Symphony lenses for my cataract operation

Eye care
1

I'm blind without a distance glasses for driving and look around and blind without a reading glass. My dr. Wanted to put Intraocular lenses for my fra sighted vision. He ignored my near sighted vision. I was having a sleepless nights thinking what will happen to my near sighted vision. So, I called him he suggested symphony lenses which will problem solve problems but not all together. But it'll cost me 

$2500.00 per eye. Insurance will not pay for symphony lenses. It's a new technology. I tried to learn more about it but not so much luck. Need some suggestions .

2

As I mentioned to you in another post by you:

The Symfony lens is a good lens, but like every other lens, it has its associated issues. I have a Symfony Toric lens in my right eye in combination with a monofocal lens with distances set for monovision and allowing me to not having to use glasses at any distance. As I have indicated in these forums before, "I am overall happy with my day vision with the combination and am satisfied with my choices. However, I do have an issue with the night vision because of multiple concentric circles seen with Symfony lens, as discussed under 'Has Any One Else Noticed This Unusual Vision Issue with Symfony Lens.'"

So, rather than repeating myself in this post, please look that over so that you are aware of the pros as well as the cons of Symfony lens.

3

I had the symfony lens put in my right eye 3 months ago and in my left eye one week ago. You are getting a good deal I had to pay $3,300 for each eye. My right eye is set for near and intermediate and my left eye is set for distance and intermediate. Everything is going good except for concentric circles around lights and Halos at night. My second surgery went much quicker than the first. I'm hoping that the Halos and concentric circles will get better in time but if they don't it won't affect me too much because I'm not out that much at night. I really put a lot of trust in my doctor to help me make the best decision. Good luck.

4

If you get monofocal IOL in each eye with post operative target of about minus 1.5 diopter you will be able to read without spectacles. With such a correction you will use distance spectacles for driving and TV etc . You will not have halos. You could still wear contact lenses for sport etc if needed. There is no extra cost or risks involved with such as there is with premium IOLs

I am an ophthalmic surgeon in U.K. but you need to talk to yours

Good luck

5

If you aren't out at night as often then your brain isn't getting practice at tuning out halos so they may take longer to resolve (though the usual use of the lens, and using it indoors in lower lighting will still help). I never considered the mild/translucent halos a problem (partly since glare disability is less, headlights are less distracting) but at 2 years postop they have started disappearing from some lights where I consistently saw them before (though still not gone from others, just faded). I  have been out less at night postop due to working more at home so that may be also part of why it took longer.

Usually such issues resolve. Google "High rates of spectacle independence, patient satisfaction seen with Symfony IOL" for details, e.g. "Most subjects who reported symptoms rated them as mild or moderate. In the U.S. study, for example, reports of severe visual symptoms were less than 2.8% for halos, none for glare and less than 1.5% for starbursts.

Historically, we have seen that 3% to 5% of patients implanted with monofocal aspheric lenses report glare and halo, so there is only a small increase in these studies. It is important to note that the use of femtosecond laser, manual limbal relaxing incisions, and LASIK or PRK enhancement were all disallowed during the study, so residual sphere or cylinder error may also have contributed to the incidence of visual symptoms.

In the European studies, subjects were asked if they would recommend the lens to a friend. Nearly all (97.9% in the Europe-1 study and 93.7% in the Europe-2 study) said yes. "

 

So the incidence of halos tends to be not much different from a monofocal, but unfortunately the minority who do see issues with any lens tend to be those who post. There is a risk of them, but people need to keep it in perspective. 

Studies actually only tend to report the incidence of halos with IOLs after 3 or 6 months go give people time to adapt since more people see them temporarily while adapting to the IOL (even those with monofocals). I haven't seen data on how quickly they resolve with the Symfony, far more people see them with a trifocal, but here is some data I saw for a trifocal (note: they moderate links, google to find the info):

"Regarding the perception of photic phenomena, 90% of patients reported to perceive halos at 1 month after surgery, although 80% of these patients described these halos as not disturbing. At 3 months after surgery, the perception of halos decreased to 50%. ... 

