need feedback re: cataract surgery & correcting for near vs far vision

Cura degli occhi
41

Dear Mario1dog 

This is a fascinating discussion.

I do hope you get a good result from your cataract surgery and look forward to hearing the outcome

As a cataract surgeon in UK my experience has been to consider monovision or low myopia post-operative target for NHS cataract patients of presbyopic age group with pre-existing myopia and who have needed spectacles or contacts for myopia since youth.

Such folk will be happy being less spectacle dependent than pre-operatively and will have much thinner distance spectacle lenses postoperatively.  

Emmetropia for distance viewing is good for folk who were used to wearing reading glasses without problems after they developed prebysopia 

Yes there are evolving alternatives with use of multifocal or 'premium' intraocular lens implants in the private/self-pay sector but these are not without issues

A key factor in selection of  the post-operative refractive target following cataract surgery is for the ophthalmic surgeon to understand the patients visual needs, visual goals and past optical history and have a good discussion on all these matters in advance of surgery. By doing such talking beforehand shared decisions and realistic expectations can be arrived at by patient and surgeon.  It is wise to set some time aside to do this talking in advance of planned cataract surgery and not just do it on the day of surgery. All too often these matters are rushed as the doctors often lack the time to undertake the discussions to arrive at bespoke decisions 

42

I ended up going with the "regular" lenses, Acrysoft brand, & had the first eye done on 5/31, 2nd eye on 6/14. The goal was to leave me only slightly myopic, so my need for glasses would be less than it was before surgery (I was told I would probably be able to perform most indoor tasks without glasses post-op) & also so my glasses would be much thinner & lighter than they were pre-op (I've been significantly myopic & had thick, heavy eyeglass lenses since 3rd or 4th grade). However, a "calaculation error" (that's what they called it, in an effort to make it not sound quite so bad) was made when determining my IOL strength & my post-op prescription ended up being IDENTICAL (that's right, identical) to what it was pre-op in BOTH eyes...in other words, they screwed up big-time! So, the lenses in my glasses are just as thick & heavy as they were pre-op...& I am NOT happy about that at all! To make matters worse, I suffered Sudden Posterior Vitreal Detatchment (sudden PVD) in BOTH eyes approximately 3-weeks after the 2nd surgery. I have been dealing with complications from that for almost a month now, with large numbers of HUGE floaters & extremely blurry vision in both eyes at times. At the very least, I feel as if I am looking through a milky film almost all the time. The guy who did my surgery has a good reputation & came highly recommended, but I have been pretty disappointed in the outcome, especially the "calculation error", which has left me with thick, heavy eyeglass lenses. Oh well, nothing I can do about it now...  

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I might also add that the guy who fitted me for my eyeglasses post-op asked me why, with the problems I've ALWAYS had focusing on my computer screen (I've never been able to read it clearly with OR without my glasses), I'd never been fitted with eyeglasses JUST for computer distance. I'd never heard of that & didn't know it was a possibility. So I had him do me a pair of "computer glasses", which he said he felt would benefit me a great deal. Boy, do they EVER! For the first time, I can clearly see my computer screen! I have complained repeatedly through the decades about the HORRIBLE headaches I suffer due to eye strain from not being able to focus on the computer screen (my job involved extensive computer work, plus the time I spend on my computer at home), so WHY has nobody ever mentioned doing a pair of eyeglasses just for "computer distance" to me before??? They were only about $100 & well worth it! I got them (& my "regular" eyeglasses too) from ReplaceALens in Denver, CO. Ordering was very easy (online or over the phone) & turn-around time very fast (mailed to my door). I will definitely use them from now on & wish I'd found them sooner. If anybody else out there has problems focusing on their computer screen, I most definitely recommend trying a pair of eyeglasses set for computer distance!!!

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If you ended up with the same post-operative refractive error as you had pre-operative it sounds like a case of insertion of a wrong powered intraocular lens implant for whatever reason.

