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What questions to ask about Premium IOLs
I'm going to an appointment next week for patient education and measurements concerning premium IOLs. I saw the ophthalmologist last week, but this session, and I gather the measurements, will be by an optometrist. My understanding and expectation is that this will be my main opportunity to spend as much time as needed getting all my questions answered. I didn't feel pressured at all into premium IOLs, and I'm free to choose conventional monofocal. Indeed, my vision is still good enough that the ophthalmologist said there's no problem putting it off for months, or longer, but encouraged me to get the measurements sooner because they're more reliable when the cataract isn't severe.
I want to make the best use of this time, so I'm wondering what sort of questions should I be asking? My main question is how would they compare with monovision from conventional IOLs. Also, since I do tax prep for a living, I can't tolerate a result that would require frequent switching of glasses between the computer and paperwork, though occasionally for the real fine print is ok. The ophthalmologist said that the most likely choices would be either the Restor or the Tecnis (but not one of each).
In the way of background, I'm 56, with -6.0 -1.25 in the affected, non-dominant eye, and -4.0 -0.5 in the dominant eye (which only has the beginning of a cataract). I've worn contacts for years, going for monovision a few years ago and then ProClear multifocals, with toric only for the worse eye. I'm also the sort who can't keep his glasses clean, which I gather makes me a better candidate for the IOLs - since my requirements are lower.
I want to make the best use of this time, so I'm wondering what sort of questions should I be asking? My main question is how would they compare with monovision from conventional IOLs. Also, since I do tax prep for a living, I can't tolerate a result that would require frequent switching of glasses between the computer and paperwork, though occasionally for the real fine print is ok. The ophthalmologist said that the most likely choices would be either the Restor or the Tecnis (but not one of each).
In the way of background, I'm 56, with -6.0 -1.25 in the affected, non-dominant eye, and -4.0 -0.5 in the dominant eye (which only has the beginning of a cataract). I've worn contacts for years, going for monovision a few years ago and then ProClear multifocals, with toric only for the worse eye. I'm also the sort who can't keep his glasses clean, which I gather makes me a better candidate for the IOLs - since my requirements are lower.
It is definitely not standard practice for a cataract surgeon to refer patients to an optometrist, who takes charge of addressing questions and concerns about IOL choice, etc. Such questions are answered by the surgeon, and a technician generally does the eye measurements. (I suspect that your surgeon also refers post-surgery problems to the optometrist.) I'd strongly suggest that you do some research about multifocal IOLs yourself before you sign on the bottom line. Frankly, I would not have surgery done by anyone who didn't have the time to answer my questions about the procedure personally. I'd wonder whether they cared more about money than about patient care.
I wore monovision contacts for years with no problem, but I could take them out. There were times that I wanted to take them out so I wasn't going to take a chance on monovision iols. Decided on the Restor. My worst nightmare. Talk about glare! Night driving was just about impossible with the starburst and sunburst glare from every light source. Explant to monofocals for distance with a slight increase in right eye. Best decision. I can see all distances Need readers for smal print. In my opinion, stay away from multofocal. If I only had two choices my choice would not be multifocal!
I would ask about how many implants of that particular lens he/she has done, and I would also ask a lot of questions about the measurements etc, which you say are to be done by an optometrist, including the methods/measuring equipment used. I would also be VERY specific about my expectations and what I consider acceptable and less-than-acceptable outcomes.
I had Crystalens implants in both eyes 9 months ago. I am NOT happy, because I am now for the first time in my life near-sighted, which for me -- and my lifestyle -- is totally unacceptable. I guess that makes me a finicky perfectionist.
Before surgery I wore spectacles for reading and computer work. For outdoor activity involving distance vision I needed contact lenses, which provided satisfactory vision but caused issues around and in the water, and used a hand lens with them if I needed to read. My stated goal for multifocals was to dispense with contact lenses, and if I could also read without spectacles, very nice, but that would be a bonus, not a primary requirement. For some reason I am now nearsighted -- need contacts to drive -- or to see clearly across the room -- and suspect I couldn't pass the driver's test without them. And although I can read anything except really fine, low contrast print without contacts -- if it mattered to me, I need a hand lens (or spectacles) to read anything at all with them, which is just kind of ironic -- I am exactly where I started: contacts outdoors with readers over them -- except that I can now read the newspaper without spectacles, if I care. I paid $6400. for this adventure, and didn't even get a copy of my eye prescription on the way out.
