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Symfony CLR

I have a question about clear lens replacement. I am 52 and I have Presbyopia as well as the following prescription. OD Sphere  +1.50 add +1.75    OS  Sphere +1.25 Cylinder -.25 Axis 175 Add+1.75
I wear bifocal glasses and contacts at times however I hate wearing glasses with a passion. I cannot read computer, cell phone, labels or basically any font without glasses and I wear my glasses or contacts 98% of my day. Distant vision is just ok however not sharp.
I am not a candidate for Lasik correction because of too thin of something I cant remember.
I have been given the option of a clear lens replacement at TLC on London with the new symphony lens with its extended range of vision and I've read people are having pretty good success with it. I understand there is some risks involved which is a bit scary I wont lie however as far as I understand they are very low.  
So I am wondering about getting some opinions on here to hopefully help with my decision whether I should go ahead. Its an elective surgery at this point and TLC tells me they have don't several CLR procedures and also to people with even a milder prescription than mine.
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Avatar universal
You are really welcome for whatever small amount of help my post may have given.  I really wouldn"t be having my other eye done if there was any way in the world I could avoid it. Pragmatism is a skill I'm having to learn the hard way!  Good luck. Sue
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177275 tn?1511755244
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Avatar universal
Excellent responces from all the above posters and I really apprieciate the opinions from both perspectives. So my first eye surgury was to be sept 4, 2 days ago, however I did cancel my appointment at this time. I've decided as I mentioned to postpone surgery at this point in time. Not sure if I will go ahead with it at some point or possibly wait until technology has improved. So thank you all for taking the time to post and to help me and hopefully others with the same concerns as me, to make an informed decision.
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177275 tn?1511755244
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Avatar universal
I should note that although lens exchange has risks, even contact lens wearing has risks for instance as do progressive or even single vision glasses. We don't usually think about those risks since they are minor, and often statistics aren't yet available on say the impact on car accidents.  Over say 30 years they can add up. Progressive & bifocal glasses can be an issue in falls in the elderly:

http://www.medscape.com/viewarticle/724889
"Multifocal glasses have been shown to impair balance and increase the risk of falls in several studies"

http://bottomlinehealth.com/bifocal-and-multifocal-glasses-and-contacts-increase-risk-for-dangerous-falls/
"A growing body of research, much of it originating at the Falls and Balance Research Group at the Prince of Wales Medical Research Institute in Sydney, Australia, has demonstrated that when older folks wear multifocal lenses while walking and also performing a secondary task — like reading a sign — they tend to “contact more obstacles” (as in, trip or bump into something). The glasses focus differently for near and far, which means that the wearer’s ability to see obstacles near his/her feet gets compromised. The fact that falls are the leading cause of death from injury among older adults in the US makes this especially worrisome."

A presbyopic correcting IOL can reduce those issues. Although I haven't seen accident statistics, there are indications that during daytime driving glasses aren't as good as contacts in certain ways in terms of potential safety (meaning they are presumably not as good as an IOL as well), whereas with night-time driving contacts aren't as good as glasses (though I suspect neither are as good as the Symfony or an accommodating IOL usually, aside from the rare person who does have glare or halo issues with those):


http://eprints.qut.edu.au/31885/1/Byoung_Chu_Thesis.pdf
"The results demonstrated that the path length of eye movements while viewing and responding to driving related traffic scenes was significantly longer when wearing BIF and PAL than MV and MTF CL. The path length of head movements was greater with SV, BIF and PAL than MV and MTF CL.
[....] Progressive addition lenses were ranked as the most preferred vision correction, while MTF CL were the least preferred vision correction for night-time driving."

   I chose to take the risk of contacts before surgery. I don't know what the statistics are for eye damage from say glasses breaking during an accident (though likely negligible).  This is a 2012 article so I don't know if the statistic has changed, but one of the more major risks from contacts:

http://www.medscape.com/viewarticle/773026_3
"The annual incidence of all contact lens-related microbial keratitis was 4.8 per 10,000 wearers."

So if a 50 year old presbyope chooses multifocal contacts and lives  another 25-30 years the cumulative risk is 120 to 144 per 10,000 which is 1.2 to 1.4% risk for that side effect alone. (though granted over that time they will find ways to cut down on the risk, and presumably proper lens care has an impact).  

Most contact lens issues of course are resolved by not wearing them, but not all like keratitis or some infections that threaten sight.

re: "or damage to the IOL (which is no longer safe to exchange) "

Even after a YAG a lens exchange can be done, it merely means the odds are the lens will need to be place outside the capsular bag which reduces the number of options available since usually 3 piece lenses are used outside the bag (and 1 piece lenses are usually what is used in the bag which is the preferred location), but there are monofocals and multifocals for use outside the bag.