I provided a report on such matters some years ago and which can be read open acess at http://www.nature.com/eye/journal/v25/n6/abs/eye201189a.html 

These 'wrong implant' episodes and not supposed to happen and are thus sometimes called 'never events' 

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I am way past ready for cataract surgery. As someone who has worn glasses for distance since 4th grade and (until cataracts got worse) never before had to use glasses to read. I know you had complications after your procedure, but I need to understand just what lenses they put in your eyes, near or far or whatever near near is. Can you read without glasses as you hoped. 

46

Greta, I've also been in glasses since 3rd or 4th grade, so I understand what your fears & questions mean! I had both eyes set for near (so, "near-near&quot, so as to approximate what I've been accustomed to pretty much my entire life. I was afraid (so was my doc) that it would be really hard for me to adjust to suddenly being farsighted, which is how most people end up after surgery, since I've been SO nearsighted SO long. The brand of my IOL's is AcrySof, & I have no issue with the brand at all. They're the "regular", NOT multi-focal. What I have issue with is that the doc "accidentally" left me just as nearsighted as I was prior to surgery ("calculation error&quot, which was quite a lot, so the lenses of my eyeglasses after surgery are just as thick/heavy as they were prior to surgery & I still have to wear glasses all the time to see, just like I did prior to surgery. The goal was to leave me only BARELY nearsighted, so my lenses would be a lot thinner/lighter, but that didn't happen because he didn't double-check his calculation of my lens strength. Yes, since I am still nearsighted to a significant degree, I can still see AT A CERTAIN CLOSE-UP DISTANCE without my glasses...so I can see to put makeup on, fix my hair, etc...I just have to have my face that certain distance from the mirror to do those things. Once you have IOL's implanted, they don't "flex" like your normal lens does, so the certain "sweet spot" distance where us significantly nearsighted folks can see clearly without glasses is fairly narrow...but it's still there. I hope that makes sense. But as we age, our natural lens loses its ability to flex (presbyopia), so you may have already experienced that aspect with your natural lens & not even notice a difference in that after surgery. I can read a book without my glasses, but it has to be held at that certain distance. If you read my last post (prior to your post), you will see what I said about having a pair of computer-distance eyeglasses done. These have been extremely helpful to me for computer work! I just told them (ReplaceALens in Denver, CO is where I ordered them from; they made them & mailed them to me) about how far my computer screen is from my face when I'm sitting at my computer desk & they figured it all out. That set of eyeglasses is only good at that particular distance (things closer in or farther out are blurry), so they only work for my computer work (or anything else at that particular distance)...but that's what I needed them for, as I've NEVER been able to see my computer screen clearly with or without glasses & experienced BAD headaches when sitting at my computer...until now, so I love them! The hassle is that I use a laptop downstairs & have my PC upstairs, so I have to remember to carry them upstairs/downstairs with me! The only thing I really WISH had happened is for my doc to have double-checked the calculation of my IOL strength, so I would have ended up BARELY nearsighted, as opposed to REALLY nearsighted. I hope this helps you!

47

Greta, see the post where I just replied to you!

48

Thank you so much. I can't stand the thought of needing glasses to read my books. It's driving me crazy now since the cataracts cause me to need them for reading and the vision is not ideal.  The last doctor I visited told me there was no such thing as lenses for close up. I knew he was lying. They all tell you that you won't be satisfied with the near vision lenses. I disagree.

There's an old Twilight Zone that always upsets me. This man's wife nags him because she hates him reading books. He works at a bank and sits in the vault to read at lunch. When he comes out, evryone is dead from a bombing. He finds the NY public library and lays out all the books he's going to read for the rest of his life. Then he bends down and his glasses fall off and break. That would be my worst nightmare. 

