Aa
my Symfony IOL results after cataract surgery
I'd posted before asking for information about lens options before surgery, but thought I'd start a new thread now that I've gotten the lens where perhaps others can add their results as well with the Symfony lens. It is a new type of "extended depth of focus" lens that uses a different design than multifocal and accommodating lenses.
I had Symfony lenses implanted in both eyes the first week of December. By 1 week postop my uncorrected vision at distance was between 20/15 and 20/20. At near my vision was already about 20/25 (but fluctuating a bit it had seemed better earlier that day). Given its improvement since then I'd guess its likely 20/20 or so, I can read the small print on my eye drop bottles for instance. Not everyone achieves this level of near vision with the lens so people shouldn't expect to necessarily get quite as good a result, and should be prepared for the possibility for needing reading glasses at near. I suspect the fact that I'm comparatively young for cataract surgery, 52, might have something to do with the results.
I had originally only planned on having 1 eye done (since the other was 20/20 correctible still), but when the patch came off the next day I discovered it might be hard to adapt to the difference in vision between the two eyes even with a contact lens in the other eye. I might have quickly adapted if I'd taken the time, but I decided I didn't want to risk it, so I had the 2nd eye operated on a few hours later.
My intermediate vision hasn't been tested explicitly but I suspect is at least 20/20. That is based on my subjective sense of it being better than near and because of the design of this lens where visual acuity drops off in a continuous curve from far to near, so intermediate should be around the same as far, definitely better then near. That is one of the differences between this lens and for instance a bifocal IOL where vision may be worse at intermediate than it is at near or far. I spend a large number of hours at a computer and was willing to risk needing reading glasses occasionally for near in order to get better intermediate vision. Most household tasks and social interactions occur at intermediate distance as well.
Unfortunately the lens isn't yet available in the US yet, they are starting a clinical trial here which is randomized with a monofocal lens (there is a 50% chance you would get a monofocal) so I went to Europe for my surgery. I figured that at my age I hopefully may be using these lenses for a few decades so it was worth a bit of effort to get a better lens. This industry publication suggests it might be generally available in the US in a couple of years, and that some US surgeons find it interesting:
http://ophthalmologytimes.modernmedicine.com/ophthalmologytimes/news/us-surgeons-anticipate-new-iols?page=0,1
"the Symfony IOL might be available in the US by late 2016 or early 2017...
Of the IOLs discussed at the ESCRS Congress, Dr. Olson and Dr. Packer concurred that the brand new Tecnis Symfony Extended Range of Vision IOL was the most interesting as it represents a new concept for addressing presbyopia that seems to overcome the limitations of multifocal IOLs....
from what I’ve heard so far from respected and trusted surgeons, patients implanted with this IOL are seeing 20/20 at distance and intermediate with very usable, J2 or J3 near vision and are not experiencing any loss of contrast or perceptible problems with glare, halos or other dysphotopsias. So, it looks like they are having their cake and eating it too.”
I had considered the option of getting a trifocal lens which targets far, intermediate, and near (also unfortunately not yet available in the US), or even a bifocal with a small add so its focused more at intermediate than near. However the studies so far seem to indicate that the Symfony provides better quality intermediate vision. In addition multifocal lenses reduce contrast sensitivity which is useful for night vision, while reports indicate the Symfony is at least as good as a monofocal lens. The other thing the Symfony does is to correct for "chromatic aberration", an issue which is discussed in this industry publication which quotes one prominent surgeon noting:
http://eyeworld.org/supplements/EW-December-supplement-2014.pdf
" Cataract surgery with an IOL with an Abbe number greater than that of the natural lens (47) can improve CA, so that our cataract patients could actually experience better vision quality than they did as young adults. "
Although the Symfony uses a high Abbe material (I'm assuming its the same Tecnis material that article lists as having a 55 Abbe), it also has other features to to correct for CA to improve image quality. It seemed like a good bet the image quality for distance would be comparable, and perhaps even better, than a monofocal lens, or an accommodating lens.
