How to deal with astigmatism and choice of IOL

[zepeye]

my refraction was measured as

Refraction  Jan 2019  (in this exam I just went for whatever made the lettering sharper and readable with my left eye, ignoring double vision)
OD: Sph -5.50 Cyl +1.50 Axis  048  VA - Dist: 20/20-1   ADD: 2.25
OS: Sph -7.00 Cyl +2.50 Axis  090  VA - Dist: 20/60-   ADD: 2.25

Up to now, I have used astigmatism correcting contact lenses and glasses (mostly wearing the contacts).
Now I need to choose an IOL for my left eye cataract surgery.

I had LensStar topography readings, and some other machine I don't remember that were to assist in determining my astigmatism correction if I choose a toric lens.

I have some question about how astigmatism may be dealt with.  

My inclination would be to get a Toric monofocal or Toric multifocal IOL.   But this comes with the risk of it not being rotated correctly.   In which case it is my understanding that a follow up surgery is done to correct the rotation.  

But I've also read about laser incisions being used to correct astigmatism.

I like the idea of being able to continue wearing contact lenses (left eye included)  if I find my distance and/or astigmatism correction after surgery is not where I want it in my left eye.   Is there an advantage or disadvantage in using laser incisions vs a toric IOL in being able to further correct my post surgery vision in my left eye with contacts if necessary?


Does a toric IOL serve to halt the progression of my astigmatism?  Does astigmatism continue to progress when corrected by laser incisions?


Thanks.

[NightHawkGuy]

Over a year ago I had cataract surgery in my right eye only and chose the Tecnis monofocal toric since that eye had about 3D astigmatism.  I wanted to avoid the cornea incisions that can reduce astigmatism, I read that after a few years that effect reduces compared to a toric IOL. I avoided rubbing my eye and have had no significant IOL rotation thankfully.

[zepeye]

Thanks.   I'm inclined to get the Toric so I can have that part of my vision corrected and if I do order glasses afterwards, perhaps I'll pay less to not have to correct the astigmatism with those lenses  .    Not sure yet whether to try a multifocal or monofocal,  This is my non-dominant left, and assuming I'll need surgery on my right eventually, I may just go distance only with that one so that I can have hopefully one eye without halo problems or night vision problems.

[NightHawkGuy]

For reference I am age 64 but my eye's prescription has not changed significantly for the past 30 years - since recently I found an old eyeglasses Rx from 1988 and it was very close to what I have had in recent years.  That is until the cataract got bad enough in my right eye to make it more nearsighted, but that was temporary until I got the surgery in that eye. I went with a monofocal toric in the right eye for distance, my left eye probably won't need cataract surgery for years but may consider either another monofocal toric set a little nearsighted for intermediate vision or perhaps a Symfony EDOF lens but not a full multifocal since that would leave out the intermediate focus range which is important to me for computer distance viewing.

[zepeye]

I don't understand.  Why do you say a full multifocal would leave out computer distance viewing?  Can't you choose a multifocal that is set for this range?

[JohnHaganMD]

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[JohnHaganMD]

Toric IOLs do not stop the progression of astigmatism but most astigmatism has stabilized by middle/older age.  Most surgeons prefer to rotate an toric IOL out of alignment rather than do laser because its more predictable.

[zepeye]

Thanks.  I'm in my early fifties, and I don't know if mine has stabilized yet.  Seems like it continues to worsen, unless it is more a factor of my progressing cataracts.  My refractive history is in my other post:
https://www.medhelp.org/posts/Eye-Care/refraction-for-eye-with-a-cataract--complicated-by--regular-astigmatism/show/3042214

If you have had the Toric lens in your eye for  a number of years and  the the astigmatism has returned, but finally stabilized, , is the laser correction an option on an eye that has a toric IOL?

[JohnHaganMD]

Yes it is an option.

[zepeye]

Before my cataract was a known issue for me, I used a toric monofocal near vision contact lens for computer distance (monitor about 26 inches away)  in my left eye (which now needs surgery).   I had my glasses set for distance in  both eyes (not bifocal or progressive).  Even now f I want to see closer, I can just take off my glasses and see  13" to 8" away.   Or  if  I have trouble seeing small print on a bottle, etc, I take a photo on my phone and enlarge it.    Later as my left eye vision worsened I had him back off the distance vision a bit in my dominant right eye when pairing it with monofocal computer distance left eye lens to help sharpen up the focus a bit.    

So I'm used to monovision contacts.  Though I would hope my distance comes out to 25-28 inch range after surgery,   I don't mind wearing contacts, have done so all my life, and if it comes down to it and I find I still need to wear a contact lens in my left eye because I'm only seeing to 14 inches, I'll do it.  

But  if if would work, I would certainly like to have a multifocal lens that lets me see at 25"-28" nearest  (computer programming) and also at farther distances.  

