Dilemma about IOL choice and monovision

[Nicklee]

First of all, thanks for reading and helping out.

I am 53 year old male, highly myopic on both eyes,left is-9.5 and right -10.5. 2 weeks back, my right eye had a detached retina.  My doctor performed a vitrectomy and also took the opportunity to remove my cataract although my cataract was still mild and on its own, would not merit a surgery but since I had the RD, doctor said to just remove it too.

Anyway, I wanted to have my new lens correct my myopia fully but incredibly, doctor said she wasn't able to get me the lens i wanted but instead suggested that i put in one that was supposed to correct my myopia to just -2.5 to -3, with the view that this eye could be used as my reading eye and keep my left eye as the distance eye.  But my right eye is my dominant eye and i am reading now that some people have difficulty training their dominant eye to be the reading eye.  I worry that if that happens, i will still need to wear glasses over my left eye to read.

Alternatively, i can opt for my left eye to correct to also about -2.0 and there will be parity on both eyes.  I will have no issues of monovision, and both eyes can read near.  I probably don't need to wear glasses at home but will then have to wear glasses when i go out.  I seem to think this is the best solution for me now but i am not sure if my reasoning is correct.

I am not sure when i will need to remove my left cataract yet, but i want to be able to think through first and make the right decision for mself when the time comes.

Would love to have your thoughts on this. Sincere thanks.

[MrPresley]

I am going to try a self-test monovision reevaluation, by using my existing contact lens for distance correction in my right eye and using my left eye for close-up and reading. I can currently read fine print quite well with the IOL in place with my left eye and not wearing glasses.

[JohnHaganMD]

Good to try now rather than after IOL inside eye. Works for some but not for most.

[MrPresley]

Yes, I return to my optometrist on April 11 for a final post cataract surgery Rx change for my glasses.  Meanwhile I figured why not experiment before officially going back to contacts after my eye drop regimen ends later in April.  Thanks Dr. Hagan.

[JohnHaganMD]

you are welcome

[Nicklee]

Strange.  I am unable to see Dr Hagan's replies.  All i see is the "=" sign.

[JohnHaganMD]

= means I have read the string to that point and do not have additional comments.

[SoftwareDeveloper]

Your comments seem somewhat ambiguous in that you say the doctor "suggested that i put in one that". I assuming you mean that is what she actually did (rather than that you need to go back to get the IOL implanted). I'm guessing since you said the first eye's cataract was too mild to merit surgery that the 2nd eye's is also mild. If  so then the best thing to do would be to consider a contact lens trial where you set the 2nd eye to for whatever focal point  you are considering for an IOL to see how well that works for you. It won't be an exact test since at your age you likely still have a larger range of vision than you'd have with a monofocal IOL, but it would give some idea of what it might be like.

I'm guessing you are wearing a contact lens in the other eye now anyway? (usually that large a difference between two eyes is hard to adapt to with glasses). Usually -2.5 or -3 difference between the two eyes is more than most people adapt to well, so how well does having your left eye corrected for distance and your right eye at -2.5 or -3 now work for you.

Unfortunately most people wait until their cataracts are bad enough to need surgery and can't get as accurate a test with a contact lens trial. I'd read that usually a -1.5 difference between the eyes  is the most many doctors consider good for monovision, while some say -2, with -3 being very much worst case.  

Depending on your budget, if the first eye isn't set at the right distance, you could consider a laser enhancement to set it slightly differently.

You could also consider trying multifocal contacts to see if those work for you, and if your budget allows it, considering whether you'd wish to risk a premium lens in the 2nd eye to give more of a range of good vision.  

The fact that she wasn't able to get the lens you wanted sounds odd,   was it a matter of not being able to postpone surgery to wait  on shipping I guess, and she had another size in stock already for some reason?  

[JohnHaganMD]

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[MrPresley]

I did not know that cataract surgery would be performed along with vitrectomy, at the same time and by the same doctor.  My own such procedures were performed by two different opthalmologists, neither of which would do what the other specialized in.

[JohnHaganMD]

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[Nicklee]

@software developer.  I am resting at home these past 2 weeks.  I haven't gone to get a contact lens for my left eye yet. It is something i am not looking forward to because i tried contacts when i was much younger and never liked them.  But i have no choice now until i have my cataract removed.

What do you mean by laser enhancement to set the right vision slightly different? What is the name of this procedure? Effective? Risks?

[JohnHaganMD]

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[SoftwareDeveloper]

If you hadn't tried contacts recently then your experience may be very different now. I'm about your age and wore contacts from the early 80s until after cataract surgery a couple of years ago, and the modern disposable soft contacts are definitely more comfortable than the original soft lenses I wore when I first started with them, and have for instance less issues with things like allergies causing them trouble. Your prescription should fall within the range of the common brands like Air Optix and Acuvue, my worst eye was -9.5 or so for contacts just before the cataract hit  and at least my optometrist had samples in stock.

One of my eyes was very left slightly farsighted, +0.5D, which isn't useful since it reduces near,  so I keep considering a laser tweak. Its not been enough of an issue to bother spending money&time on yet  (since my other eye balances it out to provide good enough near with the Symfony IOL), so I hadn't researched the issue in detail, merely enough to see that I'd be comfortable doing it based on what I'd read.

