accommodative vs. monofocal IOLs after cataracts

Continuing in the vein of IOLs for bilateral cataracts...

Doctors offer both the accommodative (crystalens) and the non-moving
(various types).
I want whichever one gives the very best possible visual acuity (with
or without glasses), and is the most fail-safe. Which one would that
be?

I think there must be some visual tradeoffs of the accomodative
implant, but can't find out what they are.

Help please.... I've been all over the web to no avail. I'll be
looking through these things until I die and I'm only 49.

Thanks,
Liz
the fussy

 

Liz,

Subject: No one can give you the "right" answer.

I have had the operation -- and selected the "fixed" lens.

i stated that I would be quite happy if I could pass the DMV test
(20/40 or better) with no lens.

I also stated that using a "plus" for reading was no problem at all,
and was quite happy with over-the-counter plus lenses for reading.

But each person is different in this regard.

The operation was excellent.

My distant vision is 20/20 -- checked in the office and at home by me.

My refractive STATE is about +1/2 dioper -- which for me is excellent.

But no one can tell you what choice you should make. I only report
the success of the "simple" lens replacement. I don't think the
"adjustable" lenses work all that well.

Also, find some people who have had excellent results from your choice
in an ophthalmologists. Find one who does this as his major
speciality.

In my case, the cataract surgery was not about being "fussy" -- for me
there was no choice.

Good luck,

 

Don't forget, though: Otis is an absolute idiot and a pathological
liar.

Caveat emptor ;-)

 

Liz,

We all wish you success with your cataract operation.

Otis

 

Liz,

This site might be helpful to you:

http://www.tecnisiol.com/

 

Continuing in the vein of IOLs for bilateral cataracts...

Thanks, Otis. Yes, I've been reading on the Technis. I see all
kinds of specs that I don't know what they are (we'll get there
eventually).

Initially, I'm just wondering whether one gets clearer vision with a
monofocal or a crystalens.
A friend just had both eyes done with the crystalens. He complains
that, when viewing things at a distance, only the central part of his
field of view is in focus. The more peripheral parts are out of
focus. Like a cheap pair of binoculars. Not like his original vision
before he got cataracts.
He finds it harder to see because of this - that it takes longer to
"read" the area around him when driving. That scares me. Is this a
feature of just the accommodative IOL, or of all IOLs?

thanks,
Liz

 

Dear Liz,

I "put off" having the cataract surgery -- until there was no choice.

For personal reasons, I choose the "single-focus" lens -- because I
like the reliablity of it, and clarity of if. This is always a
personal evaluation -- so I only represent my own experience with it
-- for almost a year.

For techinical reasons, I always confirm my Snellen as passing the
legal requirement, of 20/40 or better. In fact, my distant vision is
typically 20/20. I have my own trial-lens kit, and my refractive
STATE is +1/2 diopters (which I judge is necessary for excellent night-
vision).

Be careful in your choice of an ophthalmologist. Look for one who
does this on an almost "exclusive" basis -- he will be very good at
it.

Some more commentary to help you:

Thanks, Otis. Yes, I've been reading on the Technis. I see all
kinds of specs that I don't know what they are (we'll get there
eventually).

Initially, I'm just wondering whether one gets clearer vision with a
monofocal or a crystalens.

Otis> I think my choice is the best. The reason is that I have no
problem with near vision (with refractive STATE of +1/2 diopter). I
can read large print with no problem. And I much prefer to use a plus
for reading. I just carry a small "plus reader" in my pocket and use
it when necessary. The plus I am using to work on my computer is very
comfortable and relaxing. I don't know why anyone would "complain"
about it.


A friend just had both eyes done with the crystalens. He complains
that, when viewing things at a distance, only the central part of his
field of view is in focus.

Otis> That is the reason I choose the mono-focal. In my judgment,
the "claim" of the crystalens -- simply does not work the way they
claim it. Trouble is, you can not "reverse" this choice. I prefer to
keep it "simple" in this case, and the result is VERY GOOD.

The more peripheral parts are out of
focus. Like a cheap pair of binoculars. Not like his original
vision
before he got cataracts.
He finds it harder to see because of this - that it takes longer to
"read" the area around him when driving.

