Recommendation for upcoming cataract surgery

Eye care
1

Hi All

I am 45 year old and I am scheduled to go for cataract surgery in January 2024 in my left eye and I have some anxiety related to it. My doctor has suggested J&J AR40E (J&J Sensar Monofocal 3-Piece) lens aiming for distance vision (with emmetropia as final refraction). Although he is also fine with aiming for near vision but leaves the choice to me. However, I feel I dont have all the understanding to make an optimal decision.

I am listing below my situation and preferences and will appreciate it if you can recommend, based on your experience, what can be a good approach for me. Also, please share any epxerience/opinion with J&J Sensar Monofocal 3-Piece lenses.

  1. I am highly myopic (around -15D in both eyes) and have been wearing thick glasses pretty much my whole life.
  2. My current visual acuity is .3 in the eye that is going to be operated and .5 in other eye.
  3. My work involves heavy computer work and reading.
  4. I currently have lot of issues with night vision; halos, glares, difficulty in dim/low light conditions. This makes it difficult for me to do things like driving car at night, being in low dim places like restaurants etc. My preference will be to get rid of these issues and I dont so much care about whether I have to wear glasses (either for slight myopia or reading glasses) after cataract surgery.
2

Sensar is an interesting choice. I wonder what the reasoning is? The Tecnis 1 or Eyhance would be a more typical choices from the J&J line. They have negative spherical aberration which cancels out the positive spherical aberration (SA) most people have in their corneas. That results in better night vision for most people because the effect of SA is most noticeable when the pupil is big thereby making use of more of the lens (not just the centre 2-3 mm). The Sensar lens is a spherical lens with positive spherical aberration. Maybe you have an unusual cornea. . I'm afraid I don't understand your .3 and .5 numbers… is that decimal notation? Or logmar? And is that corrected (with glasses) or uncorrected? Do you know what it is in Snellen? . The thing I've found with glasses is I don't mind them at all for prolonged tasks like working at the computer. It's not the wearing of glasses that is a pain after cataract surgery, it's the loss of the ability to focus at different distances which means switching glasses for different tasks. So if there isn't a lot of switching it's fine. If there is a lot of switching it's a bit of a pain. The classic example would be grocery shopping where you might be constantly switching between distance vision (walking through the aisles) and near vision (reading labels). To make this more convenient some people will wear progressives. . It's hard to predict how you night vision issues might change without know what is causing them. In a typical eye with a typical cornea and no other pathology a monofocal will typically give you very good night vision without any (or many) unwanted side effects… but it's different for each person. Monofocal is your safest bet by far in this regard though.

3

It seems premature to select J&J AR40E (J&J Sensar Monofocal 3-Piece) non-toric lens. What astigmatism does the doctor predict you would end up with?

https://iolreference.com/sensar-3-piece/

I am highly myopic (around -15D in both eyes) and have been wearing thick glasses pretty much my whole life.

Getting IOLs will be a great improvement.

My current visual acuity is .3 in the eye that is going to be operated and .5 in other eye.

This would correspond to about 20/70 and 20/40 using the Snellen notation.

4

It's not the wearing of glasses that is a pain after cataract surgery, it's the loss of the ability to focus at different distances which means switching glasses for different tasks.

The glasses can be progressive or bifocal. Plus, for closer stuff, you can adjust your head or monitor position to best match your eyes. For distance you cannot adjust in a meaningful way.

An eye tuned to far makes for good safer driving, and if you don't need glasses for driving, there are fewer optical surfaces to generate glares and halos. I

The post waiting to be moderated suggest that it may be premature to select a non-toric lens.

5

are you saying the glasses are "optical surfaces to generate glare"? explain please

6

The glasses can be progressive or bifocal.

