near vision poor after getting Symfony...seeking others' experience

Eye care
1

Hi,

I'm 44 years old and just had the first of two eyes implanted with the new (I'm in the U.S.) Symfony Toric lens, which I've researched extensively and was very eager and excited to get.

Now four days since having the surgery, I'm mostly satisfied: colors are much brighter and more vibrant (and more pinkish, bluish, interestingly), my distance vision is now restored and fine, and I can see pretty well at intermediate distances, i.e. objects are clearly defined all the way in to about 23 inches away, perhaps even 21 inches away in bright light (yes, I notice some degradation in low light, more than I'd expected).

The real issue for me is my near vision, which is much worse than I was expecting. I do know that the Symfony isn't all-around perfect, that e.g. I might expect only 20/32 or so (mean uncorrected near achieved in the U.S. clinical trials). And I know that's just an average, but even the distributions left me hopeful, with 81% of trials patients achieving 20/40 or better (that's monofocally; 96% were better than 20/40 bifocally). Meanwhile, I'm struggling to make out these words as I type, pretty much anything inside of 23 inches is blurry, and in good light I can only make out the 20/80 line (if I really exert myself, I can barely make out, mostly by guessing, some of the 20/60 letters, but mostly they're entirely unrecognizable). I feel as if I could have gotten results like this simply by going with monofocals, and I'm beginning to fear this is as good as it'll get, which is depressing.

Some background facts: Pre-op, I was mildly myopic (-1.75) in this eye and mildly astigmatic (about 0.94 cylinder). Also, at 44 I'd already gotten used to presbyopia, and typically would wear +1.25 readers for near. The specific lens implanted was the ZXT150 +16.5 (1.5 D cylinder). I doubt lens alignment is off, as my distance and intermediate vision feels non-astigmatic. My other eye (right) is scheduled for another Symfony lens 10 days from now.

So, I wonder:

1) Have others had similar experiences, i.e. poorer than expected near vision?

2) Does anyone have any idea what might have caused this?

3) Can anything be done to correct it?

4) If anything can be done, should I expect my ophthalmologist to do it (without having to pay more than the significant amount I've already paid)?

Thanks for any info and advice!

2

I had same lense and am 46 years old. Had issues but not lenses related. Immediate reaction is has been 4 days so you are still healing and vision will change. If far and intermediate is good then it does not sound like you have and surgery related issues. Perhaps your second eye can be set a bit closer more for intermediate and close vs far. That is what I did. Right eye more distance less reading. Left eye more reading less distance. Both give me 20 20 unless I am reading a drug bottle ingredients.

3

You hadn't mentioned the crucial factor which is what the refraction on that eye is, which you may not know yet. I'd guess there is some chance  that you wound up slightly hyperopic, farsighted in that eye which takes way some of your near vision with any lens and could explain the results. I have Symfony IOLs in both eyes and  although one of my eyes hit the target at 0D and is what gives me  20/25 near vision, he other is +0.5D and has quite a bit less near by itself.   Also the lens is tolerant of some amount of astigmatism so it isn't clear that you could tell if it "feels non-astigmatic", and if a toric lens is rotated that impacts how nearsighted or farsighted you might be.  

In addition the time it takes to neuroadapt can vary greatly between people. One doctor who did studies comparing the AT Lisa trifocal and the Symfony indicated in email that the Symfony seemed to require  longer for neuroadaptation than the trifocal, though he didn't respond to a request to quantify the difference. In my case my near vision came and went for perhaps a day or two before settling in, and was 20/25 by testing at 1 week postop, but that might be very atypical given the doctor's comment about it taking longer for neuroadaptation than the AT Lisa tri.

The odds are very high you'd have far worse near vision if you'd had a monofocal with the same refraction the Symfony is at (e.g. also hyperopic, if that is the issue). Unfortunately the results do vary between people partly due to the quality of the rest of the visual system, and it could be you have some other issue that would have given you subpar results with whatever IOL you got.

In terms of degradation in low light, I have better low light vision than I did with multifocal contacts and don't consider it a problem. Someone I know, about the same age, with the Crystalens has far more noticeable degradation in low light (though he may be an atypical data point, individual variation). We met after a lecture in a well lit auditorium, and he showed me that holding a file folder over the near vision chart to cast a shadow was enough to reduce his near vision by some lines, but it didn't make a difference to mine. It may well be that even with a monofocal lens you might have noticed a degradation in low light vision, I've read a number of times that people after cataract surgery tend to find more light is needed, when referring to people who have likely gotten the default monofocal lens.

 

4

Same thing I went thru. Then they changed the lense to astigmatism shape a football shape. Still didn't help I could not see anything far even up 2 feet a four inch print out of the eye. Then a laser was done, it did not help. 

Went nt to another specialist. No one can explain what happened any why my vision is worse since cataract surgery. 

5

Thanks very much, Glen. Assuming this turns out to be nothing out of the ordinary, and as a worst case, that's my plan, i.e. to request a small amount of monovision, 0.5 or 0.25 D, whichever the doctor recommends. My fear with this approach, though, is that it won't be sufficient to counter, or properly complement, the poor near vision in my current eye. As softwaredev suggests below, there's a possibility, I fear, that I've been left slightly hyperopic, or (and this I hadn't considered) that the lens alignment is off a bit despite my feeling as if my astigmatism is corrected.