Otis> I am very pleased with that mono-focal. Hard to say it, but my
vision is almost "perfect". I play tennis (much better than with my
minus lenses), and love to use that plus when necessary.

That scares me. Is this a
feature of just the accommodative IOL, or of all IOLs?

Otis> I can ONLY describe my experience. Getting rid of my minus
lenses PERMANENTLY, is a wonderful experience. IN MY OPINION, the
mono-focal is the way to go.

Best,

Otis



thanks,
Liz

 

[Liz] I'm wondering whether one gets clearer vision with a

[Otis] For personal reasons, I choose the "single-focus" lens --
[snip] ..... I have no problem with near vision.....

In other words, you were nearsighted before the operation.

[Liz] A friend just had both eyes done with the crystalens.  He
complains

[Otis]  Getting rid of my minus lenses PERMANENTLY, is a wonderful
experience.  IN MY OPINION, the mono-focal is the way to go.

But..... before you got cataracts, you were near-sighted. Whereas I'm
presbyopic (I had perfect vision til my early forties).
Everyone:
If they fit me with a monofocal IOL for distance, I won't be able to
focus AT ALL on anything closer than about 10 feet - right?

(I'd still prefer that to less-than-perfect focus with the
accommodative IOL (if that is in fact the tradeoff.)

Liz
in Indianapolis

 

Dear Liz,

Subject: Selecting your preferred distance.

With the mono-focal you get a choice:

1. You can have your distant vision clear -- same as it was before
the development of your cataract.

2. If you prefer, you can ask that your refractive STATE be set
SLIGHTLY NEGATIVE, i.e., at about -1 diopter.

a. This will mean that your Snellen will be about 20/40 to 20/60 --
functional, but you will have to have a slight minus lens to drive a
car.

b. You could probably do most reading (larger print) with no glasses
at all.

3. For myself, (no, I did not lose "all my near vision") I can read
books in good light with no lens.

But that is the type of choice you should consider.

Having been totally DEPENDENT on a minus lens (since I induced a
negative STATE in my eyes as a child), I certainly would NEVER want to
get back into that situation.

But as I said, this is a personal choice -- that I have made -- and
only you can make.

Best,

Otis

 

Like your niece, huh?

At least she has you to blame....

 

[Liz] I'm wondering whether one gets clearer vision with a

Right. If I do this, how bad will my closer-up vision be? I mean,
with the monofocal, how far away will things have to be to be in
focus? My vision was always perfect until presbyopia set in a few
years ago; now the better eye can only focus on things at least 6 feet
away. How will it focus with a monofocal IOL, which has no
accommodation at all?

thanks,
Liz

 

Dear Liz,

Subject: I report only my personal experience.

You asked, "...what -- in YOUR OPINION -- is the best choice?"

I prefered the "low risk" mono-focal as being safe and wise.

I asked for "at least" 20/40 (pass the DMV). The ophthalmologist said
he could not assure of any result.

I did not know what my "near vision" would be like, but I was content
if I wore a low-cost plus for that "near" vision.

I did not know how "accurate" the operation would be. I expected my
refractive STATE to be slightly positve (just to be safe, that my
distant vision would be as clear as possible.

I was pleasantly surprised by the results on all accounts.

My over-all range-of-accommodation is 1.5 diopters (measured with a
Snellen and a trial-lens kit). For the actual range you would
subtract about 0.6 diopters for "depth of field" -- but who cares?

This means that, as a pratical matter, I can read this screen at 30
inches (I just checked) with no lens at all. For comfort, I can use
about a +2 diotper for computer and anything else. My distant vision
is great.

If you were a "hyperope", of say +2 diopters, then you would have lost
most of you "near" vision -- for that reason.

If the operation is "good" for you, and your refractive STATE is close
to zero, then you would be able to read your computer screen at 24 to
28 inches or so.

So that is my status, and that was the choice I made. (Safetly, and
ease of use.)

To further respond:

Liz> Right. If I do this, how bad will my closer-up vision be? I
mean,
with the monofocal, how far away will things have to be to be in
focus?

Otis> If they get your refractive STATE at zero, you will be able to
read in bright light at about 26 inches. (Just MY estimate). In a
dark room, you would need a plus to read.