Although I personally wouldn't have done refractive lens exchange at the current state of technology, people do need to evaluate the risks for themselves. The lesson of posts here is merely that even if it is ok for most people, the worst case can be bad so people need to be sure it is worth the "worst case" risk since *someone* winds up being the "statistic" referred to when complication rates are mentioned. Those risks however need to be kept in perspective compared the rare worst case scenarios of a damaging fall or car accident due to eyeglasses or contacts or other contact lens issues. Unfortunately I don't think there are good statistics to compare since it likely isn't always possible to determine whether different visual correction might have prevented an accident.
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177275 tn?1511755244
Thanks for the posting Garry.  It is one thing to accept risks to treat a serious sight threatening condition; yet another to get rid so something annoying like glasses in an otherwise healthy eye.

JCH MD
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Avatar universal
Or everything could go just fine with none of those symptoms As in my case and tens of thousands of others Who have lens exchange with no complications or pain and have achieved the predicted outcome

Anyone who is considering lens exchange I would say read Dr John Hagans posts Very balanced
Things can go wrong But it is far more likely that all will go well

  Gary  
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Avatar universal
Just to follow the crowd here, what they list to you as a possible complication does not begin to cover the complications that occur that they dont tell you about. Dr. Hagan wrote "The "low risks" include infection, bleeding, inflammation, swelling of the retina, blindness, need for lens exchange, lens removal or still needing glasses."

Lets look at "need for lens exchange" These are very common things that can cause a need for lens exchange. Sometimes it is too risky to proceed with another lens exchange and youre are stuck with it, even if you do replace the IOL, it may not resolve these issues- positive or negative dysphotopsias-- feeling like you have tunnel vision because there is a dark arc obscuring your peripheral, or constant streaks/sparkles/flashes/halo's of varying degrees of severity off of all light sources. People commonly develop dry eye after cataract surgery which is not really cureable and can leave you in constant pain and make your vision worse due to tear film instability or even recurring corneal abrasions. What software developer mentioned, the jiggling and headaches from reading, as well as a myriad of debilitating visual complaints that your doctor will tell you they have never heard of before and can't possibly be as bad as you say, are mentioned all the time on this forum. Oh, damage to the pupil is also a possibility which will result in permanent severe glare.
        If you proceed with RLE, it is likely you will need a yag procedure done later. Then you can worry about permanent starbursting caused by the opening being smaller than your pupil, dislocation of or damage to the IOL (which is no longer safe to exchange) permanent floaters, huge quickly moving floaters like windshield wipers across your eyes that also seem to be permanent, debilitating glare, and an extremely elevated lifetime risk of retinal detachment.

How common are these things? I don't know. I do however know that it sure seems that most of them happened to me. (And none of them were mentioned as possible risks.) I also know that if you take LASIK as example, which is supposedly almost perfectly safe with  satisfaction rate of 97%, did you know that something like 30% of all people who have had lasik done complain of night vision issues? And 40% complain of dry eye (after 1 year)? These people are considered "successful" outcomes because they no longer need glasses. They can't see at night and their eyelids get glued to their corneas and peel off like bandaids every time they blink, but their surgeries were successfull and they are "happy" with their outcome. I read a website written by a woman who had triple vision in her eye after lasik but her vision was 20/20 and the response from her doctor was that she was just too difficult to please. She is also listed as a successful outcome.

I'm not trying to terrify you, I'm simply saying that it is very likely that at least one of the things I mentioned above will happen to you. No, you're not going to go blind or end up with detached retinas, but you will have some kind of dysphotopsia, or light sensitivity, or refractive error, or slow pupil which may or may not only be cosmetic, or dry eye, or floaters, or something. (I have all of them) Everyone does, but most of these people were half blind from cataracts and are much better off than they were. You will still need reading glasses afterwards, do you want to reduce your dependence on them so badly that you will be as willing to except these permanent imperfections in your vision as someone who was going blind?
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177275 tn?1511755244
Thanks for the testimonial.
JCH MD
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Avatar universal
I had cataract surgery with one of the best MF IOL, IMO, the Tecnis 2.75.  And in a million years I would not recommend doing a clear lens replacement.  There is nothing out there as good as your natural adaptive lens.  When you hear 98% success rate, that is based on people that had cataracts and can not function.  I was one of those and my doctor rates me as a great success.  With cataracts if I went out in the sunshine everything was a blur and dangerous for me to drive.  But after cataract surgery I have halos at night and floaters and there is always the issue of enough light at close distance for near vision.  I do not care what they tell you this is major surgery on your eyes.  