More to the point, I have never gotten any real answers or useful discussion from the opthamologist as to how this could have come about. (His sole comment the last time I saw him -- after having both eyes YAG'd -- was "Well, you were farsighted and I made you nearsighted". ) Looking back, altho he is a well-regarded surgeon/faculty member at a well-known med school, I now suspect that his experience with Crystalens was limited (and have since learned he no longer is inserting them) -- wish I had pursued that question more diligently . Likewise my recollections of the pre-surgical measurements is very vague and I wonder if this was done as carefully as it might have been, as I have also heard since that it is crucial for multifocals. And I wonder if my pupil size could be a factor. So I would suggest pursuing these issues before going ahead with any multifocal, and maybe interview more than one surgeon.
And be skeptical.
Good luck
I had Crystalens implants in both eyes 9 months ago. I am NOT happy, because I am now for the first time in my life near-sighted, which for me -- and my lifestyle -- is totally unacceptable. I guess that makes me a finicky perfectionist.
Before surgery I wore spectacles for reading and computer work. For outdoor activity involving distance vision I needed contact lenses, which provided satisfactory vision but caused issues around and in the water, and used a hand lens with them if I needed to read. My stated goal for multifocals was to dispense with contact lenses, and if I could also read without spectacles, very nice, but that would be a bonus, not a primary requirement. For some reason I am now nearsighted -- need contacts to drive -- or to see clearly across the room -- and suspect I couldn't pass the driver's test without them. And although I can read anything except really fine, low contrast print without contacts -- if it mattered to me, I need a hand lens (or spectacles) to read anything at all with them, which is just kind of ironic -- I am exactly where I started: contacts outdoors with readers over them -- except that I can now read the newspaper without spectacles, if I care. I paid $6400. for this adventure, and didn't even get a copy of my eye prescription on the way out.
More to the point, I have never gotten any real answers or useful discussion from the opthamologist as to how this could have come about. (His sole comment the last time I saw him -- after having both eyes YAG'd -- was "Well, you were farsighted and I made you nearsighted". ) Looking back, altho he is a well-regarded surgeon/faculty member at a well-known med school, I now suspect that his experience with Crystalens was limited (and have since learned he no longer is inserting them) -- wish I had pursued that question more diligently . Likewise my recollections of the pre-surgical measurements is very vague and I wonder if this was done as carefully as it might have been, as I have also heard since that it is crucial for multifocals. And I wonder if my pupil size could be a factor. So I would suggest pursuing these issues before going ahead with any multifocal, and maybe interview more than one surgeon.
And be skeptical.
Good luck
The following was cut and pasted, it's from a lecture at the Hawaiian Eye 2010 conference:
"Multifocality enhances image resolution but diminishes contrast sensitivity
Ongoing design improvements aim to reduce spherical aberration, nighttime glare and halo."
Roger F. Steinert
A thorough grasp of optical physics and lens design features is essential to optimizing patient satisfaction with multifocal IOLs, a surgeon said.
“Who is the right patient for a multifocal lens?” Roger F. Steinert, MD, asked at Hawaiian Eye 2010. “Somebody who clearly desires less dependence on glasses. In the absence of that, they’re probably not going to be as happy. You also have to educate the patient that there’s going to be this process that will take potentially several months to adapt to the new visual system.”
Clinicians should also be aware of contrast sensitivity and various pathologies, Dr. Steinert said in his presentation on multifocal IOL performance.
“Because of these issues, particularly contrast sensitivity, if there’s other vision-limiting pathology, particularly in the macula, you’re probably well advised to stay away from multifocal lenses,” he said.
The evolution of multifocal lenses began with the original diffractive-refractive design that Alcon acquired from 3M. More recent changes in diffractive step design have resulted in two versions of the AcrySof IQ ReSTOR IOL, with +3 D and +4 D additions, Dr. Steinert said.