Was your vision similarly poor in your first eye? It would be nice to hear that I might still get to binocular 20/20 via a slight degree of monovision.

6

No I had CME. Corrected with meds. If you have good far and intermediate vision than it is likely a sizing issue. I would simply see if the can purposely under size other symphony. You will still have distarance but closer to 20 25 or 20 30 but near vision should be better. Again you still need to heal to figure out optimal vision so I would not rush second eye choice until your first eye stabilized.

7

Thanks, softwaredev. As for refraction, we targeted 0 D, although to be honest this was hardly discussed pre-op; and I don't know actual/current refraction, as my day-after post-op visit was very casual, informal, with no mention of what my numbers were. Instead, a nurse had me briefly read a distance chart and briefly read a hand-held near chart--no autorefractor, no "which is better, 1 or 2" with lenses, etc. Then the ophthalmologist checked me with a slit lamp and said everything looked fine, end of story. (We did then discuss my poor near vision and targeting micro monovision, assuming things didn't change.)

All of which leads me to a new question: How is this typically measured post-op--autorefractor, full manual refraction, or something else?

I plan to visit my (unaffiliated) optometrist in the next few days, and am scheduled to see the opthalmologist's optometrist in 6 days, just before surgery on eye two. So any information I can get beforehand will help in discussions with them.

Last, I'm curious about your comment about astigmatism. Are you saying that due to the tolerance to residual refractive errors with Symfony, that my alignment may be off, contributing to my near vision issues, even though my distance vision to me is now "non-astigmatic" (by which I mean, I can see sharp edges and lines far away, that when uncorrected in the past would often appear sort of ghosted, with a slight offset double image blurring them)? It seems odd to me that vision at one distance (far, as well as intermediate) would feel corrected for astigmatism, while another distance (near) would still feel uncorrected and so poorly focused. In my very limited understanding, all distances would either be corrected for astigmatism or not, which then to me suggests that seeing things fine in the distance would mean the lens was lined up on the correct meridian. With all that, I don't mean to sound strongly opinionated or like I know what I'm talking about--I'm just spelling out my train of thought in hopes of getting a better understanding.

Thanks again for all your help.

8

Sorry to hear about your experiences, did you have the Symfony implants done as well?

9

Yes.. Not much left to fix the eye. Astigmatism is apparentl to blame .

very frustrating seeing double is part of my life now. No one wants to take responsibility. I have the other one to have cataract surgery will take wild horses to drag me in again on the good eye with cataracts.msounds rediculous! 

10

Ive been holding off on my cataract surgery until the symfony was legal in the U.S.  Did u have your surgery done in the U.S.?  I reseached the symfony too. Sounds like you researched it even more than me.  Apparently it gives you a much better range than simple monofocal but it is not perfect.  Do you think it would have been different if you sacrificed a little of your nice distance vision to have better near vision.  As I understand it there is a certain range and you can set that "range" as you think will be best for your lifestyle. I know for me it would drive me crazy not to be able to read the caller ID on the phone when someone calls or not be be able to read when someone sends me a text on my cell phone.  Were you expecting perfect vision at all distances, near, medium and far?  I was told the symfony's range is not that encompassing and that there is a trade off.  Maybe your doctor might advise you get set that range to slightly more in favor of near when you do your other eye?

11

Everything being equal symfony give you closest thing to natural vision. There are trade offs. When it works it works well. I have them. First eye last September second eye lasto month. One eye set at closer foer near vision and 20 25 distance. 2nd eye set to 20 20 distance and is not as good near but both eyes working together give me full vision close near and far. Typing this on my. mobile. if you have issues it is not the lense but something else. Perhaps wrong sizing etc.

12

I'm not sure if I quite understand your situation. Are you saying you got the toric version of the Symfony to correct your astigmatism, but it didn't correct it and left you with worse vision? If it is a toric version then it might have been rotated. If your near vs distance is better prior surgery and worse surgery it might be because of how you set your focus to. But if you have one corrected eye and the other one uncorrected (only had cataract surgery in one eye) then your vision perhaps will be much worse until you have both done.

13

Yes there were two lenses the first lense not for my eye shape and then the second for symphony for astigmatism then laser. All failed and the vision in that eye is worse that it was before the cataract surgery. I cannot see a for inch letter from 10 feet. I had great vision before surgery now I cannot read street signs unless I am on top of them. Also am now stuck with double vision. Have glasses to read since surgery after time a few hours all the print is blurry even if I stretch out the page on my IPad. I Was livid at first but after 3 years just adapted to it no one can fix it since laser. 

 

14

Targetting 0D is different from achieving it, as I know from my results. Usually the lens power formulas are fairly accurate for those with low prescriptions (unlike my former high myopia) but they can still be off. Also the lens can change position during the first few weeks, moving further in or out, making the issue better or worse. Usually its stable after a month so they wait until then before prescribing correction if someone needs it, but in some cases it can take a few more weeks beyond that to stabilize. 