I had Presbyopia and wore contacts and would never have my natural lens extracted unless you absolutely have to.
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177275 tn?1511755244
To: Miggman. This is elective surgery. Take you time and learn what you're getting into. Be sure you've read this article I wrote and the discussion that follows:

http://www.medhelp.org/user_journals/show/841991/Consider-ALL-the-Options-Before-Your-Cataract-Surgery-Working-Through-Whats-Best-For-You


JCH MD
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Avatar universal
Thank you all  for your responses and posting information, I very much appreciate you all taking the time. It has definitely got me thinking about whether or not I should go ahead with this surgery. I have my first eye surgery appt for Sept 4 and the second eye a week later, but I may reschedule until I do some more research. I didn't realize that being somewhat younger actually was a higher risk of complications, i wouldn't thought the opposite would be true. I have to admit I was excited when I read about the symfony lens and I thought it was a perfect fit for me. I also want to read up on what SD mentioned regarding adjusting the lens for a tiny micro mono vision, as I dont understand what that means. All in all I'm not sure I'm ready to pull the trigger at this point. This is a great forum and I honestly havent had much success on searching online for reviews for this lens and especially from people that had the RLE with the symfony lens, i suppose mostly because it is so new.
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177275 tn?1511755244
Typo "Thank you'
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177275 tn?1511755244
Thanks Gary.  For some people it will be worth accepting fully informed risks for others once they understand the risks they will bail out.  Both are acceptable.  Some people think climbing Mt. Everest and K-2 are acceptable risks.  I personally climbed Mt. Rainier and summited Mt. Kilimanjaro (by the Machame Route).  Those risks were acceptable given my physical condition and skill level. I was asked to join a group trying to climb Mt. McKinley (Denali) in Alaska. Those risks were totally unacceptable to me.

Again that you
JCH MD
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Avatar universal
Great post John

Im sure it will help many to decide weather the risks are worth taking
Its very hard to achieve balance Most posts or articles are very one sided
one way or the other
Great post  
     Gary
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177275 tn?1511755244
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Avatar universal
The issue of calculating IOL powers is an important one. Unlike determining the power of eyeglasses or contacts, they can't determine the IOL power exactly in advance. They use various formulas to try to estimate the right lens power based on statistics from past patients. Usually those with low prescriptions like the original posters lead to fairly accurate results, not there are exceptions. If they don't get the power right, then you may need to either wear correction, or add further risks with   a laser enhancement, a lens exchange or a piggy back lens.

There is a new paper out on the issue which mentions a lower rate of hitting the refractive target than I'd have expected, though unfortunately those numbers vary quite between studies, countries, and surgeons:

http://www.touchophthalmology.com/articles/refractive-lens-exchange
"Refractive Lens Exchange
European Ophthalmic Review, 2015;9(1):17–8
...Complications do occur in RLE. The mean incidence of retinal detachment is 1 % while the mean incidence of cystoid macular oedema is 0.1 %. ..In hyperopic RLE, 88 % of low hyperopes were within 1D of the target refraction while only 58 % were within 1D of the target refraction. ... On the other hand, a different bundle of complications occurs in eyes with a short axial length. These include suprachoroidal haemorrhage and malignant glaucoma."

Experience helps with this sort of surgery, which is useful for cataract patients to remember as well, since practice helps (though skill is a factor also, not all high volume surgeons are created equal), a recent article mentions that in Canada:

http://ophthalmologytimes.modernmedicine.com/ophthalmologytimes/news/does-practice-make-perfect?page=0,1
" In Ontario, Canada, for example, the adverse event rate varied with the number of patients operated on by the surgeons in a year:

            Cataract surgeries per year                      Adverse event rate
                        50 to 250                                           0.8%
                        251 to 500                                         0.4%
                        501 to 1,000                                      0.2%
                        >1,000                                               0.1%"

Again however those are just statistics, and someone winds up being the statistic. Even with the 0.1% complication rate *someone* winds up being that statistic. However  of course most adverse events are treatable, even if you have a complication things may still work out fine in the long run. In life you often need to make risk tradeoffs, though many are small enough people don't think much about them, many people never consider the risks of say infection from contact lens wear or injuries from glasses breaking.
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177275 tn?1511755244
I received an e mail at my practice asking for more information and to justify my position. So here goes.  The risk benefit of a procedure changes when you are doing an operation or using a medicine to save a life or save vision.  Thus people with ultra serious diseases like cancer make take medications that might kill them knowing no treatment will result in death and if a certain cancer is 100% fatal and a medicine had 25% fatal results but cures 75% that 75 people's life are salvaged.  As illnesses are less severe the medications used need much better safety profiles. Who would be willing to take a decongestant with serious or common side effects? No one.

