Which IOL to choose for a cataract operation?

[Lademi]

Hello, I hope Dr Hagan (I have read his excellent post “Consider ALL the Options Before Your Cataract Surgery: Working Through What’s Best For You  2019-2020 Update”) and/or other professional or expert may be able to help with my question.

I am a 63 y o female with a 'ripe' cataract in my R eye due to be operated on 25.5.2020. Based on recommendations from my (very trusted) optician and what I read in this forum I have chosen a monofocal lens for distance vision. I trust my surgeon based on what I have heard from many sources about his skills, but I have found it impossible to communicate usefully with him on the choice of lens (I've tried 3 times!!!), hence my turning to this forum.

Some more info on my eye history and situation:
I had very good sight in the past, it's only with age that I've needed glasses.
L eye is dominant and at last examination optician told me it sees "10/10" (but I still need glasses: essential for near and mid-vision and to see better for distance).

My last glasses prescription from end Jan 2019 is as follows (I translate from a French document, hope it's understandable - very little idea of what these things mean):

Corrections 2017:
RE   0.75   ( +0.75  95)   ADD 2.75    
LE    0.75  ( +0.75  150)    ADD 2.75
Acuity with current correction or brute acuity:
AV. VL    RE    9     BINO 8    AV.VP   P3    BINO P3
AV. VL    LE    10                   AV.VP   P3
Daily subjective refraction:
RE   1.00   ( +0.75  15)   ADD 2.75    
LE    1.00  ( 0.5   160)    ADD 2.75
Acuity with day refraction:
AV. VL    RE    8     BINO 9    AV.VP   P2    BINO P2
AV. VL    LE    10                   AV.VP   P2

Since the above results R eye vision has got worse due to the cataract ripening and taking over the whole surface. Essentially all the work is being done by the L eye currently, the R is almost totally opaque: light comes through, but I see only blurry outlines of objects with it, and 3D vision is impaired (more mental guesswork and habit than actual perception I guess).

The surgeon warmly recommended multi-focals, but did not unduly press the issue when I eventually confirmed that I wanted monofocals for distance. When prompted very pointedly to tell me which IOL he would implant he said an Alcon +22.50 lens - it looked like he was choosing on the spot (true that we had just finalised the matter, but he did not consult any of my data or tests before deciding, and neither did he ask me any questions about possible wished for outcomes).

I am somewhat concerned as:
I had the impression that he had not really studied my data properly before making the choice
despite trying very hard I do not feel we had a proper discussion about possible different implants and what may be the result of each. I only got the multifocal OR near- OR far-sighted monofocal lens options offered, no discussion of further variables (power of lens and whatever else). Is my case such a straightforward one? Perhaps it is! In which case I would have appreciated him telling me so, and perhaps explaining why.
he seemed to take it absolutely for granted that I would get an IOL also on the L eye, whereas I understand that cases exist (though perhaps relatively rare) when only one eye is ever affected by cataract. Regardin this, while discussing multifocal IOLs I said that I had heard that they statistically work best if they are implanted on both eyes, and that I did not really want to operate the other eye unless I really had to, but he did not respond to this this and would still have recommended a multifocal IOL for the current ‘single eye’ operation. Even if I had multifocal ‘eye mismatch’ (which I hear happens often enough) ‘only’ over a few years before I did develop a cataract in the L eye, wouldn’t that be bad enough? Or in another scenario wouldn’t it be bad to have to operate the healthy (non-cataract L eye) to implant a multifocal IOL in order to try and fix vision?

So while I do trust my surgeon’s technical skills, I am left to wonder whether his choice of IOL is what may be best for me, though I do know that as Dr Hagan says such a choice is not a perfect science. May anyone be able to confirm that the Alcon +22.50 is a choice that seems sensible in my case? What other choices there may be, and how would the outcome possibly differ?

I also do not have any pre-op document stating the specifications of which IOL I will get: should I ask for one? I know this may be a bit paranoid on my part, but due to the lack of communication I get worried that I may not get the implant that we agreed upon! But as it is MY eye and MY life, I tell myself that it is ok to be a bit paranoid and take as many precautions as possible.

I do realise that cataract options are very routine, and that busy professionals cannot spend hours in explanations (I am a professinal lady myself, and can be quite matter-of-fact), but surely such a discussion needn’t take too long if clearly exposed? I know others have had similar communication problems, and while I excuse the ‘sinner’, I allow myself to be troubled and do something about it as it will be me who will have to live with the (positive or negative) consequence. So better be safe than sorry, or at least try!