This perception of halos decreased in all patients at 3 months after surgery. Law et al. [5] also found a reduction in the perception of halos over time, decreasing from 80% at 1 month to 40% at 6 months after the implantation of the same trifocal IOL." 

I suspect the percentage who found their halos disturbing also declined over time, even if they continued to see mild halos.

also:

"Halos: Halos around lights at night are a form of dysphotopsia that is common with multifocal IOLs. Therefore, I warn patients that this occurs and is normal. The halos improve with time and usually resolve within 6-12 months. When patients are having difficulty with halos, constricting the pupil with Alphagan-P or pilocarpine can be quite helpful. Vision training may be beneficial as well. Ultimately, an IOL exchange can be considered but is rarely needed.:" 

and:

"Neuroadaptation is a new buzzword for refractive cataract surgeons. Recent data presented as part of an online patient registry involving 20 surgeons showed that, on average, approximately 65 to 67 of the 98 patients included in a 6-month follow-up group achieved an improvement in halos, glare, and ghost images1 (Figure 1). ... "

 

6

People's visual preferences differ. Before I had cataracts I wore contact lenses in monovision and liked that. However after a few years I tried multifocal contacts and noticed that the world seemed subtly more 3D and I preferred that. I hadn't noticed the redution in steropsis while the level of monovision had slowly increased, but noticed its return when I switched to multifocal contacts.  Not everyone tolerates monovision, even if most do.

Despite the attempt to claim there are definitively "no" risks, rather than merely low risks, the American Academy of Ophthalmology notes issues regarding monovision LASIK which also apply to monovision using IOLs (they moderate links, google to find the source):

"Side effects of monovision LAISK is an important concept for both the surgeon, as well as the patient to understand, and never to be “brushed under the rug.” Side effects are a direct result of the imbalance or anisometropia caused by monovsion LASIK. Side effects include; blur or fog in distance or reading vision, glare and halos, especially at night, reduced night time vision, especially driving, reduced depth perception, an uncomfortable feeling, or even transient diplopia caused by temporary strabismus. Side effects for most patients will tend to decrease overtime as a patient adapts to their new vision. "

You'll notice btw the mention of "halos" in there, in contrast to the definitive assertion by a supposed "surgeon" that you won't have them.   One article notes:

"Greenbaum's report[13] had little discussion regarding complications of pseudophakic monovision, but the incidence of halos or glare was 20% overall."

Studies show a slight increased risk of problematic falls in the elderly with monovision correction due to reduced depth perception. Even in the non-elderly, with the Symfony I appreciate having good vision with both eyes in front of my feet for good  depth perception when jogging/hiking on trails that are rocky or with potential spots of black ice, etc. I also assume the odds are low I'll ever have a problem with 1 eye, but if I do then its useful to know I have a decent range of vision in the other. 

 Contrast sensitivity is reduced for distance and near in low light since you are mostly relying on the image from one eye for each end of the visual range.

One surgeon reports: "adjunct associate professor of ophthalmology, University of Minnesota, Minneapolis; and medical director, Chu Vision Institute, Bloomington, Minn., said that monovision is an important option for patients who are 40 years and older who want refractive surgery or presbyopia correction. "I do tell patients that a majority of patients do not tolerate the imbalance between their eyes but that I want them to hear about this as an option. I think it's important to determine the best situation for patients, whether it's through a contact lens trial or a discussion of past experience with monovision. I think following those general guidelines will help you be successful with monovision in your patients, "

 

Another paper on monovision in general, mostly with contact lenses, notes: "y. The present paper is a review of the literature on monovision. The success rate of monovision in adapted contact lens wearers is 59– 67%..." Although its notes a wide range of success rates including some higher: " (Levinger et al., 2006); and 91% for monovision pseudophakia following cataracts and 95% for clear lens pseudophakia (Greenbaum, 2002)".

Its an older paper, 2007, so its references to multifocal IOLs are to out of date technology and not relevant, but monovision shouldn't be much different.

re: "You will not have halos. "

Contrary to that absurd claim, competent surgeons, and those capable of reading realiable sources, explain that there is no IOL in existence that can guarantee you won't have problematic halos. People get problematic halos with monofocals, posts about them are around the net and recorded in lots of studies.  Yes, most people don't have problematic halos with a monofocal, few enough  that even a decent doctor won't bother mentioning it unless the topic arises. However if it does,  its irresponsible to explicitly say someone "won't get halos".The net is full of complaints from patients who had unexpected results after doctors made statements seeming to be guarantees.