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Greta, what happened to that man was my worst fear & was why I stressed SO much over the option of being set "far-far" (both eyes set to see clearly at far distances). If you go that route, you WILL NOT be able to see up close (read, etc) without glasses!!! You will have to, at the very least, have reading glasses. If you are set to be BARELY nearsighted, you will still be able to read without glasses (like you've been accustomed to) & will most likely be able to perform other close-up tasks without glasses (but would need glasses to see at a distance). If I'd ended up BARELY nearsighted, I'd be tickled to death!

50

I have had corrected monovision for 40 years, originally with a contact lens in my dominant right eye working with my uncorrected, myopic right eye. Worked great. In 2011 my O.D. sent me for cataract surgery in my right eye. The Opthamologist implanted a monofocal lens with LRI, continuing the monovision.  5 years later, June 2016, I was referred to the same surgeon for cataracts in the left eye. My O.D. and I agreed that monovision had worked for me historically, so I anticipated that the surgeon would implant a monofocal IOL. The day before surgery I paid the bill, which included $300 for an upgraded lens. I was more interested in why Medicare wouldn’t pay, than what was the upgrade. At no point did anyone describe the lens to me, and I assumed “same surgeon, same problem, same procedure”, no problem.

The day after surgery I met the Surgeon and received a card identifying the lens he had implanted. (I couldn’t read it, print too small). The Doctor suggested that I might need reading glasses, but that didn’t compute….why would I need readers if I only had cataract removal?  In the next few days I realized my arms weren’t long enough to focus on iPhone text, so I got my magnifier and read the lens identifier card….Technis1 multi focal, +2.75D astigmatism, ZKB00.  I googled that and soon understood why I couldn’t read small print (20” theoretical reading distance), and the meaning of the Surgeons suggestion that I might need readers. I dug through all my junk drawers and found a pair of Thrifty Drug store readers that I briefly used when I had contacts in both eyes 40 years ago.

Google research, including this site, informed me that I could demand the surgeon remove and replace, but that worries me. My O.D. suggested that time may fix the problem. THEN I received a bill for another $450, which the billing dept (in a different state or country) described as the difference in the uncovered cost of a Toric IOL and a Technis IOL upgrade. My choices now seem to be:

1.    Borrow $450 and wait for nature to help my vision.

2.    Live with readers, that was the reason I went to monovision years ago (and purchase a second pair of readers to “see” to tighten the screws on my old readers using  a 00 screwdriver.

3.    Make an appointment with a “competing” surgeon, for a monofocal IOL with astigmatism correction and/or LR, or

4.    Return to the original surgeon for redress.

51

You quote a price in $ and reference Medicare, so I assume you are in the US (this is a global site, and there are no multifocals approved in the US that correct for astigmatism (so I'm unsure why there would be any reference to it on the lens identifier card, perhaps you read something wrong).

You imply in "3" that you have astigmatism  , and correcting that even with the current lens might improve your visual quality potentially (though sometimes a small amount of myopic astigmatism lends a benefit without much blur, its possible yours is hyperopic and making things worse, or too large and adding blur).  I'm not sure if the "and/or LR" was a typo and it meant "and/or LRI" since an LRI (limbal relaxing incision) is one method to correct astigmatism... which can be done after cataract surgery. Some surgeons will do in their office at the slit lamp. Its a minor procedure  since it doesn't involve doing anything inside the eye like cataract  surgery does. Some surgeons prefer to do a laser incision. 

You don't state what degree of monovision you had prior to surgery, how many diopters difference there was, how near the near eye was focused. The near add for the multifocal lens you received is +2.75 at the IOL plane, which is about +2 at the corneal plane. If you had been given monovision, its likely they wouldn't have given you a difference of more than that for your myopic eye, so it isn't clear that your near vision would have been any better with monofocals in monovision, and may likely have been worse. It may be that your natural lens gave you greater depth of focus than an IOL would and so you had better near vision than you would have even if you'd gotten monofocal IOLs in monovision. 

