iol to choose

[Redbreast15]

Hi, I have to decide which kind of iol has to be implanted in my eyes and I am in trouble...I have both yes myopic, - 3,75 S -3,75 D, since I was seventeen, now I am 66 years old. I have always worn rigid and semirigid conctact lens, every day, from early morning to night, without problems. Before cataract I needed +1,50/2,00 glasses to read very small characters, wearing them on my contacts. Now I have -7,5 S and -4,5 D. I had 3 different suggestions: 1) monofocal iol to see well at far, 2) monofocal iol -2.50/3.00 in both eyes to have a very good near vision, and 3) the Symfony lens (available here in Italy). I am accostomed to have a very good near vision even without any lens or glass and I am very sensible to colours. I think that the solution n. 2 might be the more "natural" for me, but also the new lens Symfony seems very interesting even if also "complicated". I would like some suggestions. I have to decide in a few days...
Thank you for any help.

[JohnHaganMD]

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[SoftwareDeveloper]

I don't know where the claim of 3 diopters of depth of focus vs. 1.5 for the Symfony comes from, it depends on how its being measured. Regardless of how its measured   the 1.5 is wrong for the Symfony. If depth of focus is defined as the range of 20/40 or better vision then the Symfony has that from 0D to -2.5D. In reality if someone were implanted with the Symfony set at -1D, then their distance vision would still be about 20/40 and they'd have 20/40 vision all the way down to -3.5D which would be a 3.5 diopter depth of focus range.

The studies I've seen suggest the MiniWell is fairly comparable to the Symfony, there isn't as large a jump in depth of focus as that poster claims, if there is any its slight.  I'd seen some data suggesting it *might* have a slight edge but I haven't seen enough data to be sure how the various attributes (like issues of halo and contrast sensitivity) compare to be sure. The only head to head comparison I recall seeing was optical bench test data which couldn't compare such things. The MiniWell is definitely worth keeping an eye on to see what more studies show. I'd heard from some source (which might be out of date) that it wasn't yet being widely marketed but was still being tweaked before they do so.

Even if the MiniWell is a slight improvement in near vision, it would   still make sense to consider targeting micro-monovision to give it a bit more near without compromising distance.


The SAV-IOL is still in the early stages of development with very little data to go on so I'm not sure yet how it compares to the others.  A surgeon involved in testing it posted a video a couple of months ago going into details of it:

https://www.youtube.com/watch?v=_A4VvXdvSPI

which includes mention that the results of the first batch of lenses weren't as good due to the lower quality production technique used. Even though production quality has been improved, they've still only done a comparatively small number of lenses and testing.  I would be cautious about trusting the production process for a new lens company still getting its act together. Although the Symfony's optics are different than prior Tecnis lenses, its material and overall shape are the same as its widely used monofocal and multifocal lenses and presumably benefit from similar production methods they've gotten down pat.  

[4ndrew]

1.5 depth is confirm by dr holiday, that's why mini vision is recommended, if you running thru the Miniwell study, if may find the comparation between Miniwell and symfony on all distance. I manage to witness 5 post op cases on INFO, results almost same, 6/7.5, 20/02, n3 with no complaint on halo and ghost images.

[Redbreast15]

The opacity in my right eye is floating together with little flies and filaments, (and it is a pity because I was seeing so well...), it is moving, more or less depending on the eye movements; but very often it obscures my vision for 60%, and this damages also the good vision I could have with the other eye. Neuroadaptation seems quite impossible. Also the left eye has some floaters, but not so big. It seems quite impossible to me that the cause of this has been the operation in some way. Why they appear 2months after the operation? Perhaps I made a mistake and had not enough care of my eyes the days after the op? They told me that  a predisposing factor is my myopic, and the cause of the moment may be the hot clima we have also today. I  decided to wait and take some integrators (magnesium, potassium and others), that I was already taking, and to wait very good news from specialists in floater removal. Someone suggested OCT macula to do in six months.....I only hope that the floaters do not get worse!

[SoftwareDeveloper]

A so-called "secondary cataract" isn't a cataract but is what is called PCO (posterior capsular opacification) which is growth of cells that cloud the lens which are zapped with a laser. The risk of PCO tends to relate to things like the material&shape of the lens and its placement, and the surgical technique, and not the optics of the lens (e.g. multifocal or monofocal doesn't make a difference). The incidence of PCO has been reduced greatly over the years with modern lens designs including the latest Tecnis lenses like the Symfony. It used to be most people got PCO, now the large majority never get it.