In terms of laser enhancement, the most common techniques are LASIK and PRK, but there are other minor  variations on those basic approaches, and even those both mostly rely on the same laser to alter the shape of the eye. Which one works best depends on the patient and the status of their eye and their preferences (e.g. they vary in recovery time and risks), with some surgeons preferring PRK post cataract surgery, while others still preferring the more common LASIK.  The technology has been improving over time so its best to use a doctor who has the latest equipment and is up to date. Its extremely safe, though I hadn't seen good data on exactly how safe it is for a small correction like you would need. Most people getting laser correction are doing so because they had very high prescriptions, which require more tissue to be reshaped than small changes, so most of the data is based on larger changes, but even those show good results, but not as accurate as a small change will be. The little data I'd seen on small corrections looked good enough for me, as did the very most recent data on the modern techniques for larger corrections.  

Recent cursory reading suggests I'd check further into the latest updated version of TransPRK (or Trans-PRK some spell it) if I ever get around to doing this, but I'm not sure its available yet in the US (I don't know if you are here, or in another country) and I'd first consult a surgeon to get their feedback on the specifics of my eyes.  TransPRK is an  all-laser version of PRK which removes any need for the surgeon to touch your eye by hand, with the latest update relying more on the actual specifics of your eye rather than averages. I'd need to think it through more and research it, but I think the slower recovery may be worth the tiny risk of flap related issues for me.  

[SoftwareDeveloper]

oops, typo.  I meant the slower recovery time may be worth avoiding even the tiny risk of flap issues other approaches have.

[JohnHaganMD]

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[SoftwareDeveloper]

Here was a recent reference I'd seen to TransPRK from the beginning of March  (  I'd looked up some other info afterwards, though i don't see the other recent article I'd seen on the most updated procedure):

http://ophthalmologytimes.modernmedicine.com/ophthalmologytimes/news/pulse-technology-boosts-all-laser-prk-one-step-no-touch-ablation
"Pulse technology boosts all-laser PRK for one-step, no-touch ablation
... The technique--performed with an excimer laser system (AMARIS) and pulse technology (SmartPulse Technology [SPT], both Schwind eye-tech-solutions)--is able to create a smoother corneal surface.

...Dr. de Ortueta said that TransPRK has become his excimer laser procedure of choice for refractive surgery, replacing LASIK."

Though now I see this from October, and I'm curious perhaps their comment isn't based on the newest data and software updates driving the laser:

http://eyelasersurgerysydney.com.au/trans-epithelial-prk-lasik-and-conventional-prk-their-differences-explained/
"Trans-epithelial PRK, LASIK, and Conventional PRK – Their Differences Explained
...In comparison with Trans-epithelial and Conventional PRK, LASIK appears to have the least overall post-operative complications, and the fastest recovery. This is because the minute incisions in the outer layers heal more rapidly in comparison to removal of the epithelial layer."

It may be partly the issue of comparing apples to oranges when comparing complications since it says "least overall post-operative complications" since they likely vary in their severity and prognosis, though are likely rare. Again I can't seen to find the paper I saw with more details on the newest updated TransPRK, I thought I'd saved it but I don't see it and don't notice it in a quick search and I won't spend more time now. I'd just seen enough references to flap issues that the idea of avoiding one seems to make sense (as apparently it does to some surgeons), but I haven't researched it enough since I don't need to decide now.

[JohnHaganMD]

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[MrPresley]

I went for parity on both eyes, with a monofocal lens for my left eye which had a ERM procedure/vitrectomy, followed by subsequent cataract surgery a year and a half later, to approximate the uncorrected vision in my non-operative right eye.  My left eye was formerly my dominant eye.

[Nicklee]

Thanks for sharing. So both eyes are now at what degree of myopia?  You still wear glasses now?

[MrPresley]

I am going to my optometrist this morning to have my Rx for glasses corrected for distance vision for my left eye.  My right eye is already corrected in such a manner.  I can currently read close up very well with both eyes.  Ultimately in a couple of months I will go back to wearing contacts in both eyes for distance correction and use readers for close up.  I tried the monovision approach with contacts about ten years ago or longer and never did like it or fully adapt to it.

I will post back after this visit today regarding what degree of myopia I have.

[JohnHaganMD]

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[MrPresley]

Currently -4.5 in my left eye with a monofocal IOL eight days after cataract surgery, and 6.0 in my right eye which thus far has not needed any treatment.

IOP was back down to 12 after a high of 21 one day post-op.

[Nicklee]

Parity i understand is important for glasses. If you are anyway using contact lens, could you not have chosen 0 for your left and wear contacts on the right?

[MrPresley]

I originally thought about going for 0 for the IOL on my left eye, but I've gone for so many years with distance correction for both eyes I'm comfortable with staying that way.  I wondered too if wearing a contact in one eye but not the other might feel strange.  My optometrist thought it unusual that I didn't get 0 as well, but he had assumed that I was having cataract surgery on both eyes, and the cataract surgeon and I had determined beforehand that only the eye that needed it would be done.  I like that way of thinking.