Looking for recommendations regarding monovision and Apthera ic-8

Eye care
1

I am a 52 year old with a strong correction in both eyes (-4.5 D spherical, -3.5 D cylinder). I tried to contact a surgeon regarding getting lasik because my right dominate eye was experiencing worsening vision and I was hoping to get my eyes corrected to moderately myopic (-2.0 D) without astigmatism. Unfortunately, my doctor informed me that I was not a good candidate because I had a cataract forming in the center of my right eye as well as cortical cataracts forming on my left and right. Thus they recommended that I have a IOL implanted. The first doctor recommends two fixed focus toric lenses and the use of glasses for intermediate and near. But when I researched more I found there were options that were not discussed with me so I got a second opinion and did further research. To add to the issue, when I met with my optomitrist, she tested me and discovered that I had nearly 1D of preexisting monovision. Because my dominate eye is weaker than my left, and I had refused upping my prescription in my left so many times my visional range was now separate with my right eye only in focus for 1m to infinity and my left used almost exclusively from 30 cm to 60 cm (though it does have 20/35 at infinity current due to larger accommodation range than right).

I got a second opinion regarding surgery and this time brought a plan which best meets a computer jockey who spend 8 hours reading and 8 hours on computer regularly (and will do so for next 10 years). The new surgeon was happy with the plan of using a Synergy TECNIS in my right eye and a Apthera IC-8 in my left with a range set for monovision. However, he wanted me to wait a year to see if a toric version of the Apthera IC-8 was released.

Thus my question, the manufacture’s recommendation for the Apthera IC-8 is for a target of -0.75 D which is micro monovision, but has anyone had experience using this for full monovision (-2.0D)?

Given my current level of monovision (~1D) and the use of a trifocal which gives adequate near, it would seem that something in the range of -1.25 to -2D would be better than a -0.75 D which is mainly for far to intermediate range. Given the extended range of the Apthera IC-8 a -1.5 D would leave me with 20/45 at distance which I find tolerable when mixing lens from different glasses and at the same time decent vision at 30 cm. Does anyone have an opinion as to whether using the Apthera off label would be a bad idea?

2

The IC-8 uses the pinhole camera effect to increase depth of focus. It is normally only used in one eye as it loses the benefit in dimmer light. You need significant astigmatism correction and I don't think it does that either. I wouldn't over complicate things and just go with a toric monofocal in both eyes and consider mini-monovision to get a wider range of focus. The standard practice would be to target distance (-0.25 D) in the dominant eye and -1.50 D in the near non dominant eye. But, if there are other reasons this can be reversed. These targets include the residual astigmatism on a spherical equivalent basis. A toric is unlikely to correct it all. A couple of lenses to consider would be the Alcon Clareon Toric and B+L enVista Toric.

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Stay with a monofocal. If your cataract surgeon doesn't use the enVista or the Clareon, you can go with the Johnson and Johnson Tecnis1 or the Eyhance. Get at least two opinions. Try to find a cataract surgeon who is fellowship trained in Cornea/Anterior Segment surgery. They specialize in cataract surgery. Find someone who will listen to you, take time with you,  and you feel comfortable with.
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Thanks for your reply. I am still not sure if two monofocals is the best plan.

With a monofocal at -1.5 D, how close can reading be? By the numbers monofocal only has a depth of field of 0.75 D. So that has me most worried. The range I least care about is far.

As for the astigmatism. Yes I wouldn't go with IC-8 until they have a toric version. I have enough irregular astigmatism that regardless of which toric is used some amount of laser surgery will be needed to trim it for monofocal or trifocal. Currently I have 6 images in my right eye and 2 in left without glasses. With glasses my right eye has at best 2 images. I cant read at all if the text is sideways. It is only with the aid of my left that my right appeared to be normal. A toric IC-8 would be the only one that could prevent that as it corrects 1.5 D irregular.

Is there some reason to avoid a trifocal for the dominate right eye? Though technically it was once 20/20 because I could read double images, I haven't been correctable to normal since youth. A trifocal would seem like an improvement. Are those who are unsatisfied with multifocal, people who had good vision and feel it is worse? I was willing to take more risk on right because it has been poor.

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Thanks for the reply. My first surgeon wouldn't meet with me for a follow up prior to surgery so that is why I went with to the second. The second has been conducting cataract surgery since 1994 and had experience in using mixed lens to meet patient needs including mixing of biofocal/trifocal lenses with monofocal.