Optics and neuroadaptation
Clinicians and optic designers need to understand one basic law of optical physics, according to Dr. Steinert: 50% of light energy is out of focus at any given time. “That is an unavoidable physical reality,” he said.
With multifocality, the in-focus and out-of-focus images add up and produce a luminance curve. The patient with a multifocal lens is able to discriminate the edge of an image but sees that image with reduced contrast sensitivity, he said.
Glare and halo are commonly associated with multifocal lenses, Dr. Steinert said.
“The reason that you get the halos is because, when the patient is looking in the distance and they have a bright light source, some of that light is going to go through the near portion of the multifocal lens, and it will be brought into focus in front of the retina and then diverge outward,” he said. “It’s that diverging outward that creates the perception of a halo. The IOL power does have a big impact on that in terms of where that halo is located.”
Multifocality depends heavily on neuroadaptation, Dr. Steinert said.
“This computer that we’re carrying that occupies a quarter of our skull is very, very good at improving edge definition and reducing out-of-focus aberrations,” he said. “We’ve seen plenty of that with laser vision correction as well. That’s why multifocal lenses can deliver functional simultaneous distance and near vision satisfactorily in most patients.”
Evolving optical design
Improvements in optical design include aspheric optics, which reduces spherical aberration, and apodization.
“Apodization is a technique that Alcon used to basically weight the reading toward the center and delete some peripheral rings and shift to more distance-dominant with the big pupil,” he said. “That hopefully reduces nighttime aberrations but does inherently compromise reading vision under dim illumination.”
Improvements to the Tecnis aspheric IOL (Abbott Medical Optics) have centered on diffractive rings around the back of the lens rather than the front, Dr. Steinert said.
“The idea is that perhaps that is working better in giving more depth of focus because it’s closer to the nodal point,” he said. “Certainly, they have better nighttime dim-light reading because they have more rings way out to the periphery, and the intermediate works pretty well.”
Dr. Steinert offered a pearl on reducing nighttime halo for a patient implanted with a multifocal lens: 0.5 D of myopic correction in the patient’s prescription for nighttime driving glasses will shrink the halo and make it less evident, he said.
“The idea is that you put a minus lens in front,” he said. “You’re going to defocus the distance slightly because you’ll be behind the plane of the retina slightly, but that will also bring that blur circle closer to the center and make the halo less obvious.”
There is no truly reliable test of patients’ ability to tolerate multifocality in the presence of a cataract, Dr. Steinert said. – by Matt Hasson
•Roger F. Steinert, MD, can be reached at The Gavin Herbert Eye Institute at University of California, Irvine, 118 Med Surge I, Irvine, CA 92697-4375, U.S.A.; +1-949-824-8089; fax: +1-949-824-4015; e-mail: ***@****. Dr. Steinert is a consultant for Abbott Medical Optics and LenSx Lasers
"Multifocality enhances image resolution but diminishes contrast sensitivity
Ongoing design improvements aim to reduce spherical aberration, nighttime glare and halo."
Roger F. Steinert
A thorough grasp of optical physics and lens design features is essential to optimizing patient satisfaction with multifocal IOLs, a surgeon said.
“Who is the right patient for a multifocal lens?” Roger F. Steinert, MD, asked at Hawaiian Eye 2010. “Somebody who clearly desires less dependence on glasses. In the absence of that, they’re probably not going to be as happy. You also have to educate the patient that there’s going to be this process that will take potentially several months to adapt to the new visual system.”
Clinicians should also be aware of contrast sensitivity and various pathologies, Dr. Steinert said in his presentation on multifocal IOL performance.
“Because of these issues, particularly contrast sensitivity, if there’s other vision-limiting pathology, particularly in the macula, you’re probably well advised to stay away from multifocal lenses,” he said.
The evolution of multifocal lenses began with the original diffractive-refractive design that Alcon acquired from 3M. More recent changes in diffractive step design have resulted in two versions of the AcrySof IQ ReSTOR IOL, with +3 D and +4 D additions, Dr. Steinert said.