The risk of floaters similarly doesn't relate to the optics of the lens, but merely due to either the trauma of the surgery itself, or apparently sometimes whether the surgeon leaves remnants in place that he should have removed.

Yup, there are risks involved in any sort of use of a laser to treat floaters, but of course they are developing better techniques all the time to improve safety and ensure the laser won't fire if it might damage the lens or retina. So old articles expressing safety concerns may not be relevant to newer techniques. However  since I haven't needed this treatment myself, I haven't evaluated those risks in detail myself, I leave it to others to explore those risks in consultation with their doctors, perhaps consulting specialists in floater removal.

[Redbreast15]

Thank you for the links, I have read them carefully. I saw something about Yag laser, here in Italy, and about the risks of marking the implanted iol, and of injuring the retina. I understand that it's also used for the secondary cataract, that often appears, as they say, after multifocal iol implantation. I have the strong doubt that I have to expect more floaters and perhaps the secondary cataract, due to the Symfony iol.
However I begun to take integrators suggested by the surgeon, just to balance out the risks that the 38 C degrees we have now may bring to my vitreous. I think that at the moment It is better to put up with the floaters, and to try to ignore them.

[SoftwareDeveloper]

Often they say to see if the floater goes away on its own to avoid the risk of treatment. In the past there wasn't much that could be done other than major procedures like a vitrectomy to drain the eye which isn't something most people wish to go through unless things are fairly bad.

However now some floaters  are now being treated using a  laser, though not all floaters can be treated that way. The method  is called laser vitreolysis.   There has been some controversy regarding the approach in the past, but there seem to be newer lasers with features designed explicitly to deal with floaters that are starting to get more use, the Ultra Q and LEH-Vitlase (I think they are different lasers, but it might simply be rebranding of the same one by a clinic). Here are  some articles about the Ultra Q:

http://crstodayeurope.com/pdfs/0515CRSTEuro_F5_singh.pdf

http://ophthalmologytimes.modernmedicine.com/ophthalmologytimes/RC/tags/floaters/how-yag-laser-vitreolysis-can-be-used-practice-treatment-fl?page=full

http://www.retinalphysician.com/articleviewer.aspx?articleID=109108

They have a "find a physician" link:

http://www.floater-vitreolysis.com/find-a-physician/

The LEH Vitlase:
http://www.londoneyehospital.com/conditions/floaters/

I recall one surgeon mentioning a swiss made laser he prefers, but I don't have a link offhand and can't recall what it was. It does sound like the approach has a learning curve so its best to find the most experienced surgeon you can   and to be cautious about any potential risks, which I haven't researched in detail since I haven't needed the treatment myself (I just ran into someone with the issue and did a little research).

[Redbreast15]

I had my last visit of this year two days ago and the next will be next year.
I have good vision in the left eye, the right eye is a little bit myopic. I was so much satisfied of my far and near vision, but a lot of flying objects and filaments (of the corpus vitreous they told me) are seriously disturbing me.
I always have had a lot of them, with and without contacts, but now I have one of them in the right eye, since two days, that is obscuring a large part of my vision. They prescribed me some integrators, telling me that probably I'll obtain no results. Do you have any suggestion?
Thank you in advance.

[Redbreast15]

I  had my second eye operated five days ago. The near vision of the first eye is getting better, and the near vision of the second is even better, also because it is a little bit myopic. I'll have my visit in two days and I'll know how is the situation. Halos and glares are shining. I hope it's too early.

[SoftwareDeveloper]

I don't know how long you are waiting before the other eye. Again its possible that you are merely still recovering from surgery and your near vision in the operated eye will get better.  If the eye looks like it is recovered well enough to get a good sense of vision, you can use it to estimate where you might want the other eye. You could look at what the prescription for that eye is, if it is say +0.50, then look at whatever strength lens you need to see the print you'd like to see, say +1.50. Then do (reading-add - prescription) so in this example  +1.50 - (+0.50) = 1, and that is how myopic you want your other eye to be able to read that well, i.e. -1.  There is a limit to how much monovision you want to do since it reduces 3D vision, but -1 or even a bit higher is tolerated by most people (if the vision in your other eye is good enough, you might consider a contact lens trial).

