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

Cura degli occhi
21

Jason,

According to my opthalmologist, I have astigmatism in both eyes: .94 in my right (already implanted) eye, and .72 in my left eye, which is scheduled for surgery in 9 days. Those numbers are the average of three measurements (from an IOLMaster, a Pentacam, and a hand-held topographer, I believe).

Interestingly, this astigmatism has over the years been corrected differently or not at all, and always has been slight--i.e. looking at my past prescriptions, some have slight cylinger correction for left but not right, some for right but not left, and some for neither. From this I assume that the biometry numbers above are correct and measure actual astigmatism, and my prescription history just indicates my perception of it hasn't been so severe as to suggest correction during manual refraction.

The lens I have in my right eye is the ZXT150, which has a 1.50 cylinder correction and is the lowest toric correction available for Symfony (for Tecnis Toric lenses [non-Symfony, but I suspect these numbers still would apply], nominal, IOL plane cylinder numbers are about 1.45 of cylinder at the corneal plane, so this would mean I'm getting about 1.03 CYL actual correction). For my other eye, at .72, I'll be farther away from the lowest possible correction of 1.03, so, given my suboptimal experience with my current eye, I plan to question at my next pre-op visit. Perhaps no cylinder correction for this eye would be better than what the least cylinder Symfony Toric provides.

22

Jason, 

Sorry, I forgot to add: yes, I had this done laser-assisted, with the Catalys laser made by Abbott. This was included in the standard premium cost for the Symfony, and my ophthalmologist's preferred method.

23

it's incredible to me that, in order to make an informed decision on such an important matter as to what type of lens to get implanted in your eye once your cataracts are removed, you have to almost go to medical school to understand all the technicalities, nuances parameters and language to even enter into an intelligent discussion about it.  How many everyday people, who are not doctors every heard of cylinders and diopters and what 1.75 means vs 1.5 +/-.  OMG you can get dizzy trying to understand all of this.  I was just going to go for the Symfony because it had a larger range of focus than a traditional monofocal without the side effects that the multi focals were famous for.  Seeing near is important for me so I figured, if I had my optimum focus set for medium, rather than for distance, I am hoping I will have excellent near and medium and acceptable, but not optimum distance.  Am I wrong?  Every since joining this site and hearing all the horror stories of people having cataract surgery I keep delaying my surgery because, at least so far, I can still see enough near without glasses and far with glasses.  So Symfony is now legal in the U.S.?  I thought there was only one type of symfony and the only variable is what focal length to optimize it for.  I can see near without my glasses and need glasses to see far. If near is important to me, would symfony allow me to see near and intermediate at the expense trade off of not being able to see far that great?

24

They are more likely to hit the target with someone with a low prescription, and I'm not sure if it varies much depending on whether the person is hyperopic or myopic.  They are more likely to be off for those with higher prescriptions, and although I think its more common for them to be off with high myopes than hyperopes, I'm not positive. They have come out wiht some better formulas this year so the best thing to do is to be sure the surgeons are up to speed on the latest research and talk through the risks of being off target.

If they don't hit the target, that impacts micro-monovision if they aren't near enough to provide much difference, or too near and it reduces distance or stereopsis. Being off target a little bit doesn't matter too much. 

 

25

If all distances are off, that suggests that astigmatism is the cause as usually that applies to all distances (even if the Symfony is more tolerant than most lenses). Also it could be that you are still healing from the surgery. 

In terms of the lens being rotated, as far as I know they would manually rotate the lens. 

 

26

The first lense was three years ago the result vision was as explained above.

The second replacement lense was symfony done 2 years ago. Same eye this time for astigmatism . They admitted finally the wrong lense was put in the first time, after over a year of complaining. 

It should have been for astigmatism shape eye. Which means the eye shape is not perfectly round but slightly oval. 

That second replacement symfony lense done less than two years ago, was no better & my vision was blurry worse than before cataract surgery. 

The third try to fix my vision was laser . It was to clear my vision it did not. 

There is no other eye issue found it has been a problem finding why they cannot fix my vision. Now blurry, double and lost farsight which was very good before surgery in the eye for cataract surgery naw can't see a street sign. 

I have had had another opinion every possible test no other eye problems were ever identified at that time or reciently as Jan 2016, and no one wants to take responsibility. That is the unfornuate bottom line. 