Refraction needs to be measureed with full manual refraction after the Symfony IOL (or multifocals), as the Symfony site says in the fine print in the instructions for doctors. Their optics confuse autorefractors which may or may not be accurate. 

You were indicating that you didn't think the lens was rotated because you didn't think you were astigmatic. Its possible that the lens is rotated so you do have some minor astigmatism which isn't enough to cause problems with decent distance vision. That lens rotation however also influences the spherical refraction, leaving you more or less myopic or farsighted (though I hadn't thought through if that is likely the issue in your case, which way rotation would likely have shifted it). It could be lens rotation (rather than lens power) that left you hyperopic, and that on top of the astigmatism might reduce near vision.

I might consider a laser tweak to move my +0.5D eye to -0.5D or so for micro-monovision. So if you are hyperopic in that eye (and it isn't due to lens rotation), one option is  a laser tweak (to 0D or slight myopia for micro-monovision). You might wish to decide on that if possible before deciding whether to target your other eye for 0D or micro-monovision. It may be that the lens power for the other eye would be more accurate if the results of the first eye provide a clue, it depends on how similar the eye measurements are, often people's eyes are similiar, but not always. 

 

 

15

If this was 3 years ago, I'm unsure how you could have the Symfony since it was only approved 2 years ago. Unless you are saying one eye was 3 years ago and the other was done more recently with the Symfony. 

It sounds like the issue isn't related to the lens or they'd be proposing a lens exchange. Perhaps the astigmatism is irregular, or some other eye issue arose due to cataract surgery (or around the same time, out of milllions of cataract surgeries some people will have the bad luck to have some other issue just happen to appear at time of surgery).

 

16

SD,

Does the extent of being left/set to 0D vary depending on if one is myopic or hyperopic pre-surgery assuming no other conditions exist aside from astigmatism? Would it affect the choice of whether one should have one eye set for more near if one was previously far or near sighted? I guess I am trying to ask if there is a difference if a previously myopic person would end up with varying 0D results (to be left more myopic after surgery) than a hyperopic indviidual who would be left more farsighted post surgery even at 0D and whether the myopic individual would still need to set for minimicrovision for more near.

I am assuming since you lose all accomodation without your natural lens that it won't matter, but since 0D often varies from person to person I was wondering if there are pre-existing factors (perhaps astigmatism?) that causes one to be left more myopic or hyperopic and whether this affects minimicrovision.

17

Primeland, yes, I had my surgery in the U.S., and I also waited, sort of, to get the Symfony. I was originally on track to get the Tecnis low-add (2.75), though I'd been most interested in Symfony all along, but just felt my vision had deteriorated so much I could no longer wait until some uncertain future date for it to become available. And then...it became available! So I rescheduled with a new surgeon who I was told would be among the first to get access to the new lens.

As for targeting different ranges (distance, near, etc.) I believe that's more of a strategy with monofocal lenses, where the drop in acuity is more pronounced outside of the target focal distance. It's certainly possible to do with the Symfony, and is done to a lesser extent (e.g. with monovision), but its extended depth of focus means it isn't as necessary.

But I do intend to request some monovision, given how poor my monocular near vision has turned out--assuming, that is, that I can find no explanation and adjustment of some sort that would improve my near vision directly.

18

Hi WebDev,

Do you have the same amount of astigmatism in both eyes? I also share a similar experience since i waited almost a year for the Symfony to come out in the U.S. I am myopic and have astigmatism which needs to be corrected in one eye (1diopter) while the other doesn't need astigmatism correction (.5diopter) so I am considering a Symfony non-toric and a Symfony toric for one eye. But I haven't heard much info on the Symfony toric version but I'm assuming people still have good results despite the complications of a lens rotation. I was wondering if you ever considered an LRI to correct your astigmatism rather than the torics than you could have just got the non-toric version Symfony? I am also considering a bit of micro-monovision but I'm not sure if I'll be able to adapt to all the differences with one eye having a toric and one with non-toric and on top of that with the micro-monovision. I can't think about not being able to see well near since I've been myopic all my life!

19

Softwaredev, thanks, that makes sense. Perhaps the lens is slightly misaligned, leading to some spherical error, while I remain unable to notice anything that feels like astigmatism at distance.

I just did a quick distance check with some charts I use, and it seems I'm about 20/40 to 20/30-1 for distance, which surpised me. I think the huge improvement from my poor cataract-impaired vision, and the increased vibrancy in colors and brightness, led me to think my distance vision was better than it actually is. So this, to me, lends some credence to the misalignment theory--or, the spherical correction being off...

I'm hoping my optometrist can add some clarity here, and I'll report back what I learn from him. But I'm now even more concerned than previously, as it seems my vision at all distances is worse than should be expected. Near remains the most bothersome. If all distances are less than average to poor, what might be the cause?

And, slightly related, do you happen to know if manual realignment is the only resolution to an alignment issue, or are their laser-based alternatives that could be applied instead to address it?

20

Sorry for the multiple posts. Also did you ever consider having your surgery via laser-assisted and not by standard cataract surgery? Thanks.