If I relate this to my surgeon, can he provide me with the specs on the lens he plans to use in terms of  diopter and astigmatism correction before the surgery, or is this something that is finalized at the time of surgery?   If he provides this info, what specs am I looking for him to provide me  besides brand and diopter, and UV protection?  I'm not certain about the specifics and would presumably keep them in mind when gathering multiple opinions from doctors?      ( maybe avoiding a red flag where there is a large difference)

[zepeye]

Before my cataract was a known issue for me, I used a toric monofocal near vision contact lens for computer distance (monitor about 26 inches away)  in my left eye (which now needs surgery).   I had my glasses set for distance in  both eyes (not bifocal or progressive).  Even now f I want to see closer, I can just take off my glasses and see  13" to 8" away.   Or  if  I have trouble seeing small print on a bottle, etc, I take a photo on my phone and enlarge it.    Later as my left eye vision worsened I had him back off the distance vision a bit in my dominant right eye when pairing it with monofocal computer distance left eye lens to help sharpen up the focus a bit.    

So I'm used to monovision contacts.  Though I would hope my distance comes out to 25-28 inch range after surgery,   I don't mind wearing contacts, have done so all my life, and if it comes down to it and I find I still need to wear a contact lens in my left eye because I'm only seeing to 14 inches, I'll do it.  

But  if if would work, I would certainly like to have a multifocal lens that lets me see at 25"-28" nearest  (computer programming) and also at farther distances.  

If I relate this to my surgeon, can he provide me with the specs on the lens he plans to use in terms of  diopter and astigmatism correction before the surgery, or is this something that is finalized at the time of surgery?   If he provides this info, what specs am I looking for him to provide me  besides brand and diopter, and UV protection?  I'm not certain about the specifics and would presumably keep them in mind when gathering multiple opinions from doctors?      ( maybe avoiding a red flag where there is a large difference)

[JohnHaganMD]

Your surgeon can tell you what kinds of IOL she/he uses and has access to.  You can do your research you are so inclined.  Before going into the operating room the surgeon generally knows the brand, model and power.   Some surgeons use what is called ORA Technology to check IOP power after inside the eye. The technology is expensive and not widely used.    IOLs formula have a rage of error of about plus/minus 0.5 diopter.  More in very long or short eyes or previous injury, surgery or scars.

[zepeye]

Thanks.  If I understand correctly the diopter value is the power.   Is there some kind of astigmatism value of the lens chosen?

[zepeye]

Thanks.  If I understand correctly the diopter value is the power.   Is there some kind of astigmatism value of the lens chosen?

[JohnHaganMD]

Both the 'sphere" (spherical power) and cylinder (aspherical power) are in diopters.

[JohnHaganMD]

sphere is a big number typically +14 to + 24  but cylinder is low  1 to 4 Diopters

[zepeye]

The three eye medical groups I am consulting all happen to use Alcon.  Since I have astigmatism, I presume my best choice would be a toric lens, unless there are limitations/disadvantages of a toric that may offset its benefits.  So then it is a choice of AcrySof IQ Toric IOL or the AcrySof IQ Restor Multifocal Toric .  There is also a IOLAcrySof IQ PanOptix Toric, but I'm guessing that hasn't been approved in the US yet?

With the multifocal, is there some standardized fixed difference between the focal distance the near viewing keys on  and that of the distance viewing?   Or is there options in regards to in the difference between these viewing distances?

For instance, right now I am typing on my laptop at a standing desk with the laptop screen 31" away, intentionally standing back at the farthest point that seems practical to me.   With an external monitor, I could move it away even more if needed to match a certain focal sweetspot.  For me, I would rather have my near distance at  25-30" and have to use readers for nearer vision, than have a multifocal set my near vision at 12" away and have to use computer glasses for 25-30".  

I don't know if this means, because of some fixed setting between multifocal near and distant vocal points,  that my distance would be at 21.5 feet instead of 20 if I were to choose a near viewing focal point of 25-30".  

I hope I have been able to convey question about this clearly.

[JohnHaganMD]

This is your 20th post and I'm about finished commenting. This is a recent article on the last IOL  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5381044/       This is my closing summary: the problem with 'higher tech' or premium IOLs.   1. More expensive  2. Rarely eliminate glasses for everything a person does. 3. night vision and glare are more of a problem than monofocal IOLs.  4. complication rate is higher  5. reoperation rate is higher.   6. Disappoint rate is higher.  That's about all I have to say. Rest needs to come from the surgeon you choose.

[zepeye]

Thanks.  Just trying to do as much due diligence and gain as much understanding as I can in advance of meeting with the doctors, since I know some doctors may not like a lot of questions, especially the more in depth they become.   So I guess its damned if you do (try to get an accurate understanding of the pros and cons and the ins and outs of the different options) and damned if you don't (after-the-fact saying you should have researched more before choosing your lens to get the right one for you).  What I'm trying to avoid the latter, but I do see in your case, you don't like or use multifocals, and I will definitely keep that in mind.  I guess you feel like that my further questions about multifocal IOLs means I am not listening to your advice against using them, but that isn't the case.    I've used monovision with contact lenses, so I'm not averse to the idea of doing so with IOLs.    But I haven't ruled out the multifocal yet because, if they were to arise,  I may be more tolerant of some issues with them like haloing around headlights since I'm pretty used to living with it already just from my astigmatism and worsening cataract.  Plus I'm only doing the left eye and down the road could still use a monofocal in my right, dominant eye.

There are so many facets.  I forgot to even mention the ACRYSOF® Aspheric UV Absorbing ReSTOR +2.5 D Toric IOL.    That's another variable: UV protection or not.  

Can be very confusing to someone who is not dealing with all this daily for years and years.  I don't want to find out after the fact that there is some factor I overlooked in my decision process.

[JohnHaganMD]

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