Yes. I mentioned that at the end of the same paragraph. The point is everyone (doctors included) thinks the objection is to wearing glasses. It's not. Not exactly. I've worn single vision glasses my whole life. I don't care about wearing glasses. The issue is the constant mode switching in certain scenarios once you become presbyopic either due to age or getting an implant. . I experienced that last weekend doing some body repair on my car. The constant switching between intermediate to do the grinding, masking, painting vs. near vision to see the area in detail, read instructions on products, read grit numbers on sandpaper, etc… was a huge pain. I had to be constantly swapping what glasses I was wearing. . Another example is when I'm doing night activities with Search and Rescue switching between seeing where I'm going and reading my notes, or compass or GPS. These are the situations that are a pain, not using the computer… because computer use is in one place (I leave the glasses on my desk) for prolonged periods (I'm not frequently switching tasks). . Young people who still have accommodation before surgery may fail to fully appreciate that. And yes progressives are a good option but they're not perfect and not everyone can adapt to them. And they can be very expensive. I'm between surgeries so I don't want to spend money on those yet… and again, getting properly made ones can be expensive (don't ever buy progressives online).

7
  1. There are a couple of issues with being highly myopic. One is that it will be harder to predict the power needed for correction with an IOL. There are some good calculation formulas like the Hill-RBF 3.0 and I believe one of the Barrett formulas is suitable for long eyes (high myopia). The second issue is that if you correct to something closer to plano you will have a huge differential between the eyes until you have the second eye done. Some opt to do both eyes at the same time, but I would not recommend that. Ideally you want at least 5 weeks recovery for the first eye and then a refraction done to see where the eye ended up. This information should be valuable to the surgeon in determining if any correction needs to be made to the formula used for the second eye. This means you will have to go 6 weeks or so with only one eye done. I would highly recommend using a contact in the unoperated eye for that time period. Correcting one eye that much with one eyeglass lens and having no lens or a neutral lens for the other eye can be very disorienting.
  2. I assume those are logMar values with 0.3 being about 20/40 and 0.5 about 20/60? And if that is with cataracts that is not too bad. No red flag there.
  3. Most people opt to correct to distance vision and use readers or progressive glasses for near vision. Another option if you would prefer to do computer work and reading without glasses is to correct both eyes to -2.5 D. That is the normal add for progressive or bifocal glasses and provides very good near vision. You will of course need eyeglasses for distance and driving. However, they will be much thinner and lighter than the glasses you have now. A third option is mini-monovision where the dominant eye is corrected to distance (-0.25 D), and the non dominant eye to -1.50 D. Together you can have good vision from about 1 foot out to infinity, if the targets are hit. Readers may still be needed for some very difficult reading in poorer light. And some prefer to wear progressives for night driving. I would count on needing progressives. Then you have an eyeglass free option and an eyeglasses option to use. This is what I have, and I almost never wear my progressives.
  4. Your issues in vision are most likely the cataracts. I would stick with a monofocal lens to avoid any optical side effects from an EDOF or MF type of IOL. I am not familiar with the Sensar lenses but your surgeon may have picked them because they are available in very low powers and even negative powers. A very rough estimate of the power needed for -15 D eyes would be a +1 D power. Most IOLs only go down to +5 D. The Sensar AR40E (uppercase E) goes from +2 to +5.5 D, so may be still a little too much. the Sensar AR40M goes from -10 to +1.5 D, so that may be needed. Have you had your eyes measured yet? If so, the surgeon will know what power is needed. Another alternative would be an Alcon AcrySof lens that is available in those low power values. The MA60MA is listed for -5.0 to +5.0 D. . Your biggest overall risk is in missing the target. I would insist that the surgeon use at least 2 different formulas suitable for very high myopia to determine the power. One upside of targeting reading vision of -2.50 D is that the acceptable range for near vision probably extends from -2.0 D to -3.0 D. If the surgeon can land the first eye in that range, then you get a second chance to get the other eye to hit -2.5 which may be the optimum. Having them exactly the same is not essential as long as one eye is close to -2.5 D. The surgeon should learn a lot from the first eye outcome and be more accurate on the second eye. If multiple formulas are used for the prediction the surgeon can then pick the formula that was the most accurate for the first eye, and use it for the second eye. . Hope that helps some
8

I agree that progressives are very annoying when doing auto work or any situation where you have to look up at close objects. It forces you to look through the top of the lens which only has distance correction. Now with mini-monovision I only use safety glasses to keep the dirt out of my eyes.

