I would ask the surgeon if they can run those two formulas to verify they are getting the best power selection for myopia. Have a look at this article about the issue which compared various formulas for accuracy. . OPTIMIZING OUTCOMES WHEN THE TARGET IS LOW MYOPIA ANDREW M.J. TURNBULL, BM, PGDIPCRS, FRCOPHTH; WARREN E. HILL, MD; AND GRAHAM D. BARRETT, MB BCH SAF, FRACO, FRACS PDF

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im curious. how do smaller pupils lead to a better(Larger i assume) range of focus? thx

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i dont know. pinhole effect?

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That is correct. It is like simple box camera with a very small aperture (F16 or smaller). It increases the range of distances that are in focus.

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I have read all the posts. Thank you! You are helping me more than the ophthalmologist. Ron, I appreciate your knowledge and willingness to help. Of course, I have more questions. I have found two old eye prescriptions: 10/17/2017 RT Sphere; -1.75; -0.50 Cylinder 10 axis. LT -1.25 Spere and -0.50 Cylinder 175 axis. 02/03/2021 RT -2.50 Sphere; -2.75 Cylinder 073 Axis LT -2.00 Sphere; 0.00 Cylinder 000 Axis Current RT -2.75 Sphere; +.75 Cylinder 112 Axis LT -3.00 Sphher; +.75 Cylinder 164 Axis So, my question is – if I target the 10/17/2017 prescription would my eyesight be what it was then?

If I target my non-dominate RT eye -1.5 and my dominate LT eye 0.00 – is that mini monovision? Would I need bifocals or trifocals to do my bookkeeping and computer work? If nothing is done to the astigmatism will that help make my eyesight more nearsighted?

I don’t understand the astigmatism minus then plus numbers.

What are the changes in my prescription from? Is this from the change in my hardening lens which affects accommodation? The eye length?

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I want to thank RonAKA for calling this study to our attention. On the one hand, it is consistent with other studies showing generally favorable results with the Barrett Universal II formula (my own surgeon's choice). See, e.g., Oleksiy V. Voytsekhivskyy, et al., Accuracy of 24 IOL Power Calculation Methods, J. Refract. Surg. 2023; 39(4):249-256 (noting, however, that "the small amount of short and long eyes did not allow us to perform a full-fledged statistical analysis in the different subgroups, so that the results were reported with informational purposes only"). . Also, in considering or using the "Optimizing Outcomes" article, one should be aware of possible limitations. For example, a Bryan Lee reviewed what appears to be the same study in "Comparison of IOL power calculations for low myopia in monovision", American Academy of Ophthalmology (Aug. 20, 2020). I say appears because the article Dr. Lee reviewed is by the same authors but entitled "Accuracy of intraocular lens power calculation methods when targeting low myopia in monovision", and was published in the Journal of Cateract and Refractive Surgery in June 2020. Although the JCRS article is not open access, what is freely available suggests that, at a minimum, it reports on the same underlying study, and is possibly the same basic article, as "Optimizing Outcomes". . According to Dr. Lee: . First, the Optimizing Outcomes study examined 88 patients targeted for plano in one eye and -1.25 D in the other eye. Insofar as the question is the accuracy of IOL calculation formulae for myopic targets, the study may be less reliable when the targets are, for example, -0.75 D or -1.00 D in the "distance" eye" and -2.00 D in the "near" eye (using myself as an example). . Second, patients studied only were offered monovision if the distance eye achieved uncorrected distance vision of 20/25 or better and the second eye had similar visual potential. Among other things, this may have been a source of bias because entry criteria based on successful near vision performance may have produced different results. . Third, this was a small retrospective study. . Fourth, the study does not discuss biometry, so it is difficult to assess the applicability of the study's results to general practice.