Unfortunately the quality of vision people get with an IOL varies with each person. Although most people don't need glasses for anything with the Symfony (except perhaps very rarely for a rare close up task), a  minority of people do need to  wear reading correction with the Symfony. Usually people focus on getting the eyes set right to handle the majority of their tasks well, even if they do occasionally need   glasses.

[Redbreast15]

So it could be better to ask for a little bit (-1.00/1.50) myopic eye to balance the other either it is hyperopic or not. In this case I could not only read and use the computer, but also handle the very small objects I use for my hobby.

[SoftwareDeveloper]

Actually with this IOL you can be a bit hyperopic (even say +1.5) and still have 10/10 far.  

[Redbreast15]

They measured my left eye, and I have 10/10 far, so I am not hyperopic (if I understand well). The surgeon showed me how My sight could be with -1.00, -0.50 either looking at far and reading very small characters. He told me that it's possible to implant in the right eye, on the base of the prescription they already made and that is quite the same of the left, a lens 'a little bit lower which allows me to see the size print I want to see at a comfortable distance. I can choice the add to do this.

[SoftwareDeveloper]

re: " I think that -1, -1.50 could be enough to "compensate", balance the other eye hyperopic."

Yup, that is the micro/mini-monovision I was mentioning, those are a "bit myopic", a bit nearsighted. Usually with the Symfony they do 1D or  less, the Symfony page (if you click on the clinical tab) shows the results of a small bit of monovision:

http://www.tecnisiol.com/eu/tecnis-symfony-iol.htm

however you may decide you want a bit more. The thing to do is to find out what the prescription is like on your first eye, if it is truly farsighted (vs. perhaps just merely still recovering from surgery), and then what sort of add you need to do with that to see the size print you want to see at a comfortable distance. That should guide how nearsighted you want the second eye.

[4ndrew]

Go for 3 diopter EDOF lens, you don't need mini mono vision, symphony only give you 1.5 diopter depth.

[Redbreast15]

What do you mean with "a bit myopic"? I think that -1, -1.50 could be enough to "compensate", balance the other eye hyperopic. I'll try to talk about this target with the surgeon. I hope to solve the thing.

[SoftwareDeveloper]

re: "was able to read small characters wearing +1.50 lens"

The question is what your prescription is. I'm suspecting there is a very good chance the lens power they used was wrong, that they left you farsighted, which takes away your near vision. Though as I said it is possible that may be off since:

re: "first postop check"

Usually that is the day after surgery, and the eye is still very much recovering from surgery and the measurements may change and improve quite a bit.

re: "suggested the same correction in the two eyes"

If possible a tiny bit of monovision, making he 2nd eye a bit myopic,  is often used to get a little bit more near.

re: "understand by him that the Symfony iols cannot be set up even a little myopic"

They have studied mini(/micro)-monovision for this len. I suspect I've read everything on the net about this lens, and a number of surgeons talk about  doing a slight bit of monovision, and no source I have seen says there is anything wrong with having one eye be a bit myopic. If your first eye is farsighted, even if trying to get the 2nd eye to be plano (neither myopic nor hyperopic), it is best to aim to err on the side of making the next eye a little myopic worst case rather than hyperopic again.

I'm hoping that you didn't understand him correctly. If that is what he claimed, that would indicate he doesn't know what he is talking about and you should consult another surgeon.

[4ndrew]

Mono vision because symphony only provide 1.5 diopter depth of focus, not like Miniwell or INFO from SAV-IOL which give you 3 diopter depth.

[Redbreast15]

I have already had my first postop check. The surgeon sayd that my left eye was able to read small characters wearing +1.50 lens. For the right eye an equal Symfony was ordered, as the surgeon suggested same correction in the two eyes. Furthermore I understand by him that Symfony iols cannot be set up even a little myopic. I think that at the end of the story I have to wear 1/1.50 glasses for near vision. Anyhow I thank you for telling me that your night vision became better with the passing of time and I'll wait some weeks hoping the same for me.

[4ndrew]

That is because symphony only got 1.5 diopter depth, that's why they promote mini mono vision, Miniwell or INFO from SAV-IOL will give you all distance vision.