Although some results for the Crystalens look like it will similarly do well for intermediate while providing some chance at decent near vision, some showed a lower chance of good near, e.g. some of the studies listed for the March 2014 update in this government review:
http://www.fda.gov/downloads/AdvisoryCommittees/CommitteesMeetingMaterials/MedicalDevices/MedicalDevicesAdvisoryCommittee/OphthalmicDevicesPanel/UCM346413.pdf
Part of the concern I had with the Crystalens was that in some patients the lens does well, but in some it doesn't accommodate, which leaves it effectively being a monofocal lens ( but without things like the correction for chromatic abberation). There is also concern I'd read among some over whether over decades of aging anything would interfere with the physical movement of the lens, something non-accommodating lenses don't require. There is no perfect lens, so its partly a matter of placing a bet on which might work out well, and I figured that it was better to bet on something that didn't require the accommodation to work (in addition to other concerns regarding problems people have with the Crystalens, though those may be fewer in the newest versions). I hadn't searched to find the study behind the figure in this presentation, but it notes:
http://www.slideshare.net/alanglazier/accommodating-intra-ocular-lenses
that about half of Crystalens patients require reading correction. That may be in part because as it notes: ' "Pushing” does not equal “Sustaining” '. This issue is that someone with their natural lens still who is presbyopic for instance may be able to theoretically read a particular print size without glasses, but that the muscle effort to focus may be a strain to do for an extended period of time, and the Crystalens at least partly seems to require the same sort of accommodative effort. (though there is speculation it may be benefit from some extended depth of focus, which is what the Symfony is designed to use to begin with). I'll continue this in another post in a few minutes.
I had Symfony lenses implanted in both eyes the first week of December. By 1 week postop my uncorrected vision at distance was between 20/15 and 20/20. At near my vision was already about 20/25 (but fluctuating a bit it had seemed better earlier that day). Given its improvement since then I'd guess its likely 20/20 or so, I can read the small print on my eye drop bottles for instance. Not everyone achieves this level of near vision with the lens so people shouldn't expect to necessarily get quite as good a result, and should be prepared for the possibility for needing reading glasses at near. I suspect the fact that I'm comparatively young for cataract surgery, 52, might have something to do with the results.
I had originally only planned on having 1 eye done (since the other was 20/20 correctible still), but when the patch came off the next day I discovered it might be hard to adapt to the difference in vision between the two eyes even with a contact lens in the other eye. I might have quickly adapted if I'd taken the time, but I decided I didn't want to risk it, so I had the 2nd eye operated on a few hours later.
My intermediate vision hasn't been tested explicitly but I suspect is at least 20/20. That is based on my subjective sense of it being better than near and because of the design of this lens where visual acuity drops off in a continuous curve from far to near, so intermediate should be around the same as far, definitely better then near. That is one of the differences between this lens and for instance a bifocal IOL where vision may be worse at intermediate than it is at near or far. I spend a large number of hours at a computer and was willing to risk needing reading glasses occasionally for near in order to get better intermediate vision. Most household tasks and social interactions occur at intermediate distance as well.
Unfortunately the lens isn't yet available in the US yet, they are starting a clinical trial here which is randomized with a monofocal lens (there is a 50% chance you would get a monofocal) so I went to Europe for my surgery. I figured that at my age I hopefully may be using these lenses for a few decades so it was worth a bit of effort to get a better lens. This industry publication suggests it might be generally available in the US in a couple of years, and that some US surgeons find it interesting:
http://ophthalmologytimes.modernmedicine.com/ophthalmologytimes/news/us-surgeons-anticipate-new-iols?page=0,1
"the Symfony IOL might be available in the US by late 2016 or early 2017...
Of the IOLs discussed at the ESCRS Congress, Dr. Olson and Dr. Packer concurred that the brand new Tecnis Symfony Extended Range of Vision IOL was the most interesting as it represents a new concept for addressing presbyopia that seems to overcome the limitations of multifocal IOLs....
from what I’ve heard so far from respected and trusted surgeons, patients implanted with this IOL are seeing 20/20 at distance and intermediate with very usable, J2 or J3 near vision and are not experiencing any loss of contrast or perceptible problems with glare, halos or other dysphotopsias. So, it looks like they are having their cake and eating it too.”
I had considered the option of getting a trifocal lens which targets far, intermediate, and near (also unfortunately not yet available in the US), or even a bifocal with a small add so its focused more at intermediate than near. However the studies so far seem to indicate that the Symfony provides better quality intermediate vision. In addition multifocal lenses reduce contrast sensitivity which is useful for night vision, while reports indicate the Symfony is at least as good as a monofocal lens. The other thing the Symfony does is to correct for "chromatic aberration", an issue which is discussed in this industry publication which quotes one prominent surgeon noting:
http://eyeworld.org/supplements/EW-December-supplement-2014.pdf
" Cataract surgery with an IOL with an Abbe number greater than that of the natural lens (47) can improve CA, so that our cataract patients could actually experience better vision quality than they did as young adults. "
Although the Symfony uses a high Abbe material (I'm assuming its the same Tecnis material that article lists as having a 55 Abbe), it also has other features to to correct for CA to improve image quality. It seemed like a good bet the image quality for distance would be comparable, and perhaps even better, than a monofocal lens, or an accommodating lens.