I am interested as to why you think a monofocal is best for my right eye. I would be fine with a monofocal on the left as so long as it can be correctable with lens to different distances I can function. But what reason for using the same on my right?

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On a spherical equivalent basis (sphere + 50% of cylinder) my distance eye is -0.40 D. It started at -0.25 D but astigmatism went up a notch, but still have 20/20 in that eye. My near eye is at -1.60 D. With my distance eye I can see my car dash quite easily and can read a computer monitor down to about 18-20". My near eye is useful for 65" HDTV viewing at 10" but is starting to soften up a bit compared to my distance eye. I can see a computer monitor down to 8-10". But everyone will differ a little in that respect. In any case I have a substantial overlap in the eyes with full binocular vision in that range. My distance eye is an AcrySof IQ aspheric monofocal, and my near eye has the newer Clareon aspheric. Optically they are essentially identical monofocals with -0.20 um aspheric correction. Some get the idea that monofocals drop off a cliff when you get away from their set distance. Actually they have quite a wide range which can be significantly enhanced with mini-monovision. . Be careful with the irregular astigmatism. I have that in my near eye and it gives me a drop shadow on letters. I can still read J1 in sunlight but it could be better. I decided against a toric because my surgeon was not sure it would help, and suggested Lasik to touch it up. Lasik has turned out to be a dead end. If they correct the irregular astigmatism I will lose much of my reading vision (it measures -0.75 cylinder). And I have found out that it is very difficult to increase myopia sphere with Lasik. So, if you are counting on Lasik make sure the correction will be to reduce myopia, not increase it. . If you do some searching around this site you will find there are issues with the latest trifocal IOLs like the J&J Synergy, and the Alcon PanOptix. They can give significant optical side effects to the point some get them removed. I have a good friend that has the PanOptix and still needs +1.75 readers to read, even in good light. . The big advantage of monofocals is that they have the lowest risk of optical side effects, and if the power is off, they are easily correctable with an eyeglass lens. The optical tricks that the Synergy, PanOptix, and others are not easily correctable with eyeglasses. . These trifocal lenses are really only recommended for those that have "perfect" eyes. The enVista lens on the other hand is much more tolerant of less than perfect eyes. It may be harder trying to find a surgeon that uses them though.

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Part of my earlier message got cut off. Ron explained why a monofocal would probably work best for you better that I can. I will add that monofocals are less like likely to cause issues. Some like the Acysof, the enVista, or the Tecnis 1 have a long track record. I think it's best to keep it simple. I work in health care and I know a number of physicians who also feel that way.

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I suggest getting the IC-8 and plan on wearing glasses with it for additional astigmatism correction. The IC-8 will give you the best depth of focus. For me, wearing glasses is not a big drawback as long as I don't have to use multifocals or 2 or 3 different pairs of glasses. Maybe you feel differently.

I'm not necessarily suggesting bilateral use of the IC-8 but there are plenty reports of successful bilateral use. And there aren't reports, that I am aware of (and I have read everything I could find on this lens) of people who have it saying it is too dim.

Some with big pupils complain of photic phenomena.

In one study, 50% of those that got the IC-8 bilaterally achieved vision of 20-16 whereas none of the unilaterally implanted achieved this result.

Google "Small Aperture IC-8 Extended-Depth-of-Focus Intraocular Lens in Cataract Surgery: A Systematic Review." This is an overview of many studies.

There is a lot of misinformation and uninformed opinion about the IC-8. Something about the pinhole makes people think they are an instant expert on it without having to do read the actual research. So if you're interested in it, go right to the scientific sources.

I agree about monofocal for you over trifocal. With your array of eye problems I would run screaming from anyone who suggested the trifocal. In contrast, the IC-8 has been very helpful in treating problematic eyes. In an article in CRST by H. Burkard Dick the author reports on implanting the IC-8 in a patient severe eye trauma resulting in 20/100 vision and achieving 20/25. Dr. Dick has extensive experience with the IC-8. He writes:

"Patients who receive the IC-8 IOL in one eye and a standard aspheric lens in the other have achieved an average UNVA of J1, along with 20/20 for both UIVA and UDVA.1 In another study, the small-aperture IOL did not decrease binocular contrast sensitivity, even under mesopic conditions.2

Unlike other premium lenses that require specific parameters to maximize their attributes, the IC-8 is an incredibly forgiving lens."

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Thanks for the detailed reply. The published curves on the vision tests imply that monofocals fall off fairly hard, but I am glad that you are getting good mileage out if it.