Liz> My vision was always perfect until presbyopia set in a few
years ago; now the better eye can only focus on things at least 6
feet
away.

Otis> Your refractive STATUS might be postive. (i.e., checked with a
trial-lens kit and a Snellen at 20 feet). If it is, the operation
will "fix" that issue.


LIz> How will it focus with a monofocal IOL, which has no
accommodation at all?

Otis> I can not agree with that assessment. The entire eye
"accommodates" to a certain -- but limited -- extent, by perhaps 1/2
diopters. But depth of field in bright light will be +/- 0.6
doipters, or 1.2 diotpers total.

Otis> Thus, if your refractive STATE is set to zero, then you "range"
of clear focus would be from infinity to about 30 inches.

Otis> You asked my for my OPINION. You have a choice -- and have
information that the crystal lens might not be to your liking. I
think that the "claims" of the crystal lens are over-done. There are
people who will be HAPPY with it, and those who will NOT be happy.

Otis> Do your research -- but it will always be a tough choice for
you, and no one can ever give you the "right" answer. They can ONLY
give you the choice.

Otis> Good luck.


thanks,
Liz

 

I understand what you are saying, but "AT ALL" is pretty strong
language. You will be able to focus to a lesser extent at much closer
distances. Turning on a light or a flashlight is your friend. I carry
a small flashlight at all times.

I have no experience with accommodative IOLs or multifocal IOLs, but
haven't read good things. I got monofocal IOLs in both eyes, with the
correction for distance. I had presbyopia already, so it wasn't that
different, just more extreme. People with presbopia have to deal with
it, it's similar. I am heavily dependent on reading glasses, just like
I was with presbyopia.

 

If they fit me with a monofocal IOL for distance, I won't be able to

Dan,

You're right. I wasn't clear. To me, focus is a yes/no thing -
objects are either in focus or not in focus. So what I tried to say,
badly, is that after implanting monofocal IOLs, I should expect the
shortest distance at which I can focus to increase from my current
presbyopic 6 feet to a greater distance - correct?

What bad have you heard about accommodative? I've already read how
awful the multifocals are.

Right... so, the nearest distance you could focus afterwards became a
bit more wirh the IOLs, am I right?

thanks....
Liz
Indianapolis

 

I think you were clear. I'm trying to argue that it doesn't matter.
When I walk, I cannot focus on my shoelaces. Who cares? I can see well
enough to avoid tripping. I cannot focus on the speedometer when I
drive. But it is designed for that. There is a red needle, and the
numbers are very large. I can tell how fast I am going, even though it
is blurry.

I don't remember the details, to be honest. Your surgeon should have
that information. I would consider cost, surgical difficulty, failure
rate and amount of accommodation.

Yup.

 

I wasn't clear.  To me, focus is a yes/no thing -

Well, that's what I would have said too, until I got so presbyopic.

In the past six months, I have tripped over or run into many household
objects - HARD - that, because they're out of focus, I fail to notice
in time. This occurs while I'm doing something I need to see close up
for but also need to move around for (like working in the kitchen, or
around furniture) and am thus wearing reading glasses. I'm OK if I
take the glasses off, because without glasses I
a) still have peripheral vision - without it there is no hope of not
bonking my head.
b) can focus well enough on the floor to see things before I trip on
them.

So if getting a monofocal IOL puts things 6' away out of focus, and I
thus need to wear glasses to walk around, that may not be good.

How much greater?

How much more?

thanks,
Liz
Indianapolis, city of the blur

 

Dear Liz,

Subject: Why this choice (mono-focal) is so difficult.

You are wise to "explore" your choice now.

Because once the operation is done -- there is no "going back".

This is why I choose the mono-focal -- because of its simplicity, and
my own knowledge of optics.

But, as always, I can only describe my personal experience with the
mono-focal internal lens replacement.

I have no problems with:

1. Night vision,

2. Blur

3 Playing tennis

4. Passing my Snellen

I consider this operation far superior to Lasik.

Yes, I was concerned with "adverse" outcomes -- but it was worth the
"risk".