Although some results for the Crystalens look like it will similarly do well for intermediate while providing some chance at decent near vision, some showed a lower chance of good near, e.g. some of the studies listed for the March 2014 update in this government review:
http://www.fda.gov/downloads/AdvisoryCommittees/CommitteesMeetingMaterials/MedicalDevices/MedicalDevicesAdvisoryCommittee/OphthalmicDevicesPanel/UCM346413.pdf
Part of the concern I had with the Crystalens was that in some patients the lens does well, but in some it doesn't accommodate, which leaves it effectively being a monofocal lens ( but without things like the correction for chromatic abberation). There is also concern I'd read among some over whether over decades of aging anything would interfere with the physical movement of the lens, something non-accommodating lenses don't require. There is no perfect lens, so its partly a matter of placing a bet on which might work out well, and I figured that it was better to bet on something that didn't require the accommodation to work (in addition to other concerns regarding problems people have with the Crystalens, though those may be fewer in the newest versions). I hadn't searched to find the study behind the figure in this presentation, but it notes:
http://www.slideshare.net/alanglazier/accommodating-intra-ocular-lenses
that about half of Crystalens patients require reading correction. That may be in part because as it notes: ' "Pushing” does not equal “Sustaining” '. This issue is that someone with their natural lens still who is presbyopic for instance may be able to theoretically read a particular print size without glasses, but that the muscle effort to focus may be a strain to do for an extended period of time, and the Crystalens at least partly seems to require the same sort of accommodative effort. (though there is speculation it may be benefit from some extended depth of focus, which is what the Symfony is designed to use to begin with). I'll continue this in another post in a few minutes.
I thought I should add more about the flickering I'd mentioned since it isn't usually mentioned in overviews of cataract surgery or potential visual side effects to indicate why it doesn't seem to be anything to do with this particular lens. I ran into a good free ebook overview of cataracts&surgery which mentions a minor innocuous light version of it some might notice As a side note contains a good writeup of the questionable benefit of laser cataract surgery, though its a couple of years old I don't think there is yet any more evidence to change the general impression. It mentions in passing:
http://david-richardson-md.com/wp-content/uploads/ctb.pdf
"It's okay to read, but your vision may seem "jiggly". Because the lens capsule has not yet contracted around the IOL, there may be a slight jiggle of the lens with each eye movement. This is most noticeable when reading and will improve over the next few weeks."
In my case it just happens to be more noticeable and long lasting. The eye constantly makes small movements, especially while scanning to read, and the subjective impression of the image jiggling to me appears like the flicker of bad fluorescent lighting. Its likely mostly the lens needing to heal in place but it may be partly the eye&brain adapting to differences from the natural lens (in the case of your natural lens, the brain actually suppresses vision for a fraction of a second while the eye moves and while the natural lens jiggles a bit to a stop).
On this Medhelp its mentioned:
https://covdblog.wordpress.com/2014/02/10/science-and-splash-my-eyes-couldnt-rest-for-a-minute/
"You also need to know that once your cataractous lens is removed and an IOL placed in the capsular bag, the bag is floppy so to speak. Over a period of six weeks it will encapsulate the IOL or shrink wrap it.
In the meantime you could have what is called pseudophakodonesis which is simply movement of your lens until it settles into place. If you are myopic or have a large eye it would happen more than a hyperopic or small eye. Once the capsule shrinks and it stabilizes it goes away."
This notes that among those where it is bothersome (and I have all the risk factors):
http://en.allexperts.com/q/Ophthalmology-Optometry-979/2011/1/Flickering-Vision-IOL-Implant.htm
"You may experience some flickering of light or shimmering as the lens implant seats permanently into the capsule of the eye, and this may take up to three months. You may also see some edge glare during the first few months, typically in low levels of illumination.
These symptoms are more common in blue eyed patients, patients with higher levels of preoperative nearsightedness, and patients with large pupils.
Only a very small percentage of patients will notice these symptoms after three months, perhaps less than 1%."