[SoftwareDeveloper]

re: "but I must wear glasses (+1,50/2,00) to write for instance now."

Your eye is still healing from the surgery (which may cause some visual glitches) and getting used to having a new lens, my near vision was poor for a couple of days before it became good. (and with multifocals it can take a number of weeks/months for the best near vision to come in, which may be true with some patients with the Symfony as well). Many people with any type of lens   experience some visual glitches the first few days after surgery, so I wouldn't worry yet about glare and night vision. Most studies that talk about things like night vision issues are referring to the results at least 1 month or often 3 months postop.

In addition of course with your other eye not being operated on yet it won't have good near vision in that eye, and the difference in near vision between the two might lead you to do better with correction until you do. The brain can deal with some visual difference between the two eyes (like in monovision) but it may take a little time to adapt to. If your left eye doesn't have enough near vision, the can target the right one to be a little myopic, monovision.

I am suspecting unfortunately that you may have wound up being hyperopic, farsighted, in that eye, which would reduce how much near vision you get while still leaving good distance&intermediate. I'd suggest at your next postop (usually 1 week) you see what they say your prescription(/refraction) is, and what your vision is in that eye by itself.

The prescription unfortunately can vary the first few weeks until the lens fully heals into place. Usually they don't even consider prescribing new glasses until 1 month postop if the prescription seems stable (sometimes a few weeks more than that).

In terms of glare, part of what might be going on is after the lens clouded by a cataract has been removed, more light can enter the eye. Most people after cataract surgery (especially if they had both eyes done around the same time) comment on how much brighter the world is at first. I had to turn my monitor brightness way down.  It may be that at night the lights will seem brighter at first until you get used to the difference (and that the difference between your eyes may also be confusing your visual system if one eye is seeing it more brightly than the other).

[Redbreast15]

I had my operation five days ago. Now I have the first eye done, the left one, with Symfony implanted. I had asked for Mini Well, but the surgeon told me that he did not have good results with them, so I confirmed my choice for Symfony. I have a good vision far, good intermediate, but I must wear glasses (+1,50/2,00) to write for instance now. I don't know if the situation will be better when I have also the right eye done. I fear I have to forget my near vision... But I can see the trees all around me, and the leaves, and the windows of my neighbor with their small particulars. I am worried for the glares I saw yesterday night looking at the lights of the cars. They were very large and not transparent, so that it was Necessary to look away. I hope it will get better!

[4ndrew]

Symfony only have 1.5 diopter depth of focus, which means the near vision is not good as we need 3 diopter depth to get near vision. Miniwell or INFO from SAV-IOL will give you all and better distance, intermedia and near vision. US surgeons got no access to Miniwell and INFO from SAV-IOL.

[Redbreast15]

The surgeon suggested a monofocal set -2,50/3,00, to have a very good near vision, or Symfony. He did not have a good experience with Mini Well.
I have chosen Symfony. Next week I'll have operation.

[rwbil]

If you go with the Symfony, report back your results.  

[Redbreast15]

I read your experience. It was very useful.
Tomorrow  I'll ask my surgeon also about your iols. I think that the choice he will suggest will be Symfony....

[rwbil]

I had cataract surgery 3 weeks ago and had the Tecnis 2.75D MF IOL implanted.  I just posted my experience which might be of interest to you.  

http://www.medhelp.org/posts/Eye-Care/Tecnis-275D-MF-IOL-Experience/show/2597910

[Redbreast15]

I understand that when he was looking at something, (not at night) for instance a book, he saw the book as through a circle; ie one of the three circles that delimit the three concentric zones of the trifocal. This was one of the bugs of this kind of lens. I think that it is similar to what happens to me sometimes when wearing my contacts (not multifocal): I see the bordeline of my stiff lens fluctuating when there are particular situations of light, and if I pay attention to it.
I 'll have my visit with the surgeon in a few days. He suggested me first iol set for far, but I fear I need glasses for near and also for Intermediate. Then he suggested Symfony saying that I'd use glasses for near (+1,00/1,50). Another surgeon told me "only monofocal, don't use multifocal, Symfony is a kind of multifocal, you should be never satisfied with it".  Now I return to the first, a little bit informed, also thanks to what you wrote, but I am so much anxious...