Which lenses? And both eyes in the same session?

Eye care
1

I am new to the forum and I apologize in advance if those subject have been already discussed .
It’s all very confusing…and hope someone can help me.
I’m 79 and was scheduled to have cataract surgery in my right eye via the State system in Siena but finked out at the last moment. I didn’t like that I wasn’t informed as to what type of lens I’d be given and wasn’t offered a choice or an explanation.
I have now found a specialist in nearby Florence (to be paid privately) which offers
a) a choice for monofocal, bifocal and multifocal lenses.
and
b) can do both eyes in the same day, reducing stress, adaptation time, etc.
Can anybody help me with those choice?
Normally the second eye is done after a few months, is it unwise and why, to do both? The doc says that for them it is like two separate session, the patient exits the operating room, they re-sanitize everything, etc. He stressed that the healing happens concurrently in both eyes with obvious advantages.
I told him that I tried multifocals only once and couldn’t get adapted to them but he told me that those IOLs function differently, like it’s the brain choosing and there’s no need to move your head or eyes as I was trying to do with the multifocal glasses.
I was leaning towards the multifocals but reading some of the threads I started worrying as there seem to be many different kinds/makes but all with some drawback, apparently.

Can anybody help? Is there a Cataract 101 course, some place that I can access? Or hints as to what’s the best way forward for me? What kind of question to ask him and how to find out about the different lens options?
I know, these are question I should pose to a trusted, good doctor. The problem is finding it.
A friend once told me that the golden rule is to choose a good doctor and trust him.
My reply was: How can I find him!I will only know he’s good after he’s cured me, not before!
Thanks to all for whatever help you can provide.

2

Do you have someone who can tend to you nearly 24/7 after the surgery? That is the only way I would have both eyes done at once, and even then I wouldn’t recommend it. You’ll have to put drops in your eyes multiple times a day, and at first your vision will be a bit ‘off’ until things start to heal and settle down. I would find it more stressful, not less, to do it all in one go.

I’m a fan of monofocal IOLs, but then I don’t mind wearing glasses. They are tried and true, and usually produce much less (if any) in the way of glare and halos. (They are also less expensive, although that’s not why I chose them.)

I had my surgeries 2 weeks apart, and that worked well for me, but many people recommend a 6-week interval so you can see how the first IOL works out and adjust for the second one accordingly. Some people have had success with a monofocal in one eye and a multifocal in the other. Doing the operations separately will give you more options and is I think what most surgeons would advise.

3

Yes very unwise to have surgery same day both eyes for a variety of reasons I know why a surgeon does this is for clear lens exchange for people who want yo correct presbyopia. This way patient can’t compare vision.

Not saying all private clinics are that way but pays to be cautious if they suggest/recommend doing both eyes same day.

I assume you have cataracts both eyes that can no longer corrected with glasses. If they can be corrected to 20/40 or better you have time to search for surgeon and options.

First off premium lenses (EDOF /trigocal) don’t necessary mean better although if all goes as planned tend to make one less dependent on glasses - although surgeons cannot guarantee that.Premium lenses tend to have more glare and halos around nights making night time vision challenging for some. Typically those with perfectionist tendencies wouldn’t find the trade off acceptable. Monofocal lenses tend to provide best vision at one focal point. Most people opt for best corrected distance and wear glasses for intermediate and near. Some opt for mini monovision with 2nd surgery aiming for that mid range or 1 to 1.50 diopter closer and wear readers for reading.

The reason no one on the cataract forums for most part would suggest surgeries same day is it takes time (about 4 to 6 weeks) for your eye to heal and vision settle). And that’s if all goes well. It is recommended you get a refraction test 6 weeks after to see where your vision is and the surgeon can adjust power of IOL of 2nd surgery to complement first one. During healing process the IOL depending where it settles can shift and you can be + or - .25 diopter.

Take your time in the decision as it is much more difficult to exchange a lens (and costly) and requires a more skilled surgeon.

4

Yes very unwise to have surgery same day both eyes for a variety of reasons I know why a surgeon does this is for clear lens exchange for people who want yo correct presbyopia. This way patient can’t compare vision.

Not saying all private clinics are that way but pays to be cautious if they suggest/recommend doing both eyes same day.

I assume you have cataracts both eyes that can no longer corrected with glasses. If they can be corrected to 20/40 or better you have time to search for surgeon and options.