I was aware of the visual issues with trifocal. They are comparable with my current vision in the right. Residual astigmatism even with glasses is strong enough that stop lights at a distance look like the number 8 and I already see haloes and streaks at night. It looks just like the pictures of what a trifocal does at night. Which left me confused as that is what I always see in the right. Though perhaps the are worse with trifocal.

It may be because the location of the cataract. I have often wondered if I can actually see it. When using a microscope there has always been a wormlike thing in my vision. I assumed it was on the back, but now that two doctors said I have a congenital cataract I have to wonder.

I have read that lasik can only correct some problems. Sorry to hear that yours wasn't correctable. The doctor said there was a procedure he could do as while operating to deal with the iregular astigmatism assuming the toric was in place. It involved using a laser at the edge rather than center to flatten. Though I did not catch the name. He was very confident that he could achieve acceptable vision as he had done many similar corrections. The most common being using two bifocal to give mixed ranges.

Regarding the light loss on the IC-8, all of the studies I found indicate the loss of night vision is less than expected. It is cutting light to 25%, but it is also more transparent than a natural lens by about 20%. So you would expect it to be the same as 30% sun glasses. But the human eye has many orders on magnitude range so the loss is really just coming out of the rod range. So unless it is dim enough you cant see color, most people cant see the difference.

On important consideration for anyone considering the IC-8, is pupil size. The rear aperature works with the natural iris. Those with large pupils (>4mm) in studies didn't get the expected depth improvement. Those with smallest pupils (<2.5mm) saw the best range. Still larger than monofocal, but not the range stated in the company literature.

I do agree with you that having one eye completely correctable with glasses. That is why I would not consider trifocal in two eyes.

I have year to think it over, so thank you for the input. I will see about finding some studies to see the outcomes of each of the lens mentioned.

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Have a look at these figures, and in particular Figure 1 & 2. Figure 1 shows the visual acuity of a standard monofocal set for distance, as well as the same lens set for various offsets of 1.0, 1.5, and 2.0 D. 20/32 is considered to be the limit of normal useful vision for each lens configuration. So, if you draw a horizontal line at that level you can see what distances each lens configuration is useful over. . https://www.semanticscholar.org/paper/Optimal-amount-of-anisometropia-for-pseudophakic-Hayashi-Yoshida/dd8837a9151a536759f195a18d4fa94a0fbf0f90 . Figure 2 shows the combination of a lens in one eye set for distance plus the various offsets in the other eye. You can click on each figure and the Expand link for more detail, but unfortunately the complete article is no longer on line that I can find. The objective of the study was to find the optimal offset for monovison. The conclusion was the -1.5 D offset was optimum. The -1.0 D comes up a little short for reading vision, and -2.0 has a significant drop in the 0.7 meter range. The 1.5 D offset provides a significant overlap for the two eyes as well. . As you can see when you look at the complete range two correctly targeted monofocals do quite well. . On the astigmatism and impact on vision I am not sure I would draw any strong conclusions when you are looking through cataracts in your lenses. Your best indication of your outcome will be with the measurements taken by the IOLMaster and Pentacam. They should be able to predict your residual astigmatism with a non toric and toric lens. Typically (but not always) astigmatism goes down significantly when the lens with the cataract is removed. My cylinder went from -2.75 down to -0.75 in one eye with a non toric lens. The other eye with a non toric also went from -1.25 D cylinder down to -0.75 D. It had a much less significant cataract at the time of surgery compared to the other eye. . Yes, Lasik makes corrections for myopia with radial cuts in the cornea, while circumferential cuts are made further out for reducing hyperopia. The issues are that circumferential cuts have a less predictable outcome, and they typically are not stable over time, and may require multiple treatments. Limbal relaxing incisions (LRI) made during surgery according to my surgeon are not very predictable either.

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Thanks so much for the reference. It should be available on my work library. Helps to work at a large government research institution.

I don't anticipate my cylinder changing much. My lens for the both eyes has been in the -3 range since high school. The cataract is just pushing the number up further into the -4 range. Thus bringing me to the edge of my tolerance for glasses. Every time they have to up the base curve to increase the power I have to live in a fish bowl world with screaming migraines. After the last round I decided it was time to find other options.

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Thanks for the reply. I am very much in agreement that the depth of field for the IC-8 is impressive and if a bilateral implantation with a toric correction were available then it would be my first choice. The ability to deal with up to 1 D of residual astigmatism would make it the most forgiving option.

I also found the articles regarding the night vision. Your view is supported. In terms of total light one would assume there would be a loss in night vision, but all studies I can find show it not to be the case. Only by comparing the monofocal eye was it at all measurable and far less than the physics model suggested.

