What if you have zero vision problems *other* than cataracts? Lens choice? Outcome

Eye care
1

I am very confused. I’m 41, and like many I spend my working time in front of a computer. My main problem with cataracts is that I experience glare, especially from a bright computer screen, daylight, and so on. My vision is affected, but not that badly. I play baseball, and struggle to see clearly during the day. Less so at night, but it’s not perfect. I experience lots of glare (starbursts?) when driving at night. I don’t know what to call them, but I’ve dealt with them for a long time.

During my initial consultation, the doctor established that yes, I have cataracts, yes, they are worse in my right eye, yes, I suffer from significant glare, and all of that. However, I have essentially no problems with eye geometry or refractive errors. I was specifically told that there is no difference in my distance vision and near vision. I can’t seem to find any information on what this means for surgery. Most people seem to have either astigmatism or refractive errors when they get cataract surgery. All I know is that during optometry tests my left eye is still approximately 20/20 (mild cataracts) while the right eye cannot be corrected with any lenses because it’s just blur and glare, no refractive or spherical errors.

I have read about people that have gotten monofocal implants for distance only, yet don’t use or need reading glasses for anything other than microscopic print on a pill bottle. I would love to be able to see archery sights clearly, street signs, baseball, a computer screen, and all of that. I’m wondering whether that rare group that can get away with basic lens implants and need no glasses is related to eye geometry? Is it better that I have no eye problems? Worse? No change? Is it that uncommon to have only cataracts with no other problems?

2

First it is good that you have no vision problems other than cataracts. That is not a complication at all for cataract surgery. The first thing to understand is that the cataracts are inside your natural lens, and the surgery requires the removal of the whole lens which has the cataract inside it. This lens is replaced with a plastic lens that allows the light to focus on your retina like it did with your natural lens in place. These synthetic plastic intraocular lenses (IOL) are available in powers ranging from about 5 D to 30 D. If your cornea is essentially perfect, and it sounds like it is, then you will need an IOL of about 19.0 D. It will vary some from person to person, but will be in that range. . The issue with IOLs is that with the exception of some experimental and not totally functional ones they have no accommodation. Accommodation is the ability of the lens to change shape and power to let you see close as well as far. As we age the natural lens loses that ability and that is why past a certain age one needs reading glasses. At 41 you are likely approaching that age, but may not have significant presbyopia yet. . There are various strategies used by the various IOLs to overcome this lack of accommodation, with all of them have their pros and cons. Some multifocal (MF) lenses have multiple powers built into the lens and your eye is seeing multiple images with only one really being in focus. Examples would be the PanOptix and Synergy. Some people like them and others hate them. I consider them a high risk option. Another strategy is to stretch or smear the image over a range to improve the depth of focus. They sacrifice ultimate image quality for an extended depth of focus (EDOF). Examples would be Eyhance and Vivity. Some like them, and some do not, but they are a lower risk option than the MF lenses. And then then by far the most common option is to get a single power monofocal lens that give a perfect image at the distance it is set to. Examples would be Tecnis 1 and Clareon. Most (90% or more) people get a monofocal set to distance, and then use drug store reading glasses for close vision. It really puts you in the same position as an older person that has advanced presbyopia. There are also options to set the optimum focus point to a closer point. You can then potentially read without glasses but will need glasses for distance. Most who choose that end up with progressive glasses so they can read and see distance without having to put glasses on and off. . The last option, and one that many surgeons do not even mention to patients is to use a monofocal lens in both eyes but set one for distance and then set the other one for closer vision. As long as they are not set too far apart, then you can see quite well for a whole wide range of distances as the brain blends the image from each eye. That is what I have, and am quite happy with it. If you want to consider that option what I would do is get your worst eye done with a monofocal set for distance, and then after the recovery period use a contact in your other eye to simulate monovision. If your other eye is plano or requires no correction for distance, then you would use a +1.5 D contact to give reading vision. This allows you to evaluate how well you adapt to it. If this works for you then you can ask the surgeon to leave you at -1.5 D myopic in that eye and you will have monovision and quite likely independence from glasses for 95% of your needs. The other thing to keep in mind is that this does not prevent you from getting progressive glasses to fully correct for distance and close vision in both eyes. So you have two options for vision, one without glasses and another with. I have reading glasses which I use occasionally and also a pair of progressive which I almost never use. . Hope that helps some to get started on the complex process of selecting IOLs.... If you have questions just ask.