First off premium lenses (EDOF /trigocal) don’t necessary mean better although if all goes as planned tend to make one less dependent on glasses - although surgeons cannot guarantee that.Premium lenses tend to have more glare and halos around nights making night time vision challenging for some. Typically those with perfectionist tendencies wouldn’t find the trade off acceptable. Monofocal lenses tend to provide best vision at one focal point. Most people opt for best corrected distance and wear glasses for intermediate and near. Some opt for mini monovision with 2nd surgery aiming for that mid range or 1 to 1.50 diopter closer and wear readers for reading.

The reason no one on the cataract forums for most part would suggest surgeries same day is it takes time (about 4 to 6 weeks) for your eye to heal and vision settle). And that’s if all goes well. It is recommended you get a refraction test 6 weeks after to see where your vision is and the surgeon can adjust power of IOL of 2nd surgery to complement first one. During healing process the IOL depending where it settles can shift and you can be + or - .25 diopter.

Take your time in the decision as it is much more difficult to exchange a lens (and costly) and requires a more skilled surgeon.

5

It strikes me that doing both eyes at the same time is a cost saving method for the surgeon, and as a result a profit increasing measure too! My recommendation is to do one eye, wait 6 weeks for fully recovery, and then do the second eye. This lets you know what you have in the first eye and gives you some time to reconsider what you will do with the second eye.
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Bifocal and Multifocal lenses are essentially only for those that want to be eyeglasses free, and you are willing to put up with some vision compromises like poor reading in dimmer light, halos, and flare at night. They are often called “premium” lenses but remember that the premium mainly refers to the price and not the vision quality. They tend to be a compromise on quality to be eyeglasses free.
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I would suggest by far the most reliable way to get the best vision is to get basic monofocal lenses with the power set for distance correction. This means you will need reading glasses like most older people do.
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One other option but still using basic monofocal lenses is to correct the dominant eye for distance, and do that eye first to see what you get. Then if all is good, you could consider an under correction of the second eye by about -1.25 D to give you some reading ability. If you have decent vision in your second eye, you can simulate this by using a contact lens in the second eye to see how you like it, not not. This is called monovision if you want to do some research on it. It can make you nearly 100% eyeglasses free, but is not for everyone. Best to trial it with a contact lens first.

6

Sorry, I don’t know how to answer this question with a quick short response. I will break your post into 3 sections:

  1. Do both eyes at once or very close in time

I know many Ophthalmologists prefer this and I understand why. Studies have shown patients are overall happier when bilaterally implanted. It makes sense as both eyes present the same or similar picture to the brain.

BUT, I 100% disagree, even if doing the safest monofocal IOL. The only exception might be if you are getting the LAL IOL. First you did not state just how bad your vision is in both eyes. I am a BIG procrastinator and if you can still get corrections that make your vision safe and acceptable to you, I would postpone cataract surgery as long as possible as new advance lens and other technology like modular base are in the trial phases.

Having said that, everyone is different and results will vary. How about if you got a Synergy IOL (BTW in full disclosure that is what I currently plan to get for my right eye) and you have horrible dysphotopsias and you cannot stand it. Do you really want that for both eyes? Plus the option to mix and match (which again in full disclosure I will be doing) can be a great benefit. Mixing and matching can improve the weakness of a particlular IOL. Lastly let’s say you are thinking of doing monovision. If you have read this forum you will see results have varied tremendously. It is not until you get that IOL implanted and healed that you truly know your results in order to intelligent make a decision on monovision IOL power.

  1. How to find a Top Doctor (you might have to do research to find other countries equivalent)

a.Look for an Ophthalmologist that is involved in clinical trials, preferable on the IOL that you are interested in. Medical Companies want to get the best outcomes possible, so they are going to do the research for you and pick top Ophthalmologist for their clinical trials. You can go to the FDA Clinical Trials website and see which Ophthalmologist are/were involved in the clinical trials.

b.Look for Ophthalmologist that does research and publish papers, article, or/and books.

c.Go to Castle Connolly Top Doctors, these are doctors that other doctors recommend and if selecting a Tecnis product like myself, JNJ has a site that lists recommended Ophthalmologists with experience with the lens you are interested in.

d.Contact these ophthalmologists and set up appointments to see them. Just as important is to find an Ophthalmologist is that you find one that you have a rapport with and trust. During this process, I meet Ophthalmologist that I would not let operate on my eyes in a million years.

e.Do your research so that you are knowledgeable about the topic, so you can talk intelligently to the Ophthalmologist. In some cases, I knew more about the IOL I was interested in than the Ophthalmologist. I was asking them about issues like glistening and so forth.