Optics and neuroadaptation
Clinicians and optic designers need to understand one basic law of optical physics, according to Dr. Steinert: 50% of light energy is out of focus at any given time. “That is an unavoidable physical reality,” he said.
With multifocality, the in-focus and out-of-focus images add up and produce a luminance curve. The patient with a multifocal lens is able to discriminate the edge of an image but sees that image with reduced contrast sensitivity, he said.
Glare and halo are commonly associated with multifocal lenses, Dr. Steinert said.
“The reason that you get the halos is because, when the patient is looking in the distance and they have a bright light source, some of that light is going to go through the near portion of the multifocal lens, and it will be brought into focus in front of the retina and then diverge outward,” he said. “It’s that diverging outward that creates the perception of a halo. The IOL power does have a big impact on that in terms of where that halo is located.”
Multifocality depends heavily on neuroadaptation, Dr. Steinert said.
“This computer that we’re carrying that occupies a quarter of our skull is very, very good at improving edge definition and reducing out-of-focus aberrations,” he said. “We’ve seen plenty of that with laser vision correction as well. That’s why multifocal lenses can deliver functional simultaneous distance and near vision satisfactorily in most patients.”
Evolving optical design
Improvements in optical design include aspheric optics, which reduces spherical aberration, and apodization.
“Apodization is a technique that Alcon used to basically weight the reading toward the center and delete some peripheral rings and shift to more distance-dominant with the big pupil,” he said. “That hopefully reduces nighttime aberrations but does inherently compromise reading vision under dim illumination.”
Improvements to the Tecnis aspheric IOL (Abbott Medical Optics) have centered on diffractive rings around the back of the lens rather than the front, Dr. Steinert said.
“The idea is that perhaps that is working better in giving more depth of focus because it’s closer to the nodal point,” he said. “Certainly, they have better nighttime dim-light reading because they have more rings way out to the periphery, and the intermediate works pretty well.”
Dr. Steinert offered a pearl on reducing nighttime halo for a patient implanted with a multifocal lens: 0.5 D of myopic correction in the patient’s prescription for nighttime driving glasses will shrink the halo and make it less evident, he said.
“The idea is that you put a minus lens in front,” he said. “You’re going to defocus the distance slightly because you’ll be behind the plane of the retina slightly, but that will also bring that blur circle closer to the center and make the halo less obvious.”
There is no truly reliable test of patients’ ability to tolerate multifocality in the presence of a cataract, Dr. Steinert said. – by Matt Hasson
•Roger F. Steinert, MD, can be reached at The Gavin Herbert Eye Institute at University of California, Irvine, 118 Med Surge I, Irvine, CA 92697-4375, U.S.A.; +1-949-824-8089; fax: +1-949-824-4015; e-mail: ***@****. Dr. Steinert is a consultant for Abbott Medical Optics and LenSx Lasers
I had the Restor lens in my eye for one month,
How long did you keep Restore lenses before explanting?
MEDICAL PROFESSIONAL
Dear GaryFx,
I would recommend that you speak with your eyeMD about your requirements about night driving. Both of the multifocal lenses would give you good distance and near vision, although intermediate might not be great. Each lens results in a compromise of vision for distance at night with more glare and halo.
Dr. Feldman
Sandy T. Feldman, M.D., M.S.
ClearView Eye and Laser Medical Center
San Diego, California
I would recommend that you speak with your eyeMD about your requirements about night driving. Both of the multifocal lenses would give you good distance and near vision, although intermediate might not be great. Each lens results in a compromise of vision for distance at night with more glare and halo.
Dr. Feldman
Sandy T. Feldman, M.D., M.S.
ClearView Eye and Laser Medical Center
San Diego, California
I picked up a copy of my prescription history today, though unfortunately my regular optometrist is away this week. As near as I can tell, I was on monovision contacts for at least five years. I used to get both near and distant contacts for the eye that was chosen for near vision, using the far contacts in both eyes for special situations (like movies or bike riding). So the presence of two different prescriptions for the same eye shows when I was on monovision.