Many thanks for Dr Hagan and other professionals and experts for responding to our questions and queries. Much appreciated!

Elizabeth

[Lademi]

Dear Dr Hagan (and anyone else interested),

HUGE thanks again for your response and clarifications.

About the length of my message - I know, sorry! I can get a bit obsessive with details (personality AND professional habit….)

About your comments:

1) You are quite right, my cataract is NOT ‘ripe’ if that means showing white in eye as the rather stark images show - I was obviously misusing the term. I thought a cataract was defined as ‘ripe’ whenever it got to the point of needing an operation.
2) Thanks for the clarification. I decided to go ahead with the proposed INJECTION method, ie what MD1 does as standard. I can see pros and cons in both methods, and I don't want to 'upset their cart'.
3) not sure about what type of astigmatism I have; I will ask the doctor and/or optician; I’d like to know.
4) I will ask MD1 what is the ***targeted post op refractive error***
5) I do not have such data; I’ll see if I can procure it….
6) Thankfully the financial side is one thing I do not have to worry about: all costs are covered by my work health insurance. The only extra I would need to pay myself are the multifocal lens (or any comparable upgrade), if I went for that - if I remember correctly 200-400€ were quoted for it; I did not take much notice as I knew I was not going to have it. Alas “pressure shop” techniques are becoming endemic everywhere, from education to healthcare, from politics to finance…. Giving us even more reason to be grateful for those who do good work, along proper ethical lines….

I for one am very grateful for this list!

I will write again when I have updates, thanks again.

[JohnHaganMD]

Best of luck. You are doing your research at the proper time BEFORE the surgery. That increases the odds of no unhappy surprises. OTHERS TAKE NOTE.  Look forward to follow us.  

[Lademi]

Dear Dr Hagan (and anyone else interested),
I did undergo my cataract operation as planned on 25.5.2020. Up to now everything seems to be going well, my sight has definitely improved, the two eyes seem to work happily together, so the IOL was right. As far as I can tell up to now the operation and recovery went well, and I think the surgeon did a good job and chose the lens skilfully. I am due to have the 'one month later' check up next week, after which I will have my new glasses prepared. I look forward to making the most of my 'new eye'! Enjoying renewed colour brightness and better overall sight (especially sharper distance sight) has been the best part of it. I definitely see better than before, but will need glasses for best sight both near and far, but I was expecting to need them, so no surprise there.
I just wanted to post an update, to warmly thank Dr Hagan for his patience and support, and also to thank the forum managers for keeping it going - such a useful resource!
I totally agree with Dr Hagan that patients should look for a reputable practitioners, and should engage in some fact-finding and question-asking well ahead of time - at least to understand which choices we have as patients, and the consequences of such choices.
I may post again if I have something interesting to report.
Dr Hagan- again thanks and gratitude!
Elizabeth

[JohnHaganMD]

Elizabeth. Thank you so much for taking the time to report your experience.  And I'm delighted that things have gone well.  Finally I would like to thank you for saying thank you.  I have been doing the forum since 2007,  nothing in it for me, all volunteer work.  I would say about 4% of posters take the time to say thanks for advice that would normally cost in the hundreds of dollars.  Best to you.

[Candice7575]

Happy to hear of a happy outcome. i'm due to have mine done next month and have gained incredibly much valuable wisdom from this forum.

[JohnHaganMD]

Thank you both

[JohnHaganMD]

That is among the longest responses I have every received. I want again to point out that I have not examined your eye, am making generalizations and not practicing medicine in Italy.  That being said:

1. Google images a 'ripe' or "hypermature" cataract. I'm fairly certain that is NOT what you have. Your additional embellishment leads me to believe you have a posterior subcapsular cataract (PSC). Which meets your description. It develops in younger people, grows fast, often associated with diabetes, trauma and especially steroid use including steroid inhalers for allergy or lung disease.  I'm pretty sure they have some view of the back of your eye and B-scan would not seem essential given this new information.
2.  Anesthesia.  Your post is confusing.  There are two forms used world-wide   1. Injection  2. topical drops.  In injection (which my wife chose and is best for nervous people, or coughers) a short acting IV medication is given to briefly render the person unaware. An anesthetic is then injected around the perimeter of the eye (perbulbar).  The person usually wakes soon and during the procedure if the patient is anxious or has discomfort additional IV medication is moved. This type puts the eye muscles to sleep so the eye doesn't move. Gives more pain relief.    The second form TOPICAL  they just drip anesthetic on eye, one incision is made into the eye inject anesthetic into eye.  Because the eye muscles are not put to sleep the eye can both see and move so good cooperation is essential and some people get freaked about seeing what is going on. Also there is greater incidence of pain so higher # of people need additional IV pain meds like fentanyl.      The choice is yours.  We do most of our cases by peribulbar injection. You can find studies published where people had one eye done each way and the preferred is injection.
3.  Your glasses RX has 0.75 diopter of astigmatism. Most surgeons use 1 D as minimum threshold for toric IOL. But it is incorrect to say you have no astigmatism.  Now in defense of the surgeon that told you that some people have glasses astigmatism but not corneal astigmatism (the astigmatism is coming from the lens of the eye) so you might not have corneal astigmatism.
4. You need to ask WHAT IS THE TARGETED POST OP REFRACTIVE ERROR.
5. If the records you have include K readings and axial length (done with A scan) you need to be sure they agree when taken in different offices.
6. I think you said you read my article about what people need to know before they have cataract surgery.  The payment world wide for cataract/IOL surgery is going down all the time. All of the 'trade' newspapers and free circulation business journals for ophthalmology talk about 'enhancing revenue by up-grading".  This means in some offices (3 or 4 here in Kansas City, MO, USA) from the time the patient enters the staff, nurses, technicians and surgeons pressure people to upgrade:  toric and multifocial IOLs,  ORA technology, femtosecond laser, etc.   Again my wife chose a plain spherical IOL and is happy. My practice includes seeing unhappy people operated on at this high pressure shops. Most recently I saw a man that spent $12,000 US out of pocket to have both eyes done with all the upgrades. he says he was told he would not need glasses for anything. He did need glasses and  was very unhappy with his night vision. Not much I could do for him except 'get used to glasses and kiss $12K good-bye"

I think that takes care of everything.  You are so smart to do this ahead of time and note be out tons of money.

[Lademi]

UPDATE from Elizabeth:

I asked for and received copies of Jan 2019 and Feb 2020 test results from MD1's practice:
- OCT scans have been carried out both times
-  not sure whether B-Scan tests have been carried out (the highly technical results are a bit difficult for me to navigate!)

I also left a message that I had questions and MD1 called me back in response (kudos to him for that!):
- he STILL thought that he was going to implant a multifocal IOL!!!
I told him *yet again*, that I wanted a monofocal for long distance, NOT a multifocal. I think I will send him a reminder about it also a couple of days before the op, and/ or make sure on the day, as the info does not seem to be sinking in!
- he confirmed that the IOL he is planning to implant is an Alcon +22.50 or +23, depending on what looks best for post-op vision results (A QUESTION HERE: would these tech specs be the same whether it was a multifocal or a monofocal?)
- he said I am not astigmatic, hence there is no need for a Toric lens
- about the anaesthetic procedure he said that as far as he is concerned light sedation by IV (along with drops in the eye) is essential.

The anesthetist, with whom I also spoke earlier on (kudos also to him for being available to speak), emphasised that the sedation (with Sufentanyl aka Dsuvia or Sufenta, and Midazolam aka Versed) is very light - he said "almost omeopathic", and that they always proceed in this fashion for cataract ops, but that if I was thinking of a different procedure I should ask MD1 if he would be willing to go along with that (which he is not).

I understand that one of the key reasons to sedate is to prevent the patient from moving, and I can see the sense in that.

While I am slightly nervous about being drugged, I understand that it is for a very specific purpose and done by experts in a controlled context. And while I defend my patient's rights to decide, and require information about the procedures to be carried out (as will be more than obvious from my messages!), I also understand that these routines exist to try to bring about the best possible outcome and to create ideal operating conditions for the operating team. And that it may not be a good idea to upset such routines without a good reason to do so. I'll mull the matter over over the weekend and read up on the meds used, but it's quite possible that I'll decide to go along with it. While an exacting patient, I do not want to become an obnoxious one!

Thanks again to Dr Hagan for his interest in my case and any further light he can shed on the matter.
Thanks also and good wishes to other interested parties.

Elizabeth

[Lademi]

.... cont'd....

I may also try to get a (4th!), last minute appointment with my uncommunicative MD1 surgeon to have a more thorough discussion on which IOL to use, asking him more pointed questions about possible outcomes, thanks to knowledge gathered on this forum, and based on the 2 paragraphs on lenses of Dr Hagen's message above, starting "Also if you have a ripe cataract...", about which, Dr Hagen, see some questions below.