I discussed whether IC-8 with lasik was an option with the surgeon. He recommended waiting the year to see if a toric was available. I can certainly manage that long by swapping between glasses. Given my right eye is the worst, I have considered reversed monovision. But given I am already adapted to near on my left, I would have to test with contacts and glasses to see if I can tolerate it.

Thus far I have yet to find any studies on IC-8 plus lasik nor IC-8 being tested with a toric option. Many articles mention pinholes as being the solution for irregular astigmatism, but I haven't been able to find a product that matched. Hence reaching out here.

I put in a call to the makers of the IC-8 to see if there will be such an option.

Regarding trifocal there appear to be a fair number of differences in the level of forgivingness between products. Synergy seems to be one of the least forgiving. I still have more research to do on that front.

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When you get your eyes measured you should ask for the IOL Calculation sheet. And if the clinic is cooperative you should also ask for a screen shot of the cornea topography. Those two items will give you a good idea where you stand. On the topography shot look for whether or not the image is symmetrical like an hour glass or bowtie. That indicates regular astigmatism. . If you google this you should be able to find a document which is helpful in reading the IOL Calculation sheet. . Zeiss IOLMaster 700 Quick Guide Printing Functions EN PDF . Page 5 gives an example of a calculation for a non toric, and page 7 shows a toric calculation. . When you consider your astigmatism as measured for an eyeglass prescription consider that the astigmatism likely comes from three sources. One is the topography of the cornea. The other two are the shape of the natural lens, and the last is the distortion caused by the cataract growing inside the lens. Of course with cataract surgery the total lens is removed and replaced with an artificial lens, so the astigmatism in the lens and the distortion due to the cataract is removed. That is why astigmatism is likely to go down with cataract surgery. You only really know what the residual astigmatism is likely to be after the measurements are taken and the IOL Calculation sheet produced. There will also be an estimate from the Pentacam topography measurement.

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Mine is a bow tie with a curve such that it looks between a backwards S and a ?. Glasses fix the primary axis, but when the pupils are dilated the axis rotates. Wearing my glasses crooked helps at night.

I just wish I could have PRK or lasik now to remove the cortical astigmatism first , wait a few years for my eyes to heal then get the surgery for cataracts later. At -3.5 D even the slightest angle miss adjustment ruins my vision. If I didn't have to worry about the angle of the IOL, this would be much easier.

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One option you may want to consider is topography guided Lasik, sometimes called Custom Lasik. From my research and consult with two Lasik clinics it should be quite possible (but expensive) to correct your astigmatism fully even if it is irregular. I would only have them correct the astigmatism to minimize the impact on the cornea, and not address the sphere. Leave that for the IOL to correct. The plan would be to get the astigmatism Lasik done now and then do the cataract surgery after the eye recovers from the Lasik. It may be possible to cut that time to even less. Providing the Lasik is accurate you should not need a toric IOL. You will want to be sure your eyes are measured for IOLs before the Lasik so you have a reference as to what that has done. Prior Lasik does complicated IOL power calculation some.

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Here is your post that got cut off. The trick seems to be to highlight and copy it. Then paste it like I have in this post. The text seems to be there but is not visible due to formatting issues with this forum software.

"Stay with a monofocal. If your cataract surgeon doesn't use the enVista or the Clareon, you can go with the Johnson and Johnson Tecnis1 or the Eyhance. Get at least two opinions. Try to find a cataract surgeon who is fellowship trained in Cornea/Anterior Segment surgery. They specialize in cataract surgery. Find someone who will listen to you, take time with you, and you feel comfortable with."

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Thanks, Ron. It has only gotten cut off 2 or 3 times over the past year or so.

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Thanks a lot. I think my best option is to find a surgeon willing to compose a long term plan. My original goal was to get lasik or prk for the sole purpose or reducing my astigmatism so that I can function with glasses until I retire. The cataract in one eye is just a complicating factor. But it may be 10 years before it develops further given that it appears to be congenital.

If I set my goal on getting refractive surgery to get my eyes to -3D with 0 cortical cylinder, then I can last until my right cataract gets bad enough to warrant surgery or the left eye develops cataract (currently at the far edge). There may be much better IOL at that time and I will have both better vision and better options than worrying if the toric is correct and struggling to correct if it is not.

As many people on this forum have stated natural lens are best until they are not usable. So I should try to get 5 years.