 I'm hoping this supposed "surgeon" is still in training, I certainly would suggest people steer clear of anyone who exhibits either a lack of basic knowledge, or questionable reasoning regarding how to explain things to patients. 

Increases in refractive error can raise the incidence of halos, e.g. even people wearing contact lenses in monovision have reported an increased incidence of halos with contact lenses in monovision, e.g. google (since they moderate links):

"THE EFFECT OF DIFFERENT MONOVISION CONTACT LENS POWERS ON THE VISUAL FUNCTION OF EMMETROPIC PRESBYOPIC PATIENTS (AN AMERICAN OPHTHALMOLOGICAL SOCIETY THESIS)"

7

I should note that the higher level of success with monovision done surgically is likely partly because better surgeons screen patients for it with various tests more than they bother with for contact lenses (with contact lenses being one of the tests). Its preferable to have   a contact lens trial before the cataracts are too bad, though those who are young enough to have some remaining accommodation should realize it may not be entirely accurate regarding the range of vision they'd get with monofocal IOLs. 

 

8

I haven't checked on the source of this data, but it suggests caution before assuming monovision will work:

"

Dr. Marian S. Macsai, MD , Ophthalmology, answered on behalf of NorthShore University HealthSystem

Monovision LASIK surgery is an excellent option for patients over 40. However, before having this procedure it is best to have a contact lens trial to demonstrate monovision, as not all patients will tolerate this. Approximately 1/3 of the population, regardless of their prescription, cannot tolerate monovision. It is best to identify these patients prior to performing LASIK surgery."

 I will note that some surgeons do tolerance testing using techniques that don't rely on a   contact lens trial since they note that more people may tolerate it with IOLs than with contacts. Usually small amounts like the micro-monovision sometimes used with the Symfony is in the range that almost everyone tolerates easily, since it has little impact on steropsis, ec.

 

9

Neuroadpation: Just  another word for the patients learning to live with the vision issue because there is nothing they can do about it and they know that the surgeons don't want to hear abot it!

10

This may be overkil, but I figure when someone claiming to be a surgeon says something then people will take it seriously so if its misleading, its useful to post comments from other doctors and studies. This study on lasik monovision notes:

"PMID:  18061266 .....

 Of the 172 patients treated with monovision correction, only 7% chose to forego monovision and subsequently enhance the near eye to distance vision. "

Smaller levels of monovision are more easily tolerated. The London Vision Clinic notes regarding laser monovision, where "blended vision" is a smaller level of monovision:

"Approximately 95% of people are candidates for Laser Blended Vision as compared to about 50% for traditional monovision."

though it cites a slightly different stat here:

"In monovision only 60% of people given enough time, six months for example, will eventually tolerate having a difference in the eyes and the reason for this is quite simple.  The focal points in monovision are very, very small.  In other words the distance eye is only good for distance and the near eye only good for near.  There is a gap between the two and that often leaves the patient feeling very uncomfortable.  In blended vision we are able to increase the depth of field for each eye respectively to give the distance side distance vision and intermediate and the near eye near and intermediate, so that there is no gap between the eyes and therefore it is much better tolerated. 98% of people will tolerate blended vision over a six month period in comparison to the 60% that will only tolerate monovision.”

The exact statistics seem all over the map, another site says, anecdotally:

"During your LASIK evaluation, you will likely be tested to confirm your eye dominance. Also, that you can tolerate monovision. Not everyone is a good candidate. A thorough evaluation is important in this setting. In my experience, about 80% of patients can tolerate monovision. Usually, this is discovered before any procedure is performed. In rare cases, monovision is not tolerated after the procedure. Fortunately, this is reversible in most cases and the patient is then corrected for distance focus in both eyes."