I have asked the practice of MD2 if I could have a telephone consultation with him to discuss best choice of IOL based on my data, that he has (paying for the consultation of course, and with his full knowledge that I am having the op elsewhere). I could also ask him if B-Scan and  OCT tests were carried out. Not sure he will want to do that, but worth a try!

I could also perhaps ask the secretaries of both practices to tell me whether B-Scan and  OCT tests were carried out, perhaps even to send me copies of the various test results for my records. I should probably make a habit of keeping track of all of my results and medical history data for reference, especially as I am now getting on in years...

Dr Hagen, regarding your comments on possible IOLs for me:

YOU SAID, QUOTE "Also if you have a ripe cataract the measurements used to determine IOL power are often difficult. These are K reading (radius of curviature of the cornea) and A-Scan.  Both eyes would need to be scanned to see if the readings are about the same. Since your glasses RX are virtually identical the K readings and axial length should be about the same."UNQUOTE

My question: as MD1 saw me when the cataract was still very small, am I right in assuming that he could easily have gathered such measurements during the first visit? And MD2, who saw me with the advanced cataract, never said that there was any problem in getting measurement/test results/ seeing into the eye. They did dilate the pupil(s?) during the visit; I had that dilated pupil(s?) bother for hours afterwards....

YOU SAID, QUOTE "Assuming the above is done, and you don't mind glasses a spherial IOL would be fine. You are right at the edge of where a toric might be useful but it is best for people that hate glasses and want best vision without glasses."  UNQUOTE

My comment: I could perhaps try to discuss the toric option with MD1. He never mentioned this possibility, all I got was "Alcon +22.50". Does that definitely describe a spheric, non toric IOL?
I know that, all things being equal, positioning this kind of IOL is more demanding for the surgeon, and that if this is not done properly it can create problems post-op. But results would be better if the IOL was suitably chosen and the job was well done, correct? But slightly more risky....

YOU SAID, QUOTE  "Alcon makes very good IOLs." UNQUOTE.

My comment: that's very reassuring to know, thank you!

YOU SAID, QUOTE: "The targeted post op refractive error in the should be about -0.50   you should be able to tolerate that nicely with your other eye." UNQUOTE

My comment: a word is missing in the sentence: presumably you meat "in the eye"?
And also, the refractive error of -0.50 is something to be aimed for in general, or something you suggest based on my own measurements?

Again HUGE thanks for your feedback, Dr Hagen, and I am sorry for the very long message, but I do hope it clarifies some points I did not mention earlier, and that it answers some of your concerns.

I am really deeply grateful for the help and counsel received. Forums such as this - serious, professional ones - need to be navigated skillfully, but they can be a real Godsend if used properly! Thanks to all who keep them going.

With best regards,   Elizabeth

[Lademi]

Dear Dr Hagan,

many many thanks for your prompt reply and your concerns. In light of what you say, I will say more about my eye medical history.

Something like 2 and half years ago I started noticing a little opacity in the bottom left hand R eye vision. I was concerned and therefore got it seen by an Italian optician (high street shop selling glasses and doing basic eye visits to be clear), trusted friend of a friend. He told me that it was the very beginning of cataract, and that it would eventually ripen and need a cataract operation, but to go and to get it seen asap by an ophtalmic doctor to check the overall medical situation.

In due course I went to my home optician in France (the one who has been following me for glasses over the last 6-7 years), whom I chose to start with because they are a family firm (3 generations) known to be very serious and competent professionals AND with an excellent range of measuring machines. He confirmed that there was something to check, and that I should see an ophtalmic doctor asap. He recommended the MD surgeon with whom I am due to have the op as an excellent surgeon AND as having an excellent range of test machines. This optician's mother (herself an optician) has had her cataract ops done by this surgeon. Just to say that he comes highly recommended, (despite what I perceive as bad communication skills).

I eventually went to this surgeon in my home town, let us call him MD1, at the beginning of 2019. He did a range of tests (well, his assistants did), though I do not know whether he did the B-Scan and  OCT tests that you recommend, Dr Hagen. What I do know is that at this stage the cataract was still quite small (in fact some of the professionals were surprised that I noticed at all), so presumably it was not difficult to see into my eye. Result: no problem with the eye apart from the beginning cataract, but I should return in one year to see how the situation had developed.