9

are you saying the glasses are "optical surfaces to generate glare"? explain please

You have seen reflections in eyeglass lenses. That light goes places. It will reduce the available light, but can also provide artifacts other than a dimming.

Many TV shows have the actors wear glasses frames with no lenses.

If the lenses are not perfectly clean, this increases the artifacts.

10

I assume those are logMar values with 0.3 being about 20/40 and 0.5 about 20/60? And if that is with cataracts that is not too bad. No red flag there.

I had suspected they were the numbers in the Digital column of the last table of the Wikipedia "Visual acuity" article.

I am not familiar with the Sensar lenses but your surgeon may have picked them because they are available in very low powers and even negative powers. A very rough estimate of the power needed for -15 D eyes would be a +1 D power. Most IOLs only go down to +5 D. The Sensar AR40E (uppercase E) goes from +2 to +5.5 D, so may be still a little too much. the Sensar AR40M goes from -10 to +1.5 D, so that may be needed. Have you had your eyes measured yet? If so, the surgeon will know what power is needed. Another alternative would be an Alcon AcrySof lens that is available in those low power values. The MA60MA is listed for -5.0 to +5.0 D.

Good point. No toric available for those?

11

"The issue is the constant mode switching..." . Yes, that is exactly what I am trying to avoid. * Putting on glasses, then taking them off * Switching from reading to progressive glasses, and vice versa * Needing to carry one or more pairs of glasses with you * Misplacing a pair of glasses, and needing to hunt for them * Losing your glasses and replacing them

It just seems like a giant hassle. I recently had a visit from my brother, and saw him misplace his glasses as soon as he arrived, and then spend a week with three pairs of glasses strewn about the house, constantly switching between glasses on and off or tilting his head this way or that, for computer work, driving, and other tasks. And even that was not enough - when he washed dishes (he is a model guest!) they ended up filthy because he was not wearing his reading glasses and could not see well enough to determine when they were clean. That is no way to live, if you don't have to. . I have no problem keeping a pair of glasses in my car for driving, so long as I can spend the other 98% of my life not fiddling with eyeglasses.

12

Not sure if torics are available in these very low power ranges.

13

Thanks a lot David for your reply.

0.3 and 0.5 are my current best corrected visual acuity (BCVA) on left and right eye in linear scale. This translates to 20/63 on left eye (which is up for operation) and 20/40 on right eye.

I will ask my doctor about why they chose the sensar lens. So thanks for pointing out some of its characteristics.

Night vision is important as I currently find low light conditions difficult to cope with.

14

Thanks Ron and David. I will read more about mini-monovision. I have noticed that you have made a very good post on the same. Does mini-monovision ensures good night vision?

15

Hi Ron

I will try to reply point by point as you have made some very good points.

  1. I am only going for my left eye currently and as you suggested will continue to use contact lens in my non-operated eye. I am currently also using contact lenses in both eyes.

  2. The 0.3 and 0.5 are my current best corrected visual acuity (BCVA) on left and right eye in linear scale. This translates to 20/63 on left eye (which is up for operation) and 20/40 on right eye on Snellen Chart. This visual acuity is with glasses/contact lenses (Since I am highly myopic, I don’t see much without glasses/contacts).

  3. “That is the normal add for progressive or bifocal glasses and provides very good near vision. You will of course need eyeglasses for distance and driving. However, they will be much thinner and lighter than the glasses you have now. A third option is mini-monovision where the dominant eye is corrected to distance (-0.25 D), and the non dominant eye to -1.50 D. Together you can have good vision from about 1 foot out to infinity, if the targets are hit.”

a. If I go for the second option (correction for near vision), will the glasses that I will need for good distance vision ensure good night vision as that is quite important for night driving. b. Same question for third option. Will mini-monovision ensure good night vision or are there any factors that I should be aware of. c. Alternatively, if I go for distance vision, will I have poor night vision for near vision situations like reading (or being) in low light, walking in dark etc, as this is what I experience currently and find very uncomfortable. And how do people deal with that.