11

No. I literally do *not* see halos around some lights now where I *always* saw them before. I still do see halos around other lights, though they are faded compared to what they used to be. The brain is able to adapt to many things, e.g. its in reality a minor case of neuroadaptation even having vision changed by wearing glasses, contacts, or being corrected via laser or getting a  monofocal IOl leads to a change in the visual system that the brain adapts to. Although it may seem odd to think that a visual artifact you see now might actually somehow go away, it happens.

 

12

People's results vary, but in my case with the Symfony  I have what seem to be fairly typical results based on the studies. I have at least 20/15 distance vision (they didn't have a line below that to try, and that line was easy), and 20/20 pus a bit at 80cm, and 20/25 at best near (and likely at 40cm. they didn't have a 20/25 line when I was tested at that distance, but I was 20/30 and saw a bit on the 20/20 line so it likely would have been 20/25).

Although I'm one of the small minority that sees halos at night, I don't consider them a problem at all. They are so mild/translucent that I see through/past them. To balance that, the light from the headlights is much less distracting than it used to be,less glare disability, so I more comfortably see the surrounding area and that more than makes up for the halos I see through. 

Your other post suggested you were both nearsighted and farsighted, which isn't quite the right way to describe it.

The inability to see distance is called being nearsighted. If you can't see near when you wear your correction for distance, it is due to presbyopia, which is an condition that develops with everyone as they age, usually noticeable in the early to mid 40s when they start needing to wear special correction to be able to see near. Your eye can't change focus from far to near as well as it used to, and over time it will stop being able to change focus at all and need stronger readers.

 Most people getting the Symfony lens have cataracts, but it sounds like you might be talking about using it for avoiding the need to wear correction, which is called "refractive lens exchange" (RLE) or "clear lens exchange) (CLE). The vast majority of people who get the Symfony are very happy with it and would recommend it to others and make the same choice again. Most don't need to wear glasses usually, though a small % need low powered readers. Its necessary to be aware of the fact that a tiny minuscule % of people may have issues like night vision problems like halos that are bad enough they wish to get a lens exchange, but that is also a safe procedure. I figured the odds of having good vision without correction for the rest of my life were worth a very tiny chance of needing a lens exchange.

It depends on how much really near vision is important to you compared to other distances whether the Symfony or another IOL is the best choice. 

 If you are outside the US, if your highest priority is not needing glasses for near,  then a trifocal IOL has greater odds of not needing glasses than the Symfony. The tradeoff is that its intermediate vision may not be quite as good as the Symfony, with perhaps even a very slight reduction in distance as well, and it may have a slightly higher risk of night vision issues, and of slightly lower quality vision  in dim light compared to the Symfony. I figured that better intermediate vision and a lower risk of night vision issues was more important to me than very close near I might get with the trifocal. I rarely need more near than I have with the Symfony, e.g. using readers to thread a needle isn't a common task,  so I think it was a good choice in my case. 

If you are in the US there are bifocals that may give more near with the Symfony, but even less intermediate than the trifocals. (though lower add bifocals have fairly decent intermediate, not quite as good, but at the expense of less near). 

13

Hi softwaredev

I have read some of your posts regarding the Symfony with great interest.

I am planned to have the first of two Symfony lenses implanted on 27th April 2018 with the second 5 weeks later to evaluate the healed result.

Lasik is part of the package if any minor tweaks are needed.

I do not have cataracts so this is an elective RLE proceedure and have read the various posts warning not to do it unless I have cataracts,but I have carried out a lot of research and feel well informed of the shortcomings of this lens ie halos,starbursts and possibly needing low add readers for occasional very intricate work and I am ok with those compromises.

My prescription is R +3.25  -0.75x95      L +4.50 -0.5x45  so Symfony Toric lenses are planned for both eyes.

I am planning the left eye first with a mini monovision approach of 0.5 minus for near reading and to see how I like the Symfony lens.

I am tall 6`2" with long arms so a natural reading distance of 45 -50cm is being aimed for.

The right eye will be set for plano/ distance if everything goes to plan.

Now I eventually get to my questions,

1.I know that I will have a drop off of distance vision in my left eye due to the mini monovision but what distance do you think would be in focus before that happens?

2.Do you think that as only my right eye is set for plano and will be in focus at distance,would driving and playing golf etc be an issue with regard to judging depth perception and distance from other cars and objects etc?

Regards

Tom