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First the easy part. Your current prescription must be from an ophthalmologist. They express astigmatism as a positive value and has to be converted to the more standard optometrist format with negative cylinder. Your current prescription converts to the following: . Right Eye: Sphere -2.00 D, Cylinder -0.75 D, Axis 22 Left Eye: Sphere -2.25 D, Cylinder -0.75 D, Axis 75 . Most likely the changes in your prescription are due to the cataracts. . The result of eyes with astigmatism is often expressed as a spherical equivalent. It is the sum of the sphere plus 50% of the cylinder in negative format. So your 2017 spherical equivalents would be: . Right Eye: -2.00 D Left Eye: -1.50 D . If you were to target these values with an IOL your vision would be reasonable similar to what it was in 2017. IOL formulas typically use spherical equivalent in the calculation. . "If I target my non-dominate RT eye -1.5 and my dominate LT eye 0.00 – is that mini monovision? Would I need bifocals or trifocals to do my bookkeeping and computer work?" . Yes that would be typical mini-monovision. That is approximately what I have and I almost never use glasses. But, the near vision is good, not excellent. I call it a working vision. When I do fine work with something involving small screws etc. I do reach for my +1.25 D reading glasses. I do not use them for my iPhone or computer though. If this is the way you intend to go, there is likely benefit in the LAL lenses, as each person is a bit different, and they give you the option of fine tuning the amount of myopia in the near eye to suit your needs. It takes the risk out of the surgeon missing the target as well. . To make a decision on astigmatism you need to know what the computer estimates it will be after cataract surgery. Ask the surgeon for the IOL Calculation sheet. Normally less than 0.75 D of cylinder is not corrected. However with the LAL they may be able to do smaller corrections. In negative cylinder format and using the spherical equivalent formula you can see that astigmatism makes you more myopic. For example your 2017 right eye Sphere -1.75 D, -0.50 D cylinder is a spherical equivalent of -2.00 D, or more myopic than the Sphere alone indicates.

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Cool! Dr. Lee was my surgeon. (San Francisco bay area)

I got Vivity mini monovision and am very happy with it. One eye has some vitreous degeneration, which causes clear blobby floaters sometimes, but that is probably partly due to being 64 years old.

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Hi RonAKA, I have been trying, again, to gather my questions.
I have read so many posts that organizing my questions has become difficult.

One post I read: Only a very tiny minority of patients can read with monofocals set for distance, that is rare, you are lucky. The amount of near vision people get depends on their eye's natural depth of focus. Does our eyes's natural depth of focus change over time? Does this have to do with the shape and length of the eye? Oblong in my case? If so, how can you find out what your natural depth of focus is? There has been discussion on the posts about what the targets are for near, intemdiate and distance vision. Is there a rule? Even though your eye is different from mine, if both our prescriptions are -1.5, will we both see the same?

This is an advertisement for the RX Sight website https://irp.cdn-website.com/3b8c47cd/files/uploaded/RxSight%20Overview%20-%20Better%20Vision.pdf It states: RxSight also enables an EDF procedure that delivers even better UCVA at all distances and minimal vial side effects (IDE Study underway) I don't know how to find IDE studies. and Negative SA (LAL and LDD) extends depth of focus to blend near and intermediate UCVA I am assuming that Negative SA means spherical abberations. Would this cause Postive dysphotopsia = halos, starbursts, etc? I might have my terms messed up! With EDF, I don't understand how much actual clear viewing distance I would gain to enhance being nearsighted. Unable to find anything on this on the internet.

My next LAL concern is the importance of the optometrist doing the refraction testing. They have to be excellent. Also, do your eyes change enough that the results might vary from day to day? Then you have the person operating the Light Delivery Device. How much practice does this person need to be good? How do you ask the opthamologist how many LAL he has placed and is he the only doing the LDD? Does he have alot of experience doing EDF? With the short amount of time I spent with the opthomologist, he mentioned EDF - which I did not get at first because I was used to reading EDOF.

With the LAL, I can't find this information anywhere - does any opthomologist use a target IOL when the cataract is removed and the LAL implanted? I think they always do plano and adjust from there. The recommened healing time is 2 - 3 weeks but I feel I should wait for 6 weeks for complete healing. Therefore, for me to return to work I would ask for a target of RT -1.75 and LT -1.25 like my 2017 prescription. I am assuming my astigmatism will stay the same and that will add to my nearsightedness. I don't think the opthomologist will want to spend time doing all of the measurements. But they will have to if I want my LAL to be with a target. I do have "up close" glasses that are +.5D. I am trying to navigate bookkeeping work while I would wait for the LAL until adjustments. By the way, there are no refrences to patients wanting two myopic eyes.

Tomorrow I am getting contacts to find out if I can handle monovision. I don't have any idea what my prescription will be. I have bad allergies so am wondering if I can tolerate the contacts. The optometrist told me they are much better than 35 years ago.

RonAKA, thank you for your vast knowledge. You have helped me even though I don't totally understand alot..,such as the de-focus curve.