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Yes, you need a long term plan. I would not count on the cataract issue to be slow developing. You are younger, so that is a sign they may be fast to develop. Normally cataract do not become an issue until you are 70 or so. The other sign of faster development is your eyeglass prescription changing fairly quickly. For some the limit of tolerance for a cataract is the frustration of having to get new eyeglasses lenses every few months instead of every couple of years. . I think your best solution, but only if it is possible is to get custom Lasik or PRK to correct the astimatism only and leave the cylinder untouched to minimize the amount of Lasik done to the eye. You will likely have to do a fair amount of searching to find a Lasik specialist that will be capable of doing that, and has the sophisticated equipment to do the custom, or wavefront guided, or topography guided type of Lasik. Remember that you can only deal with the cornea any you only want to "fix" the astigmatism in the cornea, and ignore the astigmatism in the lens. If you try to adjust for the astigmatism in the lens then when the lens is removed, that correction will be still built into the cornea and you will have astigmatism again. So it would be very unadvisable to correct for the lens astimatism. . Remember that most Lasik specialists are really only interested in dealing with younger people that want to ditch their glasses. They compete on lower prices, and they just put in generic sphere and cylinder corrections like eyeglasses. Best to avoid those. Here is what the last specialist I went to says about Custom lasik that they do. . "About Custom Laser Eye Surgery LASIK, or laser-assisted in situ keratomileusis, is a quick, painless form of laser eye surgery designed to correct myopia, hyperopia and / or astigmatism so you can greatly reduce or completely eliminate your daily dependence on prescription glasses or contact lenses.

Your eye shape and corneal topography are as unique as a fingerprint. Before starting the laser vision correction procedure, Custom Femto LASIK WaveFront-driven imaging technology is used to generate a distinct map of your eye’s optical system, including its unique refractive error. This advanced diagnostic technology identifies the slightest eye abnormalities with far greater precision than ever before possible, including nearly imperceptible deviations known as “higher-order aberrations.” The Custom Femto LASIK WaveFront-guided treatment includes a distinct optical-correction schematic uniquely tailored for each individual eye. This data is used to customize your surgical treatment protocol, and directs the SCHWIND AMARIS® 750S excimer laser that is used to reshape the curvature of your cornea during laser eye surgery.

Once your optical system has been mapped, an advanced femtosecond laser technology, called IntraLase, is used to create a corneal flap. The corneal flap is lifted to access the underlying corneal tissue. Then, using the SCHWIND AMARIS® 750S excimer laser, the curvature of the cornea is reshaped to correct your nearsightedness, farsightedness or astigmatism.

The SCHWIND AMARIS® 750S excimer laser system is the most advanced laser platform currently available and, thanks to its revolutionary iris registration technology, is able to align treatment automatically, with the highest degree of precision, regardless of whether the patient’s pupil has shifted positions between the moment the eye was first measured and the time of treatment. Iris registration technology also ensures the greatest degree of personalized treatment, as no two eyes are the same. Once the laser eye surgeon is satisfied with the newly contoured cornea, he carefully places the flap back in its original position, where it re-seals itself to the eye, without the need for sutures.

Patients usually notice an improvement in their vision within 24 to 48 hours after surgery, and are able to return to work or their normal activities at this time. Often, patients no longer need to rely on prescription eyewear to see clearly, and many achieve 20/20 vision — or better — after laser eye surgery." . Although this only talks about Lasik, I believe the same can be done with PRK. The only differnce is that PRK does not use the flap, and the outer layer of the cornea is removed. Athletes often use PRK because it is more durable in contact sports. Although we never got to the point of talking prices, I would expect it may be in the order of $3,000 per eye. . Also ideally you want a Laser surgeon that also does cataract surgery and approaches the whole thing as a two stage project. Correct astigmatism in the cornea only first, and then does the cataract surgery to correct the sphere and of course get rid of the cataracts in the lenses as the second phase.

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There was been no detected change in the cataract from last year for the central one. Given that I have always had poor vision both doctors felt is was congenital, but if it is not that just pushes up my time line. If it is not congenital then it should develop quickly being either genetic or environmental. (I work with radiation sources but the total beta dose to eyes should have well under the level that would cause cataracts.)

I only recall once when I was very young a doctor mentioned that there was a defect in my right eye. But it was so long ago no one remembers the specifics.

My left eye is currently clear with very small age related cataracts at the edge. My right has similar very small cataracts at the edges in addition to the central one. Based on the edge ones all doctors I have consulted told me that it would be years for the edge ones to cause noticeable vision loss.