Neuroadapation can improve near vision for some people with multifocals over the first few months.  It is possible to do a bit of monovision even with a multifocal if the near point isn't near enough. A laser correction could focus the near point in further than it is now, while not impairing your distance vision in that eye as much as full monovision with a monofocal would.

 

52

Gosh...I can't believe I have found this site with your query which is exactly my own situation right now. I am very worried about seeing into the distance permanently and not being able to focus sharply for near (say when applying make-up....I am a singer). What did you opt for in the end? I was thinking of telling my surgeon I want a lens that leaves me  a bit more myopic than 20/20...I assume by doing this my clarity at near distance would be something just shorter than arm's length. Would this do? I will need both eyes doing eventually......Because of this dilemma, I have put surgery off twice now and thinking of trying Can-C eyedrops....does anyone have any experience of these?

53

Carolyn, and I am in your boat!  What did you end up doing?  If you'd be willing to post again about what your other referrals yielded, it would be hugely helpful.  I just had right eye done for distance not realizing I would be LOSING my near reading vision.  Docs assume you realize that.  It's been a shock, to say the least.   Can't read, can't see iphone or computer.  In a tizzy about what to do now. Am told by current surgeon it is not safe to replace the new lens for near vision.  Also, i'm told that having each eye set differently has a drawback re field of vision --something that matters a lot as you age.  All to say, eagerly awaiting your developments/decisions.  Thanks.

54

Please DO that I ended up not being able to get near vision on my other eye with contacts apparently a surprise to my surgeon as I had a lazy eye as a child and even though I had early surgery in childhood it ambliopized 

is a horrible feeling not to be able to see up close 

my surgeon tried to convince me to monoficals both for distance but the idea at 48 not to see my child if I could not find my glasses and not be able to read a word is truly horrible

just got an exchange to symphony Tori and unfortunately blurred with and without glasses now

not sure what my options are scared to get surgery in my other eye now 

Any thoughts anyone ????

55

is early for me ; 10 days after lens exchange from simple Tori for distance which I hated ; I could not tolerate the contact for near vision ( seems my left eye can't get to see near )

i now got symphony on my on my right eye and everything at any distance is blurred and fuzzy 

laser tweak ?

it ended up that my cataract is incipient and maybe I did not need cataract surgery at all but have really bad astigmatism 

i am very confused ,went to a reputable second opinion but surgeons don't seem to like the extended visits with questions and concerns 

I am a pediatrician and my experience has been somewhat shocking 

Thought I must get educated first before getting a now third opinion 

I wonder if at least for distance I will need something done to my left eye soon ( LASIK ? ) as I have  too much astigmatism un corrected now on that eye 

56

i thought it was only my doctor

please make sure you get all your questions answered before you proceed 

I wish I did not do mine 

57

had I done it I would have had no surgery 

now number 2

Please talk to me about tweaking I am seeing b

very blurred and not satisfactory at any distance  10 days after Symphony

please advise

Also I have developed opacity apparently common and will need YAG ? Can anyone comment on that will it make clinical improvement yo my vision 

can I have tweaking and Yag?

when I asked my surgeon who has become not nice at all what if this did not work ( Meaning Symphony ) she said you may need to have again the Tori for Lind distance and to the other eye for long distance too

i am terrified as I hated not being an

ble to read and it would just be worse with both eyes for distance 

keeping positive but when I hear you say the results with symphony are almost immediate I am accepting it just did not work for me ?.

58

Which city ?

59

Make sure they don't assume you will tolerate monovision I could not get my eye to see near , spent three months trying the most uncomfortable glasses even reverse vision until I gave up

in your boat is awe full not to be able to read !!!

i can't imagine both eyes for distance 

try the contact lenses in the other eye 

I got replacement 10 days ago , 4 weeks after my first surgery 

with the same surgeon as every other told me it was too risky unfortunately symphony is not working as expected for me 

60

My respect you are a surgeon yet a fine clinician