 

27

Thanks for the reply WebDev,

I'll be getting mine done without laser as suggested by my opthamologist. You mentioned you read a lot of information regarding the Symfony torics, do you think the Symfony torics have overall more problems than the non-toric Symfony? I'm only assuming because the possibility of lens rotation that exists with any toric IOL. I'm asking because since the Symfony iteself is more tolerant of astigmatism I was wondering if it might be worth it to avoid the toric version and stick to the non-toric version in hopes that it adjusts with my astigmatism. Then again I've only read about the non-toric version and have not heard much about the toric version.

28

I had first eye done with laser and second without.  Both my experience and results were much better without the last\er.  Had symfony toric inplanted in both. 

29

WebDev

Sorry to hear you are struggling with near vision with Symfony IOL.

I am a 58 year old cataract surgeon in US- I just had a Symfony placed in my right eye 2 weeks ago.  I have NO relationship with the manufacturer or the surgeon who did my surgery.

The IOL is functioning correctly.  There is no near vision with this IOL.  I too notice I'd like clear near vision at a shorter focal point than what I'm getting.  I was near sighted to start (-2.75D) so had superb near vision from 8-12 inches.  I had quite blurry vision at distance with that refractive error.  I knew I'd need readers or a progressive add lens for my electronic medical records system - so I had that ordered before my surgery.  I think because you are so young, you still had a good amount of accommodation (ability to focus at near on your own), that you assumed your "extended depth of focus" from the IOL would allow at least near vision to maybe 18-20 inches.  Actually, I thought I'd have near vision in that range.  So it's somewhat disappointing for me since my whole day is using electronic medical records in clinic.  I'm in blended lenses all day.

Now I still have to have my left eye done and I think it will be a bit better with binocular vision in these IOLs, but they were designed for vision beyond 20 inches.  

I waffled about whether to just have a monofocal IOL and stay -2.75 to preserve good near vision and live the same as I have been all my life, but I wanted to be able to counsel patients about the TRADE OFFS/COMPROMISES of this technology.  And everyone charges A LOT for this technology.  And I paid FULL price just like everyone else.  I do think it's expensive.

If it really bothers you, you can discuss an IOL exchange with your surgeon.  You can place a Technis multifocal (3 different powerr of near vision).  You will need glasses for intermediate vision.  Or place a MONOfocal IOL, but you will have to choose between good distance vision and dependence on glasses for near and intermediate, or  some form of near vision (but NOT BOTH near and intermediate) and glasses for distnce.  It's all trade offs until technology improves the range of vision.  That's years away for now.  And of course the other side effects to deal with such as poor (my opinion) vision in low lighting conditions, halos/glare/starbursts from lights in low light conditions (not a big deal to me).

Reread your consent form and patient info to see if he (she) offers IOL exchange covered by the original price.  Some surgeons do and some don't.  

My colleagues who offer this technology vary on explantation statistics but it's not a rare thing- maybe as high as 10% for some.  

It's impossible to know what these IOLs are like until you have it implanted in your eye and are living with them.

Keep in mind it's a lot more difficult to remove an IOL than insert one.  So different risk factors when returning to the OR for IOL exchange.

If you were 10 years older and dealing with loss of near focus, you might interpret your situation differently.  But it's tough for younger patients who had good distance and near vision prior developing cataract.  Back in the day, my young patients (under 45) were happy with distance vision post op and freaked by loss of any near vision.  It's a difficult situation to adapt to (years before multifocals).

I have been reluctant to advocate multifocals because I know glasses will be necessary for some range of near vision.  Now that I have one, I'm definitely going to recommend them to certain patients that I think would "get it" about it's limitations.

In your circumstance, you had no choice about developing cataract at a young age where you would be losing some degree of near vision even with the "latest technology", but among your choices of IOLs- multis, accommodating, or monofocal IOLs, I think you made a good choice given the state of technology available in the US at this time.  And to reiterate, I have no financial interest in ANY IOL company or financial relationship with any distributor or hospital, surgery center, or surgeon using this technology.   Good luck, update us on what you decide!

 

30

Hello Brian,

Thank you for your honest insight. I too have been contemplating my cataract surgery for about a year or so until the Symfony has came out in the U.S. I am myopic so I can relate to the struggle mentioned in this thread. Not having near vision post-surgery seems scary and a bit disappointing since my long wait. I also have significant astigmatism in one eye that needs to be corrected while the other one doesn't have as much so I guess I'd have to be getting a Symfony toric and a non-toric Symfony for the seperate eyes although I'm not sure if both will work well with one another. This also worries me because I swayed away from monovision but people tell me that micro-monovision will be easier to adapt too. I am just hoping it feels "natural". Reading about the lack of near vision would you encourage individuals to set their eyes differently in focus perhaps 0.5 off for more near vision? Also did you consider micro-monovision prior to surgery? Thank you.