Another source notes that other parts of the visual system can be looser at first as well:
http://www.science-bbs.com/150-med-vision/3cfabedd0bbe1663.htm
" Your lens is gone and with it goes some of the stabilizing support for your iris. Without it, the iris "jiggles" after saccades. We see it happen in the microscope. Normal, no biggie. "
Although it may be normal to some degree, in some cases like mine it is problematic when reading, but odds are it will go away soon (though it does take longer with a minuscule minority of people who do post around the net, but the odds of it are low).
http://david-richardson-md.com/wp-content/uploads/ctb.pdf
"It's okay to read, but your vision may seem "jiggly". Because the lens capsule has not yet contracted around the IOL, there may be a slight jiggle of the lens with each eye movement. This is most noticeable when reading and will improve over the next few weeks."
In my case it just happens to be more noticeable and long lasting. The eye constantly makes small movements, especially while scanning to read, and the subjective impression of the image jiggling to me appears like the flicker of bad fluorescent lighting. Its likely mostly the lens needing to heal in place but it may be partly the eye&brain adapting to differences from the natural lens (in the case of your natural lens, the brain actually suppresses vision for a fraction of a second while the eye moves and while the natural lens jiggles a bit to a stop).
On this Medhelp its mentioned:
https://covdblog.wordpress.com/2014/02/10/science-and-splash-my-eyes-couldnt-rest-for-a-minute/
"You also need to know that once your cataractous lens is removed and an IOL placed in the capsular bag, the bag is floppy so to speak. Over a period of six weeks it will encapsulate the IOL or shrink wrap it.
In the meantime you could have what is called pseudophakodonesis which is simply movement of your lens until it settles into place. If you are myopic or have a large eye it would happen more than a hyperopic or small eye. Once the capsule shrinks and it stabilizes it goes away."
This notes that among those where it is bothersome (and I have all the risk factors):
http://en.allexperts.com/q/Ophthalmology-Optometry-979/2011/1/Flickering-Vision-IOL-Implant.htm
"You may experience some flickering of light or shimmering as the lens implant seats permanently into the capsule of the eye, and this may take up to three months. You may also see some edge glare during the first few months, typically in low levels of illumination.
These symptoms are more common in blue eyed patients, patients with higher levels of preoperative nearsightedness, and patients with large pupils.
Only a very small percentage of patients will notice these symptoms after three months, perhaps less than 1%."
Another source notes that other parts of the visual system can be looser at first as well:
http://www.science-bbs.com/150-med-vision/3cfabedd0bbe1663.htm
" Your lens is gone and with it goes some of the stabilizing support for your iris. Without it, the iris "jiggles" after saccades. We see it happen in the microscope. Normal, no biggie. "
Although it may be normal to some degree, in some cases like mine it is problematic when reading, but odds are it will go away soon (though it does take longer with a minuscule minority of people who do post around the net, but the odds of it are low).
On the lens itself, I thought I'd note a new paper that shows intermediate vision after 3 months of 20/10 (translating units from their -0.33 logmar), even better than the distance vision of 20/20 (0 logmar) for distance:
https://ascrs.confex.com/ascrs/15am/webprogram/Paper16964.html
" Preliminary results of 30 eyes that completed the 3-month follow-up showed mean monocular UDVA of -0.01±0.10 LogMAR, mean binocular UIVA of -0.33±0.06 LogMAR and mean binocular UNVA of 0.12±0.11 LogMAR. Refractive predictability was excellent with a mean SE refraction of -0.15±0.33 diopters. Contrast sensitivity was similar to published data for a normal population of similar age. 5% of patients complained of mild halos and no patient complained of glare or starbursts. 82 % of patients were completely spectacle independent with 18% needing glasses for near."
It appears from papers I'd seen on multifocal lenses that vision at all distances seems to be improving for the first couple of months especially, and then to some extent for several months afterwards. One doctor who studied the Symfony mentioned in email that the Symfony (with its alternative approach rather than being a multifocal) seems to take longer for neural adaptation than a trifocal, though he hadn't responded to a followup question asking to be more specific and quantify the difference a bit.
https://ascrs.confex.com/ascrs/15am/webprogram/Paper16964.html
" Preliminary results of 30 eyes that completed the 3-month follow-up showed mean monocular UDVA of -0.01±0.10 LogMAR, mean binocular UIVA of -0.33±0.06 LogMAR and mean binocular UNVA of 0.12±0.11 LogMAR. Refractive predictability was excellent with a mean SE refraction of -0.15±0.33 diopters. Contrast sensitivity was similar to published data for a normal population of similar age. 5% of patients complained of mild halos and no patient complained of glare or starbursts. 82 % of patients were completely spectacle independent with 18% needing glasses for near."
