IOL exchange or YAG?

Eye care
1

Hi everyone. I’m new to this forum but I’ve been reading the threads for the past few weeks and am very impressed by everyone’s knowledge. I feel silly that I did not search for this type of forum before my initial cataract surgery.

A little bit about me - I had cataract surgery two years ago on my LE at the age of 30. RE is healthy for now. I had the PanOptix Multifocal lense implanted. I was told that I would have ideal distance, intermediate, and near vision. However that was not the case. After the surgery all three types of vision were poor. So two months postop I had Lasik performed to correct my astigmatism and refine my vision. Postop my distance improved to 20/20; however my intermediate vision is still not ideal; and my near vision is poor. In terms of intermediate, I can see clearly at one very specific “sweet spot” otherwise it is blurry. At my follow-up appointments were I articulated my frustration with my vision I was told that my eye is dry and that could be contributing to the poor vision so I have been using Hylo drops on a regular basis without much improvement. This summer I noticed a decline in my distance vision so I went in to see my optometrist and he detected early stage of PCO and recommended the YAG laser. Due to fear and anxiety I decided to wait. In the past few weeks I have felt a further change in the vision which I would describe as hazy so I went to see my optometrist again who reported that the PCO has gotten worse and referred me back to my cataract surgeon. My cataract surgeon is now offering the Vivity lense and offered an IOL exchange or the YAG procedure. I asked about the risks of both and was told that the risks associated with the IOL exchange include infection and retinal detachment; and that the YAG laser is safe. However after reviewing this forum I’ve see that many of you refer to the IOL exchange as risky and that there are side effects associated with the YAG as well such as starbursts and potential pitting. In terms of visual effects, I do experience prominent halos while driving. For me, in terms of my line of work, I feel like intermediate vision is important to me and I do not feel like the YAG will correct that hence I am considering an IOL exchange. I would appreciate any feedback or advise. Also, I am located in Canada and open to see another doctor for a second opinion if you can recommend someone. I’ve seen Dr. Safran’s name on this forum but with COVID I feel like travelling to NJ (USA) might be challenging at this time. Thank you for reading my long post.

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That is a difficult position to be in and I can't really offer any advice based on personal experience. I am in Alberta and had my first eye done about a month ago. It is a monofocal AcrySof IQ and has worked well for me so far. But of course I cannot read up close with it. A friend had both eyes done about 1.5 years ago in Calgary using the PanOptix. She has not been entirely happy with the outcome. Initially the distance she has described as very good, but the up close not so good. She uses +1.75 readers for reading especially in lower light. And she has the halos issue at night. More recently she thinks her distance has suffered some too, and may also be having issues with PCO. Last time we talked she had not gone back for a diagnosis. She is not considering a lens exchange and seems prepared to live with it, but says if she had it to do over again, she would not go with the PanOptix. . My surgeon did not encourage me to go for the multifocal lenses. He said that he had a hard time recommending them as he would not put them in his own eyes. That along with my friend's experience kind of ended that discussion. That said, there are many here that seem to have good outcomes with the PanOptix. . My surgeon was Dr. Rudnisky from the University of Alberta here in Edmonton. Days after my surgery was done, my wife was referred to him also for cataract surgery. It takes nearly a year just to see the guy for an initial consult. Hopefully you are in a province where the wait lists are not so long. In any case with regard to YAG risks, Dr. Rudnisky has done some research on it, and has the opinion that risks are very low. You can find some more information on it if you do a google search for this article. He is quoted and referenced in the article. . Review of Opthalmology PCO: What’s Wrong With Doing a YAG? . I was not aware that the Vivity lens was available in Canada. When my second eye is to be done, I will consider that lens. It is not going to give the same range of vision as the PanOptix, but it should have fewer optical artifacts like halos at night. I am currently doing monovision with a contact in my non IOL eye, and that also seems to work pretty good. So I have two options in mind; mini monovision with a monofocal, or with the Vivity. . If you post your province you may get some recommendations for doctors. I am not aware of those that specialize in exchanges, but there must be some doing them. It seems to be a specialist procedure.

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Hi Curious - not a great predicament to be in and I feel for your situation.

If you have the YAG it will make an exchange near impossible. It seems as though you have never been fully satisfied with the outcome of your surgery.

We are all patients as far as I know on these forums so very hesitant to recommend one procedure over the other. I too am in Canada (east coast) and would shard your concerns about covid and trip to usa. Is there another specialist in Canada (Toronto, Montreal, or Vancouver) that would be able to offer an expert opinion?