31

UPDATE: Well, I got to my optometrist, and got some bad news on two fronts: I have a good amount of residual astigmatism (it's now .75 down from .94 pre-surgery), and also I'm overcorrected and now have 0.5 D hyperopia. Via manifest refraction I'm 20/30 - 1 for distance, due to both, but mostly the astigmatism, the optometrist believes.

I now have an appointment with the surgeon in two days. I'd like to get my already implanted eye resolved before continuing with the other eye, but I'm not sure what my options will be. It seems to me a laser correction or re-alignment of the IOL might work, but I'm not sure.

32

I'm afraid I don't know, and I wonder myself, as my second eye has less astigmatism than my first (only .72, where the first eye had .94).

I don't know if the tolerance of residual refractive error applies to astigmatism in addition to spherical error, so I'm not sure whether it'd be wise to not attempt to correct it at all. My instinct is that it's better to try to correct it than do nothing, as a little improvement is better than none, and you may get it fully corrected. I'd imagine they'd have to be way off axis to add astigmatism. (Then again, I know it's tricky: each degree off means a ~3% reduction in correction, so if rotation is off by just 30 degrees--one clock hour--all correction is lost.)

My understanding is that the ZXT150 that I have is the lowest correction available (I see a ZXT100 referenced as available in Europe, but not in the U.S.) The ZXT150 has 1.5 D cylinder, which translates to 1.03 cylinder at the cornea, and is meant for correcting 0.75-1.50 (the numbers are from the Tecnis [non-Symfony] Toric sheets, but I assume the numbers would be the same).  The apparently unavailable ZXT100 is 1.0 D, or 0.69 at the cornea, and targets 0.5 to 0.75, which I would expect would be the best fit for me if available. So I'm not sure what I'll get. I have an appointment coming up with the surgeon pre-op and will check then.

33

Brian,

It's nice to have, for this discussion, a participant who is not only a cataract surgeon but also a patient who has had a symfony lens implanted in one of his eyes too. Wow. perfect.  So here is my question.

I have been putting off my cataract surgery until the symfony was available in the U.S.  I guess it now is.   I spend a lot of time indoors and I have been nearsighted all my life.  I can't see anything distance withotu my glasses and I cannot see anything very near unless I take my glasses off. I have progressives.  When I sit at my desk in front of my computer I take my glasses off.  I cannot imagine how uncomfortable I would be not being able to read a text message on my phone without having to put on "readers".  I like being able to walk around my apartment without glasses and I like, when the phone rings, being able to read my caller ID without having to find my glasses to see the screen.  Near vision is very important to me and I really  do not want to lose that.  I was under the impression that, with the symfony, you had an extended range of focus greater than simple monofocal lenses and that, for example, if I wanted to see clearly near, within 12 inchees, for example, that I would also be able to easily read my computer screen, which is about 27"- 30" away too.  Probably would have to sacrifice my distance vision to achieve that but that is a choice I thought I would have with the symfony.  Are you saying that, if I want good near vision with the symfony that I won't not only have any decent distance vision but I also won't even have good intermediate vision as well?   So what is the point of the symfony.  If that is the case, what is the difference between the symfony and a standard monofocal set to near?  I thought the whole point of the symfony was the extended focal range.  What am I not uinderstanding?

34

I'm still happy I chose the Symfony, for what it's worth. I knew going in that my near vision would be the worst off, relatively. I just didn't think it would be off as much as it is I'm still hopeful that I can get the residual astigmatism and added hyperopia resolved via laser or some other means--and both of these are things that can occur with any lens, including monofocals.

Symfony, which includes both toric and non-toric, was approved by the FDA last month and is now available in the U.S. Unlike multifocals, which are more like bi-focals, it typically provides distance vision comparable to monofocals, and good to excellent intermediate vision, and decent to good near vision; multifocals, meanwhile, have good near and good distance, but have a noticeable drop in acuity in between, in the intermediate range. Since I'm in front of a computer all day, intermediate was important to me (also for social interation and general getting around). Given that and the fact that Symfony also lacks the glare/halo issues associated with multifocals, that's what I chose.

35

Brian,

Thanks very much for the reply. I should've been clearer in my initial post that I'm not dissatisfied overall with the Symfony. And in fact the issues I'm having, it turns out, seem due not to the lens but to, I guess, bad measurements and unlucky orientation of the lens (it turns out I went from nearsighted to now 0.5 farsighted, and my astigmatism went from 0.94 to only 0.75).