One Clinical trial Ophthalmologist that I talked to had implanted every premium lens out there and gave me the entire rundown of his experience with the different IOLs. He was so impressive I was planning on making a 5-hour drive to that doctor, but in the meantime, I found another Ophthalmologist in my area who did trials, written papers, goes around the world doing cataract surgery for the poor and had a really good reputation. And just as important I had a great rapport with.

  1. Which IOL to Choose

No one can answer that for you. There is no IOL on the market today that can do what the natural young lens does. All current IOL come with tradeoffs. You have to research each IOL, find a doctor who has lots of real world experience and results with that IOL and make the best informed decision for your case. I can only give a general rundown:

Non Premium Monofocals:

These are the most common IOLs implanted. They will have the best contrast and the least issues of any lens (unless you consider close vision an issue). They have been around and tested for a long time. A Monofocal lens should provide great distance. In general close vision is reading your cell phone or a book, maybe 33cm-40cm. Intermediate is about 2 feet or so. A perfect example might be the dashboard on your car. Monovision is an option to gain close vision, but again not everyone does well with monovision. Monovision is too long to go into at this time and Ron is more the expert.

Everyone Visual Acuity will vary as there are so many factors, such as short eyes, astigmatism, cornea damage, Gaucoma, previous Lasik surgery, and on and on.

Premium Monofocals:

LAL – If considering a monofocal I would recommend giving this IOL serious consideration. I have had Top Ophthalmologist highly recommend this lens. Having said that it has been around for a while now, but not as long as the standard monofocal so there is the test of time issue.

What makes this lens great is no matter what equipment Ophthalmologist use they don’t always hit the refractive mark and in a few cases can be way off by more than 1D. And let’s say you decide to do monovision. You want to hit those marks.

But it even gets cooler than that. From what I understand you can adjust the LAL more than once. So you decide on monovision, but not 100% sure how much monovison. So set 1 eye to plano and then try various settings with the 2nd eye to see which one works best for you. I would only consider micro-monovision like -0.75D, but if I had the option to adjust it you could try a different setting and see if you end up with a lack of stereopsis or other problems.

There is a really good panel discussion about this lens in May on youtube. Search for The Light Adjustable Lens Live Panel Discussion. It is by Summit Eye Care.

Again if I was going to do a Monofocal I would personal seriously consider the LAL.

Crystalens Lens – You hardly hear about this lens anymore. This is the only FDA approved accommodating
IOL. Many people did not get accommodation or much accommodation, so you were paying premium price for a monofocal lens that did not give the range of vision expected.
But from what I have read Crystalens at distance provides the same level of contrast as a standard monofocal and you are likely to get some accommodation. This lens could be a great mix and max with a
PanOptic Trifocal IOL.

IQ Vivity and Tecnis Enhance - The newest hottest IOLs on the block. A refractive IOL that provides some EDOF. I think IQ Vivity is around .5D and Eyhance a little less. So not a lot EDOF, but combined with micro-monovision you should get decent intermediate and some close up vision.

Now here is the part that is trick. I have read that Vivity gets EDOF by manipulating SA. So that means contrast sensitivity will not be as good as a standard monofocal. Could the average person notice the difference, I don’t know. But I suggest you get an Ophthalmologist who is an expert with these lenses so you can discuss that exact issue. And of course there is the test of time issue.

I tried mono-vision with contacts and I know it is not the same, but I hated it. I need good distance vision. That is why I say if doing mono-vison go with micro-monovision (<-0.75D). If you do that with Vivity you will be getting -1.25D of mono-vision, preferable in the non-dominate eye.

Enyhance is a little less clear to me as from what I read there is no CS lost, but there is no free lunch and you don’t gain much EDOF. I am not even sure it is much better than some monofocals. But IMHO you have to be giving up something to get even that little bit of EDOF. So this one needs further research.
Vision acuity is more complex than it sounds. There are just so many environment factors and so many ranges to go with those conditions. Will you be able to see well indoor at a concert or basketball game vs seeing up close in dim light vs moderate light vs bright light.