Thus the risks for say cosmetic surgery needs to be very very low because no one dies from looking old, tired or wrinkled.  There are many respected surgeons including in our practice that do clear lens exchanges.  This is how these patients are approached:  try and take care of the refractive problem with glasses or contacts or external refractive surgery.  Make sure the person understands the risks involved and has a reason other than pure vanity for which glasses/contacts/external refractive surgery will not suffice.  Favor individuals who have early cataract formation or a strong family history of cataracts.  Decline people with unrealistic expectations or who imply that if a complication occurs "somebody did something wrong and I'm suing!"  This attitude is rife in the USA and fostered by the unremitting advertising of trial lawyers trolling for dollars.

If you go back through these eye forums there are discussions about great new eye procedures that in retrospect did not turn out well at all and most or all people who had them wished they had not gone with "the newest surgery or device on the market.    Examples include radial keratotomy (RK)  many of whom now are extremely over corrected or have debilitating glare due to cataracts and their corneal scars;  hyperopic thermal keratoplasty; corneal "intacts"; anterior chamber semi-flexible IOLs such as Azar an Stableflex; glass IOLs, generic voltarin eye drops to name a few.  

If a person is this far and wants to take these risks then by far the most important thing is the skill and experience of the surgeon. This type of surgery does not lend itself to the occasional surgeon or anyone whose team for computing IOL powers is anything less than spectacular.

JCH MD

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Avatar universal
Yup, even someone that age is comparatively young for cataract surgery and oddly the risks of detachment are higher, as they are for males, however

re: "(larger eyes probably) "

The original poster indicated he has a hyperopic prescription, which usually tends to indicate smaller eye components, it is high myopes that tend to have have large eye structures that tend to be more prone to risk of detachments than others.  Some of the studies though that talk about  higher risks of detachment for high myopes are older studies from decades ago  that predate modern surgical techniques that seem to have have reduced the risks quite a bit. The risks seem to be   larger for high myopes still, but I'm not sure that I've seen agreement yet on what the statistics are using modern methods.


re: "lower levels of vision in poor light, in an IOL, as opposed to a natural lens"

I think that tends to vary depending on the person (and the lens, even monofocal IOLs vary in their optical qualities)  since even without a cataract contrast sensitivity goes down with age, though its more noticeable with folks past their 50s I gather.  At 52 I think my low light vision is better after surgery than before cataracts (and while the cataract in one eye was bad, the others was barely visible, if I hadn't noticed the imbalance between the eyes I might have put off getting it treated). My impression may be flawed though due to better visual acuity perhaps playing a roll, and because for a few years I usually   wore multifocal contacts before surgery which tend to reduce contrast sensitivity so I may not be remembering the time before that well enough.
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Avatar universal
Hello, you may wish to consider the higher risk of a PVD after cataract surgery, especially since you are relatively young, and male (larger eyes probably) factors which both increase your level of risk.    Although the recognised risk for you would be slightly above 6%, successful cataract patients are hard to monitor over a timescale of the decade during which the risk is greater of a PVD, than for someone who has not had cataract surgery.  This is  because the IOLs are smaller, the older bit of vitreous in the middle may already be liquid, and there is more room for it to 'slosh around' hence pulling the jelly off the retina, I have read the real risk could be as high as 20% in your age group.  Older people have probably already had a Post Vitrekus Detachment and got on with it, floaters, risks and all.  Although not serious in itself, PVD floaters can be very annoying and of course there is a small associated risk of retinal detachment to consider as well.  

I'm sure you are also aware of lower levels of vision in poor light, in an IOL, as opposed to in a natural lens.  At  night time I can almost imagine my cataract is in the other, operated, eye, the levels of my vision are reversed, (yep, I still have an op to go).  Just food for thought, you asked for comments so here are mine.  I really wish you well, but if I were you I would wait as long as you can , the rate of change in this field is A MAZ ING
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Avatar universal
re: "from what I understand JohnHagan is an experienced cataract surgeon, he advises you against clear lens extraction. "

This is an issue where large numbers of surgeons are on each side of the issue. Merely citing one surgeon's views doesn't settle the issue, it is merely a reminder that there are surgeons who are opposed to the practice and that patients therefore should be particularly sure to evaluate the risks in consultation with doctors that have examined their particular case (perhaps getting more than one opinion).