  1. If I go ahead with current plan for distance vision and if that misses the target dur to really long eyes in my case, then can you summarize what can be the implications. My eyes have been measured and in doctor’s notes I can see the following:

IOL proposal IOL: J&J AR40E (located in the back) Diopter: -2.5 Expected refraction: -0.47

The first one is IOL choice but I am not sure about what is meant by Diopter and Expected refraction. May be I should consult him on this and also find out what formula has been used.

Lastly, I would also like to let you know that I have very long eyes (32 mm) if that is of any help in this discussion.

16

I drive in the city with street lighting without eyeglasses and just mini-monovision. When I drive in the country with no street lighting I feel safer using my progressive glasses that corrects both eyes to plano. That is about the only time I use my progressive glasses.

17

Diopter: -2.5

Expected refraction: -0.47

Let me take the easy one. I think he is aiming for making your best focus to be about 2.13 meters (7 ft), which would be trying to give you good distance vision. He will not be able to get that precisely. It is a target. If he gets close, that will be wonderful.

18

Hi Trilemma

Can you please explain how you obtained 2.13 mts.

19

3 a If you correct to near vision in the -2.5 D range you should get very good night vision with eyeglasses. I am thinking your current issues are due to cataracts. If there are other issues then vision might not improve as much as expected. If you only have a cataract in one eye, it would make me think there may be other issues associated with the very high myopia. . 3 b Mini-monovision without glasses is unlikely to give quite as good vision in the dark. With glasses it should be just as good as the near vision solution. . 3 c If you have distance vision you will need reading glasses or progressives for near vision. Vision should be good with appropriate glasses. . 4 A miss with distance vision will mean you will need eyeglass correction for both distance and near. Progressives would be the best solution. . I suspect the Diopter -2.5 is the power of lens they are predicting. That is a bit more negative than the +1 I guessed at. And based on the range I found on line for the lenses it would require the AR40M lens and not the AR40E, but perhaps what I am looking at is not currently accurate. The expected refraction is the predicted eyeglass correction you will need to get full distance vision. This is a reasonable amount under 0.0 plano. In theory it should get you close to 20/20 vision unless there are other issues with the eye. . I think your single biggest issue is accuracy of predicting your power needed. For sure you should ask what formulas are being used and why. The article below suggests the Barrett Universal II is the most accurate for eyes with axial length greater than 30 mm. This paper is from 2019 and the Hill-RBF 3.0 formula is much newer than that and may be good to. As minimum ask to see the predictions of the Barrett Univeral II and the Hill-RBF 3.0. The Hill formula is AI based and has been recently updated with new data. It is said that it will warn you if the eye dimensions are outside of the range it is accurate for. . https://pubmed.ncbi.nlm.nih.gov/30876784/ . You can go as far as asking for the detailed IOL Calculation sheet which will have the eye measurements on it. There is another recent thread here where I posted links to the IOL formula calculators on line. With the detailed eye measurements you can enter the data yourself and do the calculations with the various formulas. Here is a link to the formula thread. . https://patient.info/forums/discuss/iol-power-calculation-formulas-805028 . I like the mini-monovision option, but with the issues in predicting a power I think the -2.5 D near vision option is safer. With mini-monovision you need to get both eyes close. With the near option if you get one of two close you should get good eyeglasses free near vision. Either option is correctable with eyeglasses so you don't paint yourself into a corner.

20

My guess was that the IOL power to be used is -2.5 D which is very low, but in the range needed for very highly myopic eyes. And the expect outcome is -0.47 D which means about -0.50 D myopic instead of -15.0 D as the eyes are now. This is basically distance.