Defractive IOLs

These IOL, which include Trifocal and EDOF IOLs, give you improved intermediate and close vision but they all come with tradeoffs (Dysphotopsias & Contrast Sensitivity loss). This category is a paper in itself, so I will not go into details unless you are interested in a defractive IOL. I personally have a defractive lens. In the US the main defractive lens currently would be Panoptics and Symfony IOL. But just Yesterday, hot off the press, the Synergy is now available. I actual have the Tecnis MF low add, which is a bit of older tech now and plan on getting the Synergy IOL in the other eye, which I hope will be a mix and match that will bring better close vision and better night time vision. Again I am a fan of mix and match!

Well hopefully this gives you some ideas.

7

“They are often called “premium” lenses but remember that the premium mainly refers to the price and not the vision quality.”

LAL!! I must admit I laughed when I read that. I will have to use it in my replies and give you a footnote.

8

You asked about a Cataract 101 course. Here is a brief and to the point article on that subject. You should be able to find it by googling for this phrase. We are not allowed to post links here.
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Choosing an Artificial Lens for Cataract Surgery Written By: Cheryl terHorst Reviewed By: J Kevin McKinney MD May. 14, 2020

9

My God! I don’t know how to thank all of you enough for your kind help, suggestions and hints. Lot for me to digest and sorry that I couldn’t more than once like all the answers.
The first impression is that I should be careful regarding everything which is non the true and tried monofocals, should avoid having both eyes done on the same day and,if possible, procrastinate.
I feel that I can procrastinate, my vision is not so bad after all (with glasses) but I’m told that contrary to past recommendations now surgery should be done earlier as it is an easier procedure (apparently).
RWBIL articulate and comprehensive answer was, alas, beyond my pay grade as I’m not familiar with some of the acronyms.
At this point my plan is to book a visit with this doctor and, armed with your suggestion, see how it goes.
I’ll keep you informed hoping not to be bothering too much.
Once again, thanks!

10

If you can still see well with eyeglass correction and have any interest in the monovision solution, now would be the best time to do a trial of it with contact lenses. With many people their vision has deteriorated with cataracts so much they cannot do a trial to see what it looks/feels like.
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Doing a monovision trial with contacts is fairly easy. You need to get a current prescription for correction. For example if your prescription is -3.0 D in both eyes, you would get a -3.0 D contact for the dominant eye to see distance well. And in your non-dominant eye you would get a -1.75 D contact. This will leave you 1.25 D under corrected and should allow for closer distance reading of books and the computer. Switching contacts is easy of course and you could try a little less and a little more than that for under correction to see what works best for you. With an IOL it is a one shot deal. What you get is what you get. That is why it is important to try it with contacts first if you are considering it.
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You might want to be prepared for a little pushback from the surgeon if it is one that specializes in the so called “Premium” lenses. Monovision just uses standard monofocal lenses which have no premium price (i.e. profit) associated with them, unless they are toric ones for astigmatism.

11

Maybe things have changed in recent years, but when I was researching the various premium lens back in 2015, I talked to several people that had cataract surgery and I experienced the opposite. They all got monofocal lens and did not even know about premium lens, until I asked them about it, as that is what their Ophthalmologist picked for them. They were not given or made aware of any options. Maybe things have changed a bit since then. But from what I have seen most Opthalmologolist were just pushing monofocal and you had to be self-aware of premium lens and find a doctor who even knew about them.

12

Wow, something else to consider.
I’ve never used contacts in my life and sincerely the idea scares me a little even if I know that millions use them.
I just hope that this doc has an open mind.
What about doing cataracts early as against when they are “mature” as they used to say?
Reading your various comments has helped me focus on what’s important. I do know that I wouldn’t like seeing, blurred vision, etc. I’d love to get rid of glasses but not at that cost.
Thanks again!

13

If you have access to a Costco they make it pretty easy to try contacts with a free trial. You would have to explain to them that you want to simulate monovision so they give you the correct power of lenses. I am now simulating monovision with a Kirkland contact lens in my non IOL eye and it is the most comfortable contact lens I have ever used.
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I am not up to speed on the need for the cataract to mature. I am in Canada and we often have a long wait for cataract surgery so I guess they naturally mature while you are on the wait list!

14

yes that is do true about Canadian Health system - hurry up and wait!!!

15

No Costco…I live in Italy and I wonder who to ask for trying monovision. I wonder if the doctor is familiar with this and if he will suggest it.

16

I would expect your surgeon would be familiar with monovision. The concept has been around for a long time. It would be worth discussing it with your optometrist as they should be familiar with it also. Most will prescribe contacts. And most contact suppliers offer free samples to try.