Many experienced cataract surgeons perform clear lens extraction. While I wouldn't have chosen lens replacement if I'd never had a cataract, each person needs to make their own risk assessment, even if we may disagree.  

Here is a journal paper from a couple of years ago from some experienced surgeons in the Survey of Opthalmology going over the topic and some of the issues and studies:

http://www.researchgate.net/publication/262193174_Refractive_Lens_Exchange
"Refractive Lens Exchange"

It mentions for instance that:
"Small hyperopic eyes with shallow anterior chamber are more predisposed than other eyes to angle-closure glaucoma. This makes moderate hyperopia an indication for RLE, offering a good risk/benefit ratio"

The original poster only has mild hyperopia so that may not be a factor consider in their case, the point is merely that the risk/benefit ratio differs for each person. Unfortunately I don't have time to gather statistics on refractive lens exchange issues. One problem is that although for the most part the risks are the same with cataract surgery, some of the statistics may be misleading since the average cataract patient tends to be much older than the typical RLE patient, and more likely to have co-existing other eye problems which may lead to different complication rates. Even many of the statistics for cataract surgery don't break things out by age, and unfortunately studies are often out of date and based on older surgical techniques.

Here is an overview of cataract surgery which talks about some of the complications and rates:

http://www.allaboutvision.com/conditions/cataract-complications.htm

Here is a study published this year on surgeries in the UK (and again rates can vary by country, and by doctor, with experienced surgeons having lower complication rates):

http://www.nature.com/eye/journal/v29/n4/full/eye20153a.html
"The Royal College of Ophthalmologists’ National Ophthalmology Database study of cataract surgery: report 1, visual outcomes and complications"
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Avatar universal
I would go and see a consultant Then have a good think about what he or she tells you
Statistics do vary depending on who you ask
Mine was a great success As were many before me and after
But realise that it is quite rare for patents with a good outcome to bother posting on a forum
So you will mainly hear from the 2% that didn't have a happy outcome to there surgery
As I said in my previous post It took me ten years to decide to go ahead
For very similar reasons that you have stated
  Gary
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Avatar universal
Hi, from what I understand JohnHagan is an experienced cataract surgeon, he advises you against clear lens extraction.

To me your prescription of is not very long-sighted at all - I think you would be nuts to go under the knife for this small correction.
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Avatar universal
Oops, I meant visual acuity was *almost* 20/15 early on at distance, and since its improved since then its probably there by now but I hadn't checked.

I had good luck with multifocal contacts back before I had cataracts, you might consider trying different brands since different ones seem to work better for different people. You could also try monovision with contacts, though I personally much preferred multifocals. I didn't notice the reduction of 3D vision with monovision since I started that when I first was presbyopic and got used to it, but when I switched to multifocals I noticed how much better my 3D perception was.

In terms of the actual statistics of problems, they vary depending on the country and the clinic and doctor. You could try asking your doctor for stats.  I don't have more time to post now, but perhaps I'll find a general link to typical states tomorrow if no one else has done so by then.
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2 Comments
rgp multifocal contacts work better than soft because the lens moves on the eye. When you look down the botton eyelid will push the lens up and offcenter to put the reading power in front of the pupil. Also one gets accustomed when blinking to allowing the upper lid to pull the lens into the desired positon. It takes about a month to overcome discomfort and another couple of months to get to the point that you are not always aware of them, but it is worth it for the better vision. I would recommend doing the rgp multifocals if you are motivated not to wear glasses. I  would not do a clear lens extraction until or unless I had a cataract.
That being said now that I have a cataract I will be going with a Symfony most likely and maybe an AT LISA trifocal. Leaning toward the Symfony.  
rgp multifocal contacts work better than soft because the lens moves on the eye. When you look down the botton eyelid will push the lens up and offcenter to put the reading power in front of the pupil. Also one gets accustomed when blinking to allowing the upper lid to pull the lens into the desired positon. It takes about a month to overcome discomfort and another couple of months to get to the point that you are not always aware of them, but it is worth it for the better vision. I would recommend doing the rgp multifocals if you are motivated not to wear glasses. I  would not do a clear lens extraction until or unless I had a cataract.
That being said now that I have a cataract I will be going with a Symfony most likely and maybe an AT LISA trifocal. Leaning toward the Symfony.  
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