Best,

Otis

 

Sounds like you are learning, the HARD way, that wearing reading glasses
while walking around is a bad idea. I just did a simple test. There is
a postcard lying on the floor about six feet away. It is blurry, and I
can only read one word, which is in very large print (SUNSET, as in the
magazine). With my reading glasses on, which I need to see the computer
screen in front of me now, I cannot read any words at all on the
postcard six feet away. It's not the monofocal IOLs that are causing
the problem, it's the reading glasses.

Wearing glasses to see six feet away doesn't sound reasonable. I
suspect that they would have to be prescription, since even the mildest
OTC reading glasses are designed for reading, not middle distances.

I would suggest that you have some long talks with your OD. Your OD is
the expert on this. After that, some long talks with your surgeon.

More than one doctor on this group has advocated not getting IOLs for
distance vision, but rather middle vision. I believe we are talking
about +.5D. This means that your distant vision would be a little
blurry, until you put on your -.5D glasses. This would not be my
choice, but it is a matter of personal preference. Your surgeon will do
whatever you want, as long as you convince them that you have thought it
out and will live with the consequences.

You might want to consider monovision, having the eyes focus at
different distances. That wouldn't be my choice, either, but maybe it
would be yours.

The other thing to consider, is that even though the surgeon will try to
give you what you want, there are variables that cannot be perfectly
controlled. If you ask for distance vision, you may end up with middle
vision anyway. Worse yet, you might end up with vision beyond infinity,
which means that everything at any distance will be blurry, without
glasses (or contacts).

In the dim light where my computer is, looks like 10 feet is about it.
In brighter light, where the pupil gets smaller, not so much.

Presbyopia is a bitch. But, like the weather, lots of people complain,
but nobody does anything about it. For a person without presbyopia,
cataract surgery with monofocal IOLs will be a big adjustment. For me,
with significant presbyopia already, it wasn't that big of an
adjustment.

 

All I can say is based only on my personal experience and common
sense. I support the choice of middle distance, unless your aim is to
score high in snellen reading.

No matter what distance you choose, you will need corrective glasses
for other distances, so why not choose the one that serves you best
most of the time?

If you are a truck driver, you'll probably choose long distance
vision. If you make jewelery 8 hours a day, perhaps near vision is
your best choice. But if you drive sometimes, read sometimes, spend
some time at the computer, make lunch (and eat it too!), watch TV, sit
with friends and family in the evening and spend most of your time
indoors (like me) -- IMO intermediate vision should be your choice.
You'll need glasses for driving and for reading, but you will see
where you are walking and be able to function well a great portion of
your time without any corrective glasses.

This was my choice and I do not regret it. And the hell with the
snellen -- I want to function well and be comfortable, and I am not
after a 20/20 achievement. As a presbyope I use progressive glasses,
but I read that many people have problems adjusting to them. For me
it was easy, despite my other eye problems. BTW, I recommended this
choice to some friends and they are content and happy with the
results.

Accommodative? Forget it, all I hear and read is bad reports,
frustrations and disappointments, but certainly the cataract surgeons
make a lot of money on them.

 

[I omitted some of our messages for brevity]

No, of course not. Reading glasses only focus on things very close
by.
I'm trying it too now. I can read print about 1/2" high at 6'
without glasses.
But I need the glasses to type this message.

Well, I didn't know how bad it would get. If one truly could only
focus on distant things, then you'd need glasses to walk around.

I don't have one yet. I don't trust my current doc; I don't like his
attitude.

I understand. Why do they suggest this? Just because of the
problems below?

Yeah, that thought occurred to me, too. I gather that the lens
settles into the eye not always quite in the expected place. This
sounds like a mess. I hope for the most mistake-proof implant
possible, whatever it is.

Well.....
If they can't get the lens to settle in exactly the right place,
doesn't that mean that your two eyes are not quite the same? i.e.,
even though the intention was to make them both end up focusing at the
same distance, they probably don't do so exactly - right? And also
that the *difference* in focus between them is now also different than
before the surgery?

So....
Were your eye muscles able to readjust, afterwards, in order to focus
anew and now using both eyes differently? Or are you stuck with
getting perfect distance focus out of only one eye, and a slight blur
out of the other?

This bilateral thing is gonna be the pits.

thanks,
Liz