Symfony CLR

[miggman]

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.

[JohnHaganMD]

I don't recommend clear lens extractions so I will not comment. The "low risks" include infection, bleeding, inflammation, swelling of the retina, blindness, need for lens exchange, lens removal or still needing glasses.

JCH MD

[Garrry]

Ive had syphony lenses in both eyes just over three weeks ago
I had  poor distance and close wasn't good  and that's while wearing glasses I had astigmatism in both eyes - 4.5 and 5.5 I think
My distance is great and I can read the fine print on labels
Im still wearing sunglasses for driving in bright daylight But that is no hardship
The operation lasted an hour and five minutes to do both eyes
no pain or discomfort
The results are immediate
We went for a family day out at the sea side the following morning
and I could see fine With the aid of my sunglasses
Im 53  now I went for laser surgery ten years ago and was deemed not suitable for  laser of any type
I wish I had had it done ten years ago
Good luck with what you decide to do
  Gary

[JohnHaganMD]

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[miggman]

Thanks Guys I guess what I'm struggling with is my eyes are correctable with glasses. I just hate wearing them. I sometimes wear bifocal contacts however I cant read the computer for a long period because its not a clear view. I work in a body shop so I am at times in the office doing estimates etc and at times I am in the back shop working on cars. Tipping my head back constantly to get a good view through my bifocal glasses to view minor imperfections on what I am working on is extremely annoying. I assume as usual this procedure is done in cases where your eyes are not correctable with glasses. So is the risk worth it? I do know its a very common procedure. Does anyone know that stats for complications or where someone could research Stats on lens replacement surgery?

[JohnHaganMD]

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[SoftwareDeveloper]

Although lens replacement surgery is overall very safe, that doesn't mean it is absolutely safe.  Even if problems are rare, *someone* winds up being the statistic, so you need to carefully consider whether the risks are worth the benefit. Posts on the net give a disproportionate view of the problems since most people only post here after surgery only if they have a problem. (though some post beforehand asking for more info and post followups even if things qo well to provide some reassurance that not everyone has problems).

I had a problem cataract and had  Symfony lenses implanted in both eyes in December at the age of 52. I had delayed getting surgery for 2.5 years until the cataract in one eye was causing too many problems because I preferred to wait for a better lens to be available. I actually travelled to Europe to get the Symfony since it isn't yet approved in the US but I felt it was a better fit for my needs than the lenses approved here.  They are developing new and better lenses all the time, I'd have preferred to not need surgery until a more typical age for cataracts so I could have waited for a better lens that would restore full accommodation, or at least more like say in your thirties.

As far as I can tell, in terms of the lenses that are out there now, for my needs I  made the right choice going with the Symfony lens since my visual acuity is great, it was 20/15 early on (probably there by now) for distance and at near its 20/25. I can read the fine print on medicine bottles like the postop eye drops, and I can read the text on my  phone for email or web use. My night vision is better than I can remember it being before (I always felt my night vision wasn't that good). I do see halos at night, but they aren't bothersome since I see through/past them and since my vision is so good. If you do get the Symfony, I'd consider shooting for some tiny micro-monovision like -0.5D to -0.75D (check the Symfony website for a chart of outcomes).

That said, I actually have a very rare side effect from the surgery that seems likely related to the eye anatomy and the fact that I was highly myopic (not an issue you have) and likely nothing to do with the lens choice.  The point is that  I am one of the "statistics", and given the results  I would have preferred to not have had cataracts and not needed surgery at my age and have just worn correction.  That said, I know that again my problem is rare (and likely stems from having been highly myopic, which put me at risk of many things that you aren't at risk for). Everyone needs to evaluate how much risk they wish to take. I'd never risked LASIK despite being highly myopic, but many people do. (and I might actually risk a laser touchup if my side effect ever goes away to make it worth it).

Hopefully I will neuroadapt and this problem will go away, but they don't know if it'll be any day now or months, or never. The issue is that when I try to read, I have the impression of light flickering (for the first few months the text actually looked like it was jiggling up and down as my eyes moved to read, but that went away). Its like bad fluorescent lighting, but just a few herz,  to a degree that isn't merely annoying but is headache inducing. It is so bothersome I can't productively read a hardcopy book (even wearing correction doesn't make that viable), even if I can glance at a page occasionally or my smartphone for a minute. Fortunately it is much less at computer distance so I can do almost all my reading that way  (though I still get headaches from it, they are getting better all the time so I'm hopeful they will eventually go away).  

In my case due to having been highly myopic, removing the larger myopic lens and replacing it with a smaller one led to the iris losing support and jiggling when the eye moves (like it does when reading especially), iridodonesis they call it. Its not something other people would notice, but capturing it on video it is very noticeable and abnormal. That rarely has visual impacts even when its noticeable, but in those with light colored eyes in rare cases it can (I think the stray light varying as the iris moves, due to darker striations). Though they aren't positive that is the cause, it seems the most likely. Its possible that the lens capsule is also jiggling due to loose zonules but I hadn't tried to narrow it down since the recommendation in either case is to wait and hope I adapt and it goes away  (the surgeon had looked at my eyes before when dilated with their standard drops which are cycloplegic, they  paralyze the muscles that attempt accommodation and leave the zonules tighter, which may have led jiggling to be less noticeable.  I hadn't bothered having them check  with a non-cycloplegic or without dilation to try to pin down the cause for sure since its academic if I just need to wait and try to adapt for now).


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[CBCT]

I would like to add that any lens replacement (clear or cataract) is not the same as natural vision.  You sacrifice any accommodation, and glare and halos could become a
problem.  It is also possible that the surgery will induce additional astigmatism.  I chose cataract surgery because I was not comfortable driving at night.  After cataract surgery, I still had serious night halos and glare which continued to precluded night driving. Additionally, I became very sensitive to light to the point that I wore sunglasses and a visor even when indoors.   I ultimately had both IOLs exchanged -- which was complicated and had subsequent retinal issues.  My conservative advice is to give it time.  At some point, you will likely need cataract surgery; and you will benefit from improved technology.    Best wishes.

[SoftwareDeveloper]

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.

[bwalters56]

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.  

[bwalters56]

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.  

[etrader]

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.

[Garrry]

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

[SoftwareDeveloper]

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"

[Wolfhall]

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

[SoftwareDeveloper]

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.

[JohnHaganMD]

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

[SoftwareDeveloper]

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.

[JohnHaganMD]

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[Garrry]

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

[JohnHaganMD]

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

[JohnHaganMD]

Typo "Thank you'

[miggman]

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.

[JohnHaganMD]

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

[rwbil]

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.

[JohnHaganMD]

Thanks for the testimonial.
JCH MD

[Anomalychick]

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?