I knew my near vision would likely be the worst after surgery; I just didn't think it would be as bad as it is. At ~20/80 near, I'm in the very low end of the distribution (comparing my outcome to those in the U.S. clinical trials, where fully 81% ended at 20/40 or better (the rest being 20/50 to, like me, 20/80).

It's not a complete shock, as presbyopia had set in about a year ago now. It probably wasn't as bad as it would have become, but I was at least getting used to dealilng with it.

Given the residual error I have, I scheduled an appointment with my surgeon two days from now. I'm hoping he has ideas and a willingness to resolve the issue with my current eye. I'd like to get that done before proceeding with my other eye, since it could affect the amount of monovision to target.

I'll update once I know what he recommends.

Thanks!

36

WebDev,

​I've seen several opthamologists and most mentioned that any astigmatism significantly lower than 1.00 was not worth correctling (like for my 0.5 eye). Although from my knowledge I stil see it that correcting any amount of astigmatism is worth than to leave it alone.. It's interesting you mention the ZXT100 though that targets smaller amounts of astigmatism, do you know if this is available in Europe and if it ever will be in the U.S? I've heard there were multiple versions of the torics available and since the ZXT150 might cover the majority I think that may be one of the reasons why the other versions are not available (I heard there were like four of them). Please keep me updated on what information you get from your next visit regarding astigmatism and your monovision choice.

37

So I am still confused.  Are you telling me that the symfony is supposed to get over 80% chance of seeing 20/40 in near vision as well as excellent in intermediate and distance and that, for whatever reason, u were just "unlucky" that you were in the minority of those people whose near vision didn't come out so well?  Seeing excellent in near is more important to me than seeing excellent in distance.  I know the overwhelming majority of peole prefer distance to near but not me.  I have had to wear glasses for distance all my life so I m used to it.  I decided to wait fo the symfony because it seemed to offer what the mulit focals offered, plus the advantage of good intermediate, plus the other advantage of much less chance and severity of halos at night that the multi focals are so famous for.  So now I am reading that you had the symfony in one of your eyes and were surprised at the unexpected poor results for your near vision.  So my question is, I was told I have slight astigmatism but not so bad.  I have to go back and get precise numbers tied to that so I can post more precise information here I guess.  But I thought if I adjusted my focal target to say intermediate instead of to disntance, that my extended "range" that the symfony gives you would be enough to give me excellent near and intgermediate, even if my distance was not as perfect as I could have made it if I set my tartget focal range a little further out.  Am I missing something?

38

If the IOL is rotated, then rotating presumably would impact the issue. If the power is still off, then it can be corrected by a lens exchange or laser correction. Unfortunately it can take a number of weeks for the refraction to stabilize after surgery so it would be a while before most surgeons would consider a laser correction since they wish to be sure to get it right, though I don't know how long is typical offhand. Usually they wait a month before prescribing glasses, though in some cases vision isn't stabilized yet and they wait a couple of months, so presumably they'd wait even longer before doing surgical correction. 

39

Astigmatism as low as 0.5 they usually correct via incision rather than through a toric lens. Part of that involves merely strategic planning of the incisions they need to do anyway as part of cataract surgery, to locate them where their surgically induced astigmatism will counter existing astigmatism rather than add to it.

40

As WebDev indicated in an update on this page, his current subpar results are due to residual astigmatism and the lens power being off target leaving him hyperopic. They aren't indicative of the performance of the lens itself, vision with a monofocal with the same residual refractive error issues would be much worse, and it would cause trouble for any other premium lens as well. 

That said, it is true that the results of lens studies are just averages since the actual results vary with each person based on the quality of the rest of their visual system, e.g. its natural depth of focus and the sensitivity of the retina, etc. There are a tiny minority of lucky people that can even read a little with a monfocal set for distance, but its best to plan on average resutls, while being prepared they may not be quite as good.

I wouldn't say the Symfony offers the same as bifocals in that the odds seemd to be that its  intermediate is likely better buts its near not quite as good. Yes, locating the focal point at intermediate rather than distance would give very good near, up  to a point. Unfortunately as you get nearer in, it takes more diopters to provide additional near so there is a limit to how near you'll get with any IOL since they don't provide the 18+ diopters of accommodation a young adult has. At the spectacle plane, a focal point of - X diopters focuses at (100 / X) centimeters, so -1D is at 1 meter, -2D is at 50 cm, -3D at 33.3 cm, -4D at 25cm, -5D at 20cm, etc.