Fast forward to the end of 2019 and I could see that the opacity had progressed from bottom left toward top right to cover almost the whole R eye field of vision. My trusted optician confirmed my perception and said it was time to see the specialist surgeon again, and probably plan the op. Already concerned by the lack of communication skills of MD1, and also for a second opinion I decided to go and visit ALSO another highly recommended ophtalmic surgeon in the nearby town, let's call him MD2.

Both MD1 and MD2 visited me early Feb 2020, did measurements and tests (but again not sure if they did B-Scan and  OCT tests), found no problem apart from the cataract and recommended scheduling in a cataract operation soon. MD2, a more communicative type, commented that my R eye cataract was not the typical 'old age' one, but of a type that is often, but not always, connected with other conditions (diabetes etc), though theres is no such connection in my case (I am quite healthy overall, take no meds, fairly fit for my age...). He called it a specific name which I can't remember, perhaps a "cortical cataract" (I went to look at the various types of cataract and the description of this one seems to fit) - a characteristic of it being that rather than being 'diffused' and starting at the centre, it starts off-centre and grows from there: it develops faster and is more bothersome to vision than the more common 'old age' one, he said. He pointed out that having it in one eye does not necessarily mean that the person will get it in the other eye, and stated that my non-cataract eye, the L, was in very good shape for my age.

I scheduled ops with both MDs for April 2020, knowing that I would need to get things organised with family, logistics etc to decide which op to keep and which to cancel. Eventually I chose the close to home MD1, despite the bad communication skills, because:
- he operates in a top level hospital (the other one operates in a private clinic)
- hospital and practice are just around the corner from home (logistically much easier for me and my family)

With the covid emergency the op was postponed, and the new date scheduled is 25.5.2020 as I said.

In light of the above I hope, dear Dr Hagen, that some of your concerns (for which huge thanks, it is extremely kind of you to share your expertise in this way!) will have been resolved. I do believe that my cataract operation is probably a very run-of-the-mill one, but I am still concerned about

(1) the choice of IOL, as explained in my previous message

and

(2) after having seen the anesthetist a couple of days ago about the choice of sedation: they plan eye drops analgesic only, along with light IV sedation: a  mixture of two medicines that would calm me for the 20 mins necessay. I've seen discussions and articles on this forum and elsewhere on this topic. I understand that this, along with the 'topical only' anesthetic one, is a very standard way to proceed, and favoured by many people. But I'm not sure I like the idea of IV sedation and being 'half out', so I am going to enquire whether proceeding in a different manner is at all possible, and what that would entail.

.... to be cont'd....

To be cont’d….

[JohnHaganMD]

Elizabeth: I would put the brakes on immediately and recommend you not proceed with  surgery until you interview a second surgeon.   A surgeon must be skilled but a physician must be communicative. Suppose you had a problem or a complication where having a physicians that LISTENS and COMMUNICATES is important.  Would you want to have a problem with a surgeon that doesn't even talk or listen before you have the surgeon.   I don't understand all the notations. I have some concerns about your case.   Let me get they out there. At 63 it is unusual to have a "ripe" cataract in one eye and no cataract or small cataract in the other.  A ripe cataract is opaque and the surgeon can't see through even if dilated.  Such an eye needs both a B-Scan and  OCT. It is important to know what is going on in the back of the eye. I have seen such cases where the retina was detached, where there was a tumor in the eye or other problem that can be diagnosed with those tests.  Some cataract surgeons don't have all those intstruments in their office in which case you should be referred PRE operatively to a retina surgeon for a posterior segment evaluation.

Also if you have a ripe cataract the measurements used to determine IOL power are often difficult. These are K reading (radius of curviature of the cornea) and A-Scan.  Both eyes would need to be scanned to see if the readings are about the same. Since your glasses RX are virtually identical the K readings and axial length should be about the same.

Assuming the above is done, and you don't mind glasses a spherial IOL would be fine. You are right at the edge of where a toric might be useful but it is best for people that hate glasses and want best vision without glasses. Alcon makes very good IOLs.  The targeted post op refractive error in the should be about -0.50   you should be able to tolerate that nicely with your other eye. There is absolutely no reason to do your good eye if it sees well and has no or small cataract.  

I am very concerned about your eye and your situation. I would urge 2nd opinion with another cataract/IOL surgeon and if your truly have a ripe/white/opaque cataract a consultation with a retina surgeon for B-scan and attempt at OCT.

I would ultra worried about proceeding with just one opinion but a non-communicative surgeon.