3

I don't wear glasses. Sunglasses are fine, but regular glasses I have never worn. Contact lenses, also never (again, no geometry or focus problems). I have read a little bit about monovision, and people seem to be a bit reserved in their evaluation of it. Multifocals aren't something I can find a lot of information on. Why do you consider them high risk?

I think the thing that is throwing me off is that I have quite literally no idea how I'm supposed to see. As far as anybody can tell, my cataracts are congenital. I have always had starbursts on lights at night, and while I used to see better in general I have been getting progressively worse (people with corrected vision have told me that they can clearly read things that I cannot at all). So I'm struggling with the idea that while options aren't perfect I have absolutely no idea how much better my vision will be with cataract surgery. I feel like seeing worse is not really possible, but maybe it is.

4

MF lenses tend to have issues with glare, halos, and spider webs (halo plus glare). A monofocal IOLs avoid that effect. Have a look at this article to see what these issues may look like. Your starbursts at night are likely similar to what a MF lens will cause. Getting a monofocal IOL will get rid of the starbursts that you are seeing now. Google this: . CRST Today CATARACT SURGERY | AUG 2016 Night Vision and Presbyopia-Correcting IOLs Daniel H. Chang, MD . There are pros and cons to every IOL. There is no perfect solution. The trick is to pick one that minimizes the cons.

5

I'm in precisely same situation as you, 44, normal eyes, no astigmatism, excellent range and sharp vision from near to far. I have medicine induced PSC which have pretty much ruined my otherwise great eyes.

I struggled through looking at lenses for over a month and had massive anxiety because I had zero idea what to expect and what my vision will look like once the IOL is implanted. It's easier for people with myopia or hyperopia to fathom what compromised vision looks like. Being fairly young I didn't want to mess up my contrast or color vision and the ability to get the best machine refracted prescription glasses money can buy so I went full circle back to least risk monofocal lenses.

The main take-away is that the amount of light going through your lens is always constant and usually not in your control a lot of the time and lenses spreading light over multiple focal points inside the eye will always come with a hit of contrast, which has an impact to low-light conditions. Monofocals will always use maximum amount of those photons for that one focal point. So you are essentially making a trade-off between image quality and range. Also with multifocals you have other issues as your eye is presented multiple images at once in different ranges, which means the image will always be fuzzy, your brain will learn to live with it, or not (assuming the refactive target was met in surgery). The newer category are the EDOF lenses which are monofocals with an elongated depth of focus to help improve the range nearby. This comes also at the expense of image quality and contrast, depending on how much extension of focus is implemented.

I had my surgery on friday the 3rd of March, a bit over a week ago. We had Eyhance for -0.25-0.3 ready to go, but because it doesn't have as good a distance vision i was worried I wouldn't have any usable glasses-free vision at any distance. That fear was probably unfounded. With monofocals you will anycase have generally that one sharp focus point which starts to diminish fairly quickly. Extended focus of the eyhance has some benefits there as the drop in image sharpness will be a bit less steep (though not by much). Ron's description of smeared distance vision is probably quite exaggerated to what the reality of that lens is and if it's clinically visible to the person is uncertain. Another concern was that you couldn't auto-refract glasses with EDOF lenses, but having 0 experience in actually getting prescription glasses of that nature I have no reference if that's actually of any concern or not.

So long story short I now have a Tecnis1, a lens with a long track record, in my dominant eye which ultimately got set to plano. This means my distance vision is pretty amazing. The color and contrast are mind blowing, but definitely the image stops being sharp relatively "far" away. I could've wished for a closer target like -0.25 but my eyes and the lens power wouldn't have allowed that since they only come in 0.5 intervals generally. The way your vision works for a distance lens is is that you'll have a clear panoramic view of far up until ~1-1.5 meters (4-6 feet) and then the sharpness drops so anything nearby will be 'overlayed' on that sharp thing but are fuzzier the closer they are. You will still have functional vision so you'll see all objects just fine, they just don't have any finer detail. My biggest fear was that you're practically "blind" nearby but that's not really how things are.