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First to be clear I cannot read with my distance set monofocal eye at reasonable reading distances. I can just start to read at about 18-20" or so. Reading would be bad at the normal 12-14". I get my reading from my other eye which also has a monofocal, but is not set for distance. It is set at about -1.60 D. With that eye I can read well and can even see down to 8" in good light. That is how mini-monovision works. . Yes for sure depth of focus changes with age. At age 45-50 people start to lose their ability to focus closer. It is called presbyopia. That is when people start to need bifocals or progressives to see close as well as far. . Yes, basically if the outcome of the eye is -1.5 D you are going to see pretty much the same as another person that also is at -1.5 D. There will be person to person differences but in general the refraction is a good measure of your focus distance. . I don't know that much about the LAL and ability to extend depth of focus. They could give you more astigmatism which would help with depth of focus, but it would also hurt visual acuity. It sounds like it is a work in progress. . My thoughts would be that if you want to target myopia in the -2.0 D range in both eyes, to get good reading vision, using the LAL lens is probably overkill. Just using a standard monofocal and doing one eye at a time with 6 weeks between them should give you good results. If the first eye is a little off the second eye can be adjusted to compensate. Probably not worth spending the extra $$ on LAL if that is all you want. . On the other hand if you want to do mini-monovision, LAL is probably a very accurate way of doing it because they can adjust each lens to get what you want. . If you do not have a LAL surgeon lined up you may want to post at another site called MedHelp Communities Eye Care. There is a Dr. Hagan there that is quite helpful and based on his posts his clinic does LAL. He has recommended clinics in other cities for posters that do LAL. . With your contact lens trial you should get your dominant eye corrected as close as possible to plano, and your non dominant eye left at -1.50 D on a spherical equivalent basis. That is your sphere plus 50% of the astigmatism. The contact lens fitter should know about that.

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I do understand that your reading vision is from your monofocal set at -1.6D.

I did not have luck with the contacts today. I don't know what the target was because my vision did not change much from the way that it is now. Because the cataracts are too bad. This optometrist is also the doctor that does the refractive exams for the LDD adjustments. I don't think there is a way for me to try-on mini-monovision.

I have also seen a second opthomologist at Discover Vision, Dr. John Doane, in Kansas City. He is in the same practice as Dr. John Hagen. Dr. Doane did my husband's Lasik surgery 25 years ago. I think I will make another appointment with Dr, Doane to see if he can help me navigate the LAL process. He did tell me when I had my appointment that some of his patients have said they have the best vision in their lives.

I did find more information on EDOF: The Monofocal IOL With a Twist A misconception about the LAL is that it’s a simple monofocal lens aimed at precision distance vision. While this is partly true, it’s also highly oversimplified. It is indeed a monofocal lens; however, given its aspheric design, it does allow for an element of extended depth of focus (EDOF). This aids in extending visual range even in a plano targeted eye. Additionally, patients can elect to add negative spherical aberration to their nondominant eye during the light treatments. This adds an additional 0.50D-0.75D of EDOF, providing a solution for presbyopia and reducing the need for reading glasses postoperatively. In our practice, we have strayed away from the term “monovision” as it implies full ocular independence and loss of binocular balance. Instead, we use the term “blended vision” because there is substantial overlap between the eyes, allowing for binocular summation for maintained depth perception. About 80% of our patients choose some form of blended vision, with the nondominant target being -1.00D to 1.25D on average. The beauty of the LAL is that we can customize the near target based on lifestyle. The added EDOF of the nondominant eye still preserves usable distance visual acuity. Even with a -1.25D target, a healthy patient can often maintain 20/30 or better unaided distance visual acuity without glare or halos.

I ask: "This adds an additional 0.50D-0.75D of EDOF "- how does that translate into what a person sees?

Once again, thank you !

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Curiously, the Premium Vision Surgical Centres in Ontario, whose website promotes both the Eyhance and Light Adjustable IOLs, uses "blended" in its Eyhance discussion: "Eyhance Blended Vision is similar to conventional monovision (MV). Both methods involve correcting the dominant eye for distance vision, while the non-dominant eye is corrected to be slightly nearsighted for near vision. Unlike monovision, EBV offers a greater range of sight (focal depth) in both the dominant eye and the non dominant eye. The advanced design of the distance Eyhance lens allows it to offer vision throughout far and intermediate ranges, reaching as close as 60cm away. This is complemented by the near eye’s ability to see from a meter away, to as close as 40cm. Together, these lenses overcome the weaknesses of monovision by covering the entire range of vision, from distance up to 40cm, without creating a Blur zone in the middle. Essentially, this new Blend Zone makes it easy for the brain to merge the images of both eyes thereby achieving true binocular vision. Overall, EBV helps adaptation and depth perception...." . My point is that the proposed virtues of the LAL IOLs can be at least approximated at substantially less expense. That said, if one can afford and chooses to pay for the LAL solution, I wouldn't doubt, but don't know enough to endorse, claims that it offers some greater likelihood of success.