The interesting thing is that a) the difference between the near and far prescriptions (for the same eye) was just 1.25, but b) the prescription for the far contact was 0.25 less than my eyeglass prescription for the same eye. Also, when I finally decided to try the multifocal contacts, it was after trying a spread of 1.5, but also the eye used for distance had gotten worse while the eye used for near had gotten better. I'm not sure how the spread between the two eyes relates to the spread between the near and far prescriptions for the one eye that got both contacts - a question that I'll ask my optometrist when he returns.
As for my exam this week, I'm postponing it. Not so much because of the issues raised here, but because it wouldn't have been covered by insurance, though the fee was only $125. It would have been a two and a half hour session. In my mind, optometrists often understand the refraction issues better than the surgeons (who, after all, should be concerned with the surgical skills and medical issues, the biology more than the physics).
The interesting thing is that a) the difference between the near and far prescriptions (for the same eye) was just 1.25, but b) the prescription for the far contact was 0.25 less than my eyeglass prescription for the same eye. Also, when I finally decided to try the multifocal contacts, it was after trying a spread of 1.5, but also the eye used for distance had gotten worse while the eye used for near had gotten better. I'm not sure how the spread between the two eyes relates to the spread between the near and far prescriptions for the one eye that got both contacts - a question that I'll ask my optometrist when he returns.
As for my exam this week, I'm postponing it. Not so much because of the issues raised here, but because it wouldn't have been covered by insurance, though the fee was only $125. It would have been a two and a half hour session. In my mind, optometrists often understand the refraction issues better than the surgeons (who, after all, should be concerned with the surgical skills and medical issues, the biology more than the physics).
Questions to ask.... well, you've had monovision, and multifocal contacts. Which vision did you like better? That's a start.
There's crystalens, it doesn't have as much risk of halos and glare. But some people report they can see the "edge" of the lens. Might have something to do with pupil size? Sometimes it doesn't work and then you've spent your money on an overpriced monofocal.
There's the multifocals.... I don't know about the full refractive rezoom... I haven't heard of many getting that lens lately. Might get some bad halos.
There's the Tecnis and ReStor. From what I've heard is you get better dim light reading with the Tecnis because it's fully diffractive, but might have more of a chance of halos at night. You get less halo and glare for night driving with the ReStor with it's apodization and outer refractive ring, but you might need a little more light for small print in dim light. So what would you want more? Or would even a small risk of either be unacceptable?
Also, the Tecnis compensates for .27 corneal abberation, and the ReStor .20. So it also might depend on the amount of positive aberration of your cornea too for the best lens for the job. That's something your eye doc would need to measure.
I had sph -2.75, cyl -.50 axis 101 OD, and sph -2.50, cyl -1.00 axis 035 OS. So I had astigmatism in both eyes and got 20/16 and J1 reading with ReStor. No LRIs during surgery, or lasik after. I think the suregeon must have had a magic wand or something. Point is, multifocals can work with a certain amount of astigmatism I guess. I'm proof.
If you have a really good surgeon with gobs and years of experience, he should be able to tell you how well you would do with each option. But I hoped I gave you some ideas at least for the monovision/multifocus/accommodating lens decision.....
:)
There's crystalens, it doesn't have as much risk of halos and glare. But some people report they can see the "edge" of the lens. Might have something to do with pupil size? Sometimes it doesn't work and then you've spent your money on an overpriced monofocal.
There's the multifocals.... I don't know about the full refractive rezoom... I haven't heard of many getting that lens lately. Might get some bad halos.
There's the Tecnis and ReStor. From what I've heard is you get better dim light reading with the Tecnis because it's fully diffractive, but might have more of a chance of halos at night. You get less halo and glare for night driving with the ReStor with it's apodization and outer refractive ring, but you might need a little more light for small print in dim light. So what would you want more? Or would even a small risk of either be unacceptable?
Also, the Tecnis compensates for .27 corneal abberation, and the ReStor .20. So it also might depend on the amount of positive aberration of your cornea too for the best lens for the job. That's something your eye doc would need to measure.