My previous prescription +1 readers which i didn't really need much until the cataracts started clouding my vision give me the best function around the house and they have a pretty long area where things are very good. The quality of store-readers is definitely worse, but I bought a chunk of them and i've been using 1,5's or 2.0's when working on the computer. If I could easily get readers in .25 intervals i would experiment with them more, but amazon deliveries aren't fast enough for me to play with them and most market readers are only, again, available in 0.5 intervals. I've also noticed that in very good lighting (full daylight) i'm able to read a LOT smaller print at arms length and things generally sharpen up. When your pupil is small, the depth of focus will also increase with a tecnis1, albeit probably not as well as with the eyhance which has been designed to take more advantage of that effect and shift the lens power to closer vision.

I was looking at the eyhance for a long time but a lot of the discussions here, especially Ron's points about "smearing the distance" and potential issues in getting glasses scared me off of it, probably for nothing and part of me still thinks I could've maybe picked that lens also and maybe actually enjoyed the less steep defocus curve in well light conditions. My second eye is due for surgery in 2 weeks. I may get a Tecnis1 set to -0.25 or -0.5 for that, the prescription on my other eye is a bit different, though also quite close to 0 naturally, so i may get something that improves my range a little bit. Also putting an eyhance on the non-dominant is on the table. I would potentially prefer using the same lens though to get consistency.

Ultimately, no matter what lens you pick, there's no guarantee of going glasses free and you will not have clear vision at all distances, such a lens doesn't exist today. With monofocals you will need glasses for the use-case you didn't target. I enjoy having a great panoramic view to the distance as I feel less claustrofobic that way. I'm planning to get the best glasses money can buy to handle my vision at closer ranges.

Varilux X series looks interesting as it has a 'depth of field' feature where everything in arms length should be sharp and you don't need to look for a 'sweet spot' with your glasses to read your phone etc. At least if they work anything like advertised.

6

the auto refractor is not a problem at all with diffractive EDOF. i played around with a friend's autorefractor after symfony and it was accurately reporting what i need for distance each time. now with eyhance since the central zone is for intermediate i dont know how it will play out.

you should get sample + lenses from your optometrist in increments of 0.25 (+0.5, +0.75, +1..+2.5) and wear it on your tecnis eye and see if you are ok with the distorted distance it produces to get your sweetspot.

being 44 doesnt help with your near vision. good luck.

7

As I said in another thread, it may be a little harsh to say that an EDOF IOL "smears" the image, but it is in effect what it is doing. Here is an illustration that compares the monofocal (top image) to the multifocal (middle image) to the EDOF (bottom). I suspect the images are exaggerated to show the differences though. . image . To the OP, the other thing worth mentioning about a monofocal lens is that your vision does not drop off a cliff when the viewing distance gets closer. Most people will get pretty good vision down to 2-3 feet with a monofocal set for distance, and then it starts to be not usable. And each person will be different. For me personally with a monofocal in each eye, I see quite well in these ranges: . Near eye: 8" to 7-8 feet or so Distance eye: 18" to the moon

8

yeah, being 44 isn't helpful, but but getting eased in to presbyopia is a better prospect than abruptly losing your ability to accommodate have sharp vision so far out is definitely causing my head to spin somewhat. Symphony is a diffractive lens for sure with all the baggage that comes with it, i need to check if i can get some help from the nearby glasses stores to get some more range to my readers, but at least i've been looking at the off-the-shelf readers and they tend to be pretty limited in the available powers at least what i've seen over here :)

9

I believe strongly in getting second opinions. I would do that, and make sure it's with a fellowship trained cornea/anterior segment ophthalmologist They are specialists in the cornea and in cataract surgery.

10

my message is moderated for some reason. tru readers come in +0.25 increments check them.

11

I know they do, i just couldn't find any off the shelf in the 'normal' stores here. I need to find some time and make some calls to the eyewear shops in the city.

12

dollar tree has readers with +0.25 increments but they start at +1. the tru readers start at +0.5 for sure as i have the +0.5 and +0.75.

13

Keep in mind the main issue with needing readers is having them when you need them. There is a reason Costco sells them in sets of three. I always recall my friend who got PanOptix in both eyes saying that needing readers was the most disappointing part of getting them. She said she thinks she has about a dozen readers spread around the house; upstairs, downstairs, in the kitchen, in the sewing room, in the trailer, in the truck, in the car, in the Arizona winter home, .... . I seldom use them and have one pair at my desk, and I am not totally sure where the other two are. I think, one in my truck, and the other in our trailer which is in storage.