When deciding on my own IOL intermediate was also important to me as I am on a computer a lot for work. I went with the EDOF lens Symphony and been happy with the results. I do see concentric circles around certain lights at night which I was aware of prior to surgery. There is always some trade off/compromise to make in selecting a lens.

Hope you do find an expert to help assist you in this decision. Best of luck to you.

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You are in a tough situation and for whatever reason, my non-medical impression is it seems that the prescription for the lens you got was not correct. If you have difficulties at all distances then overall something is wrong. Does a low powered glasses improve your vision? If so then glasses plus YAG might be the most practical route. I had the PanOptix multifocal installed in both my eyes, followed by the YAG procedure four months later. All is fine now. It seems I need to post my positive results, as a counter, every time Ron makes a post about his friend who had a poor experience (hey Ron, how is it going). I am fairly sure I have seen reports of an IOL exchange being performed on eyes that had a YAG procedure, but it is likely more complicated. In theory it may be possible to clean-up the PCO during an IOL exchange, but the PCO could come back. More research and consultation necessary. There are some excellent surgeons here in Toronto, but as Ron suggested the wait times are long. Suggest you get a second opinion unless there are significant discounts or full coverage of the IOL exchange with your current surgeon.

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Hi Chris, thanks for your response. Which surgeons in Toronto do you recommend?

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Hi, it sound like we are in the very same situation. I have a monofocal IOL in my left eye - Tecnis, the right one is OK. I've been dealing with Postitive Dysphotopsia for >2 years and now have been diagnosed with PCO recently. So, I'm facing the very same drama - to exchange it or YAG it. I also don't know what to do. My heart says - exchange it. My mind says - YAG it. I also considered Mr Safran, but I live in Europe what makes it even more difficult to travel, yet not impossible. I'd really like to keep in touch with you if you want.

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Hi Ron, thanks for your response. I've noticed on this forum that you are very knowledgeable when it comes to contacts. i was wondering what your thoughts are on trifocal contact lenses?

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I have used spherical and toric contact lenses but not the multifocal type. About all I can say is that I have seen some suggestions that it may be worth trying the contacts before one decides to do a multifocal IOL. That said, I am not sure how accurately they predict what a multifocal IOL would be like. Just based on the spherical ones I have tried, I would think the Alcon Dailies Total 1 Multifocal might be a good one to try.

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The #1 is Dr. Raymond Stein at Bochner Eye-Institute. This is where I had my surgery performed. There are other good clinics but I do not have first hand experience with them.

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hi curious, some people do experience gaps with trifocal as you describe. that you are just 30 you are used to very good vision so you notice bad vision even more. sorry u r dealing with this at 30. i am 44. vivity is a good choice but i expect your near and intermediate will be average with it. the halos will improve with vivity. don't YAG unless you have ruled out exchange for sure. exchange is very risky with an open capsule after YAG. you would have to YAG after the exchange anyway. dr. shannon wong replied to me that the risk of lens exchange with non-YAG eye is similar to a cataract surgery.

men below 50 are at risk of retina detachment after YAG so an annual retina check would be recommended. i have the symfon6 and am similar to you. bad near from the get go. intermediate become bad with PCO and now distance has tanked. i am seriously considering the synergy for the next eye. it is not yet available in canada but available in Canada. if i like it then i will exchange the symfony for synergy. there is no easy answer and wish you the best.

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Hi soks, thank you for your response. What kind of lens is synergy and where is it available?

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synergy is a mix of bifocal and trifocal. it is a new tecnis product. it is available in everywhere except US. it allows vision at 33cm. people have complaints about it as well and there will be halos with it too.

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mix of bifocal and edof. i mispoke.

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My thoughts are since you are only 30 is to proceed very carefully and to get a second opinion before doing anything. That suggestion by Chris of Dr. Raymond Stein looks very good to me. He has quite an impressive CV and I would think could give you good advice. You do not want to go down dead end roads where you have no options in future for remediation of the vision issues. Not sure how determined you are to be glasses free, but one non invasive option may be to use progressive lens glasses. Since you see well in the distance, the progressive lenses may help you enough for the intermediate and close vision ranges. . By any chance was your PanOptix lens a toric type for astigmatism? If so is it possible it has rotated out of position for the best astigmatism correction? If so, it should be much less invasive to correct the rotation than to do a total explant.

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Hi Ron. My IOL lens is not toric because I had a very mild astigmatism. However two months after my cataract surgery I had lasik to refine my vision and correct the astigmatism.

I tried a progressive lense and couldn't adapt to it cause my right eye is relatively healthy.

I'm leaning towards a IOL exchange for vivity - I'm interested in continuous intermediate vision.