It appears from papers I'd seen on multifocal lenses that vision at all distances seems to be improving for the first couple of months especially, and then to some extent for several months afterwards. One doctor who studied the Symfony mentioned in email that the Symfony (with its alternative approach rather than being a multifocal) seems to take longer for neural adaptation than a trifocal, though he hadn't responded to a followup question asking to be more specific and quantify the difference a bit.
One more new article with a good summary of the lens, and the state of others in the works (e.g. the next generation accommodating lenses seem a bit less promising than the impression I'd had in the past) just a clip:
http://www.reviewofophthalmology.com/content/c/52313/
'IOL Alternatives to Multifocality
Avoiding glare and halo while expanding focal depth is the primary goal of these implants.
“The first thing to understand is that the term diffractive optics doesn’t necessarily imply multifocality,” says Daniel Chang, MD, an ophthalmologist from Bakersfield, Calif., who is an investigator for the U.S. trial of the Symfony. “This is not a multifocal lens, but it does use diffractive optics to do two things: First, it corrects chromatic aberration. Second, it uses these optics to extend the range of quality vision.” '
http://www.reviewofophthalmology.com/content/c/52313/
'IOL Alternatives to Multifocality
Avoiding glare and halo while expanding focal depth is the primary goal of these implants.
“The first thing to understand is that the term diffractive optics doesn’t necessarily imply multifocality,” says Daniel Chang, MD, an ophthalmologist from Bakersfield, Calif., who is an investigator for the U.S. trial of the Symfony. “This is not a multifocal lens, but it does use diffractive optics to do two things: First, it corrects chromatic aberration. Second, it uses these optics to extend the range of quality vision.” '
Great to read your recent posts.
I am now 1 week after the surgery in my right eye (Symfony). Left eye clear from cataract - so untouched (myopic: -4.25) - I use a contact lens in this eye.
My results - good distant vision (with good contrast - also at night), intermediate - quite good - I can read a computer screen quite well, near - needs to improve - I can not read a newspaper with my right eye.
Flickering - I also have it sometimes, most of the time not disturbing.
Regarding Halos - I see some around light sources in the night but also not disturbing,
With the contact lens in my left eye - good all around vision (I am 42 - no presbyopia yet).
Bottom line - I am satisfied with my decision to choose the Symphony lens, I still hope that near vision will improve with time.
I am now 1 week after the surgery in my right eye (Symfony). Left eye clear from cataract - so untouched (myopic: -4.25) - I use a contact lens in this eye.
My results - good distant vision (with good contrast - also at night), intermediate - quite good - I can read a computer screen quite well, near - needs to improve - I can not read a newspaper with my right eye.
Flickering - I also have it sometimes, most of the time not disturbing.
Regarding Halos - I see some around light sources in the night but also not disturbing,
With the contact lens in my left eye - good all around vision (I am 42 - no presbyopia yet).
Bottom line - I am satisfied with my decision to choose the Symphony lens, I still hope that near vision will improve with time.
Thanks for your quick reply. I didn't realise I had to come to the web-page to see replies, thought I might get an email or something!
I saw the surgeon last week, vision, halos etc still seem to be the same. He said my retina is inflamed and gave me additional inflammation reducing eye drops (still using the ones given to me after the surgery) for three weeks.
I have to go back at the beginning of February for a refraction eye test to see how short sighted I am at that time, presumably to assess for laser treatment.
I did read it takes about 3 months for the eye to heal following surgery, so will just have to be patient and hope things improve.
I saw the surgeon last week, vision, halos etc still seem to be the same. He said my retina is inflamed and gave me additional inflammation reducing eye drops (still using the ones given to me after the surgery) for three weeks.
I have to go back at the beginning of February for a refraction eye test to see how short sighted I am at that time, presumably to assess for laser treatment.
I did read it takes about 3 months for the eye to heal following surgery, so will just have to be patient and hope things improve.
Thank you for your willingness to put forth so much information about the Symfony and your experiences with it. I live in the US and am considering traveling to get the Symfony. I have scanned through many of your posts, but do not recall seeing the name of the doctor who did your procedures. I would appreciate it very much if you would share the doctor you saw and your thoughts about whether you would recommend that doctor to others. I want the best lens put in by the best doctor but am concerned about how to go about making that happen in another country.
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