I had sph -2.75, cyl -.50 axis 101 OD, and sph -2.50, cyl -1.00 axis 035 OS. So I had astigmatism in both eyes and got 20/16 and J1 reading with ReStor. No LRIs during surgery, or lasik after. I think the suregeon must have had a magic wand or something. Point is, multifocals can work with a certain amount of astigmatism I guess. I'm proof.
If you have a really good surgeon with gobs and years of experience, he should be able to tell you how well you would do with each option. But I hoped I gave you some ideas at least for the monovision/multifocus/accommodating lens decision.....
:)
A few posters here, including me, have had extraordinary success with multifocals, as you can read here:
http://www.medhelp.org/posts/Eye-Care/IOLs-Positive-experiences/show/1159017?personal_page_id=971173#post_5377635
When I commented to my surgeon about the relative rarity of happy campers regarding these lenses, he said that patient selection was the absolute key. Extensive measurements of my eye dimensions, my hyperopia and absence of significant astigmatism, and my own attitude about wearing glasses contributed to my success with the much-maligned reStor lenses.
I agree with other posters about the importance of talking directly with your surgeon about lens selection. I made several appointments just for this purpose, and my doc was very, very patient with me. You want to assess the attitudes and ideas of the doctor who will be slicing (one hopes delicately and carefully) into the instrument you're going to use to see stuff for the next forty years.
http://www.medhelp.org/posts/Eye-Care/IOLs-Positive-experiences/show/1159017?personal_page_id=971173#post_5377635
When I commented to my surgeon about the relative rarity of happy campers regarding these lenses, he said that patient selection was the absolute key. Extensive measurements of my eye dimensions, my hyperopia and absence of significant astigmatism, and my own attitude about wearing glasses contributed to my success with the much-maligned reStor lenses.
I agree with other posters about the importance of talking directly with your surgeon about lens selection. I made several appointments just for this purpose, and my doc was very, very patient with me. You want to assess the attitudes and ideas of the doctor who will be slicing (one hopes delicately and carefully) into the instrument you're going to use to see stuff for the next forty years.
I too agree with JodiJ and Londonbridge. Definitedly consider monofocal lenses. You'd be suprised as to what can be achieve with monofocal without the hassle and problems with the multifocal. I have been there.! A good surgeon is the key.
I echo JodieJ's comments. Do a lot of research and be sure to talk to the surgeon who will be doing the surgery. Consider all options including monofocals set for blended vision which may be just as well or better than the multifocals.
londonbridge
londonbridge
I didn't mean to suggest that I couldn't get answers from the ophthalmologist, it's just that they schedule the extended appointment with the optometrist, who specializes in screening for refractive surgery as well as the premium IOL screening. I'm planning on getting my prescription history from my own optometrist, to let me judge how I did on the monovision contacts before switching to the multifocals.
But I'll answer my own question with a link to http://www.cataractfreeamerica.org/cataracts/cataract-doctor-tough-questions.htm. I don't think I'd ask them all, and some I can research online, but it's a tough list. My ophthalmologist is an AAO fellow, re-certified 2006, a clinical instructor at a local med school, no malpractice claims, certified for both ReStor and Tecnis multifocal.
But I'll answer my own question with a link to http://www.cataractfreeamerica.org/cataracts/cataract-doctor-tough-questions.htm. I don't think I'd ask them all, and some I can research online, but it's a tough list. My ophthalmologist is an AAO fellow, re-certified 2006, a clinical instructor at a local med school, no malpractice claims, certified for both ReStor and Tecnis multifocal.
I can offer a non-professional opinion only. (1) I think that you should be discussing your options with your surgeon, not with the optometrist who is doing your measurements. (2) You need to do a lot more research before you choose a multifocal IOL like ReStor. There is a wealth of information in the archives of this website, but stick to the more recent threads. People with larger pupils and significant astigmatism are probably not good candidates for ReStor. (3) If you've been happy with monovision contacts, you sound like a good candidate for monovision with IOLs. Consider an AcrySof toric IOL for your non-dominant eye to correct your astigmatism. (4) In your place, I'd consult a second surgeon for recommendations, preferably someone who would address my questions and concerns personally.
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