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I think that quote involves some degree of exaggeration and is overall misleading. There are a number of lenses that use spherical aberration to give some EDOF effect to a monofocal. The B+L enVista does it, as well as the Eyhance. But the gain is modest if distance vision is not impacted significantly. It is more in the order of 0.25 D gain, not 0.5 to 0.75 D. . I think the "blended vision" is more marketing hokey pokey. To get to the point of being eyeglasses free with the LAL you need to use mini-monovision. They are just changing the name of it to make it sound different. Mini-monovision has a significant degree of overlap and does not compromise depth perception, unless you go with a differential between the eyes of more than 1.75 D or so. This marketing is similar to the Lasik surgeons who promise to "fix" your eyes so you can see close as well as far like you are young again. What they are really doing is mini-monovision, but with a laser. . I would take that stuff with a grain of salt. The real advantage of the LAL is being able to adjust the power after implantation. Since you were not able to use contacts to simulate mini-monovison that would be a big upside for you IF you are going to do mini-monovision. It would let you test it out to see how much differential you like after they are in your eyes. The other advantage of the LAL is that they can correct astigmatism to a degree with it. That will give you clearer vision. It is better to get more depth of focus with the sphere power of the near eye, than it is to stretch it with astigmatism. Like using positive asphericity it does make a modest increase in depth of focus but with a visual acuity penalty. . But, I say "IF" because there is no real advantage to LAL if you only plan to do both eyes myopic in the -2.0 D range. The surgeon will have two chances to give you that using just plain old monofocals.

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Julie We have had posters here who have also been confused. Some got "analysis paralysis," thinking and re- thinking all their options. I've done it myself. As one cataract surgeon told me, "There is no one right way to have your cataract surgery." At some point, you have to just do it. For me, I like to keep it simple, and stay with something that has a track record. I would go with a monofocal like the Eyhance or the Clareon. Or the Tecnis 1 or the enVista Getting. really good eye measurements and using a skilled, experienced and caring cataract surgeon is paramount. You're going to be all right. I wish you well.

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While endorsing everything @Lynda111 says, one point I'd add is the importance of deciding on your vision priorities in the context of the plusses and minuses of different possible approaches. Some people, for example, choose multifocal IOLs for the possibility of achieving, or of having a greater likelihood of achieving, good distance, intermediate, and near visual acuities. Others, myself included, are unwilling to risk the negative optical/visual side effect experienced by a significant number of multifocal recipients. And for many multifocal IOLs--or the LAL for that matter--simply aren't an affordable option. . And there are choices within the monofocal category, too. Some simply prioritize seeking the best distance vision attainable. Others, @RonAKA and myself, for example, choose monovision--for us, in its "mini" form--aiming at good visual acuity at more than one focal distance. @RonAKA chose distance and intermediate, and may have lucked out and also gotten some functional near vision. I chose intermediate and near, and depending on the results from my second eye, scheduled for August, may also end up with functional distance vision. . Given all the variables and uncertainties, however, I follow my own sympathetic surgeon in urging you not to overthink your choices.

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Just to be clear, the near vision I got was quite intentional and well planned. It was not good luck. If there was any good luck involved it would be the intermediate vision I got with my distance eye. Most people with monofocals do not seem to see well down to 18" like I can with my distance eye. Some cannot even see their car dash clearly. So I lucked out in that respect. I suspect it is due to being myopic prior to surgery, and being 73 with smaller pupils, and in being very careful (thanks to my surgeon) not to go over into the plus side of plano. . If I was to do the near eye over again there is only one thing I would change. I would get a 1.0 D cylinder AcrySof toric lens to reduce my cylinder, and go one step higher in overall sphere power to give me more residual sphere myopia. The end spherical equivalent still would have been in the -1.6 D range, but it would be more pure sphere power and less astigmatism cylinder. Astigmatism can give you some near vision but it is not the ideal way to get it. It compromises visual acuity. I get drop shadows on text especially when reading white text on a black background.