14

I don't use readers that often, but I do find that prescription readers (mine cost $44) were MUCH better than cheap over the counter readers.

15

Yeah I 100% get that, the good thing about distance lenses is also that plus readers are usually abundantly available if you're in trouble, but I haven't seen any minus readers in the shops around here. I'm having to get used to this mess and I may end up regretting everything at some point in time. But as said before, there are 0 guarantees with any of this so erring to the side of image quality is not necessarily a bad thing. I do feel a lot more disabled than I did before my cataracts got bad even if my image quality and corrected sharpness is better than ever before.

16

I think the issue is that if that 'smearing' is ever visible to the user and if it's actually clinically significant. Ultimately the effect should be better acuity nearby. Having a few pixels off the distance isn't necessarily an issue to achieve that. If it weren't for the severe contrast hit I could've picked them easily.

17

I am in almost the same situation. I am 55 and never needed glasses for distance and only started using reading glasses about 5 years ago. I have cataract in one eye only for now. My doctor wants me to get Vivity and I have been leaning towards monofocal becasue I wanted the best quality vision possible. But I couldn't figure out what blurry near vision meant after the surgery. I assumed that I would be effectively blind when it came to near vision. But based on what I have read, it sound like it will be like being farsighted (presbyopia) where you see everything in near to mid distance but slightly out of focus and need glasses for reading or doing detailed work.

I also assume that since I use reading glasses with my good eye, I will still need reading glasses afterwards whether I get Vivity or monofocal.

Any feed would be greatly appreciated.

18

Having good vision before cataracts is a good thing. However, the cataract is inside the natural lens, so it has to be removed, and that lens needs to be replaced with an artificial lens. . You are correct that getting a monofocal set for distance is very similar to having presbyopia due to age. Your vision remains good. It is just that your arms become too short to hold stuff far enough away to read it easily! But, at age 55 you likely still have some accommodation or ability to focus nearer, so a monofocal IOL is probably a tough worse. It varies from person to person but in general if a monofocal IOL is set for distance or better still about -0.25 D under plano you should be able to see clearly down to 2-3 feet. Most will see the dash in their vehicle. . And yes the reading glasses you need for your other eye should work on the IOL eye as well. . The Vivity does let you see a little bit closer, but not a lot. If I recall correctly you gain about 10" closer vision than a monofocal, but that is still not enough to read for most people. And, you do take on a risk of halos around light at night. Some adjust to it, and others do not. I seriously considered the Vivity in one eye, but got cold feet at the last minute and went with monofocals. . The other option that some surgeons do not explain is mini-monovision. That is where you set one eye to see full distance (-0.25 D), and the other eye is set to be mildly myopic at about -1.5 D. It uses standard monofocal lenses, with the only difference being the power chosen for each eye. This is what I do, and I am at least 95% free of wearing glasses. My range of vision is from about 8" out to the moon with both eyes combined. Some simulate it with contacts before they go ahead with it using IOLs.

19

Monovision IOL configuration where one eye is set for distance and the other eye is set the other one for closer vision is not without its own set of risks. Despite the use of monovision for targeting higher levels of myopia for near vision to offer high levels of spectacle independence for reading; it can cause issues in patient neural adoption, stereoacuity, contrast sensitivity, depth of field perception, and ocular dominance. Some people (about 10-15 %) do not adapt well to monovision. They may experience a feeling of being somewhat “off balanced” or will develop eyestrain and frequent headaches. The more significant impact could be the catastrophic loss of visual field benefit provided by a single eye all together in the event of disease or damage. Monovision problems can be significant, and one should discuss them with an eye doctor, before opting for this treatment option.

20

From reading here and other sources, the downsides of monovision are why many cataract surgeons don't do it unless the patient has previous successful experience with it, which seems like a wise way to go. Also why mini-mono is favored over full these days. As to the danger of losing one eye, that's always a tragedy. So long as the remaining eye can be corrected by glasses or contact, I don't see why it would be any worse than in other circumstances. Post-cataract surgery limitations would be there, but that's the joy of aging. . My father was blind in one eye from birth and had cataract surgery in the good old days when they removed the cataract and you wore bottle glass type glasses after and some people were all but blind with them (had an aunt in that category). Being pigheaded and vain, my father insisted on a contact lens and continued to manage just fine till death, including driving. Had to use readers on top of the contact for close work of course.