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I would think because of your age you would not need a progressive eyeglass lens for your right eye, just a normal correction for spherical and/or cylinder, as you should have good accommodation for close up. . I thought it might work in your left eye to correct the remaining issues with the PanOptix without doing an exchange. That is quite a bit more complex with all the correction going on with the trifocal technology in the IOL. . I think the Vivity is a good lens for distance and intermediate, but probably needs reading glasses, or progressive prescription to get very good reading. There is not a lot of clinical experience reported on it yet. Some claim they use it for mini monovision, but I have not seen detail on how much anisometropia is used for monovision. I believe it is claimed to give about 1.5 D of range when fully correcting for distance. Perhaps with .75 D of monovision it could be pushed to a range of 2.25 D or a bit more. I do plan to talk to my surgeon about it when it comes time for my second eye to be done. I am currently using 1.25 D of anisometropia monovision with a contact lens and it is pretty good for intermediate, and OK for some closer up. I can read most of what is on my iPhone 8+ with it, but just barely.

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I had a progressive lens made for the RE and normal correction for the RE - but couldn't adapt to it. I'm functional now at near and intermediate because of the RE. I'm going to see my doctor this week and ask about vivity results. I'm okay with wearing glasses for near. I just want a smooth transition from intermediate to distance.

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I've posted this elsewhere, but given the thread hear about the vivity lens, I thought I would post here as well: I had a Vivity lens implanted in my dominant eye in July and in my non-dominant eye in August, 2021 . I have been following threads on this site for a year and wanted to express my gratitude by sharing my experience of Vivity with you . I was 49 when I had the procedures done. Before cataracts, I wore glasses for distance, mostly for driving, though my vision was good enough to pass the driving test without them. Then, in my 40s, I started also wearing glasses for reading, if I was reading for a long period of time. Glasses were helpful but not essential. Then I got cataracts. Boo! I did a lot of research about IOLS and finally decided on the Vivity for both eyes. The negative post on here scared me but I figure that those who have positive experiences tend not to post. Thus, I am posting to share my almost-entirely positive review to help balance the scales. I live in the Bay area in California. If your interested, I highly recommend my surgeon. Reach out if you'd like his name. I had my dominant eye set for distance. From that eye I can see from the horizon to my fingertips clearly. My vision is 20/15 in that eye. With my phone at arm's length I can read fine from that eye . Under dimmer conditions, it's harder to see near distances (fingertips to nose), but not terribly so.

My non-dominant eye was set at a -.75 , so mini-monovision. With that eye, I can see mid and near crystal clear. Distance in that eye was 20/70 after a week, if I remember correctly. I can see well enough to drive, even if I only had that eye.

Combined I have 20/25 distance and I can read fine print with ease, 10" or further from my face. That's my vision and I am very pleased. I told my surgeon that I would rather have to wear glasses for seeing distance then have to wear glasses to see my phone, computer, or book. Turns out, I don't have to wear glasses for any of it!

However, I did hope to have no starbursts or auras. That's Vivity's main sealing point over other multifocals. I have both anomalies. Plus, in darker places, if there is light on the side of me, it sends rays through the edges of the lens creating a distracting flickering light. So that all is a disappointment. However, it is in no way incapacitating, just annoying and unexpected. I can drive safely at night, no problem. If my contrast sensitivity is diminished, it is not noticeable enough for me to be bothered or limited by it.

Given that every lens is a trade off, I'm happy with my choice of Vivity in both eye with mini-monovision, and I'm happy with my outcome. I can see well at all distances without glasses. In fact I can see better than I have in 30 years! I like how I look in glasses, so I can wear glasses to slightly improve near or far without feeling too vain (but absolutely don't need to wear glasses at any distance, except for very very small print in dim light). As others have posted, if I did wear glasses to adjust for the mini monovision, my vision would probably be even clearer under dim light, which would be a bonus!

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Panoptix lenses are disappointing. Alcon claims high satisfaction but I doubt it. Alcon dislikes feedback, but does have a complaint process. The FDA does also. Please use the processes.

Re Alcon Panoptix multifocals. Lenses are uncomfortable, poor toric design (corrections require surgery) flickering and huge starbursts which are seemingly universal. Yet ophthalmologists are recommending these multi focals. More income from these surgeries maybe? Alcon's satisfaction statistics are suspect. Not to be believed.

I recommend using another type of lens. Period. And if like your Panoptix, great. If not, complain.

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Issues with halos, flare, and spiderwebs are not unique to PanOptix. Other multifocal IOLs like the J&J Synergy, have similar issues.