IOL

[Linda1748]

Dr. Hagan,

Following your suggestion, I have made an appointment with a doctor from Wilmer Eye Institute for a cataract consultation on my other eye.  I have the same horrible results as everyone else with the Rezoom in my right eye and am leaning towards the monofocal for my left eye.  From reading the posts and independent research, there does not seem to be a monofocal lens either that does not have side effects of halos, glare, spider webs, rays, or ghosting.  Cataract surgery has been around for a long time -- has technology really not improved?  Until I started the priolopine for my right eye, I had extreme difficulty driving at night.  Prilopine only seems to last a couple of hours but at least I can drive to and from my destinations.  I can't imagine what it would be like to have the glare, ghosting, etc. in both eyes.  I am only 53 and am not ready to give up driving at night and having a life that includes night activities.  Would you give me names of other lenses that I can research on my own so that I can be prepared when I see my new doctor?    Thanks.

[John C Hagan III, MD, FACS]

The state of the art is a ASPHERIC MONOFOCAL IOL  our practice uses Tecnis with great success and rarely do we have complaints of flare, glare, ghosting, rays, reflexes  all known as dysphotopsia.

JCH III MD

[javadesigner]

How would you compare a TECNIS mono aspheric to a ALCON mono aspheric ? Isn't the TECNIS silicone-based and isn't that considered to have it's own set of potential problems compared to acrylic ? I've seen some top cataract surgeons myself (I have bilateral PSC cataracts) and everyone seems to have more experience with ALCON in general ? Why ? I am genuinely curious..

[John C Hagan III, MD, FACS]

1. Tecnis is available in both acrylic and silicone.
2. Our practice has no experience with the Alcon aspheric IOL
3. Alcon is perhaps the largest industrial concern in ophthalmology. We have used many Alcon IOLs in the past before the Tecnis became available.

JCH III MD

[JodieJ]

Each of the three manufacturers of aspheric IOLs (Alcon, AMO and Bausch & Lomb) claim that their lens is the best.  As far as I know, there is no independent research comparing them.  I suspect that they are equally good.

In my area (Chicago), my impression is that the surgery centers utilized by the top cataract surgeons tend to stock only Alcon IOLs.  Maybe it just isn't cost efficient to stock two brands of aspheric lenses, and Alcon is better at marketing.  I ended up getting Alcon IQs, with excellent results (although I really loved the patient education video at www tecnisiol com).  

[John C Hagan III, MD, FACS]

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[javadesigner]

Are you plano in both eyes, JodieJ or do you have modified monovision ? How easy/hard is it to do near things (makeup/shaving, switching quickly between computers, books/manuals, cellphones, etc) ? I'm myopic, 35 (had PSC since 31 and they are pretty bad right now), but from what I've read, people sometimes miss their vision and regret surgery ? What are the pros/cons in daily life, JodieJ that you have personally experienced ?

[John C Hagan III, MD, FACS]

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[MikeV99]

I had RK about 15 years ago. I am most likely going to have cataract surgery in October. The surgeon who did my RK (located out of state from me) says he can put in Crystalens. On the other hand, the doctor I now see says he tried Crystalens, had so many problems, and his group now refuses to use them. I now live in Arkansas and I think only one surgeon in the entire state will use Crystalens.

The local doctor suggests using the Tecnis IOL.

I am trying to decide which direction to take. Both surgeon are very qualified.

I have read a lot of negative posts from the Crystalens patients. Of course, this could be a very small percentage of the entire population since one would expect unhappy folks to be more likely to post here. Some of the posts suggests that I might hope to only need reading glasses with the Crystalens.

I understand that if I use the Tecnis monofocal aspheric IOL I will most likely use a modified mono-vision technique and need to wear progressive bifocals after the surgery.

Exactly what does that mean? Would I need to wear glasses 100% of the time with that technique? I have no problem with reading glasses since I have been using them for 20 years or so.

I had hoped that I could get rid of glasses at other times. I had been very near-sighted before RK and it was so incredible the freedom from glasses made. I now have 4 different pairs of glasses for the different activities in which I participate.

What is a realistic expectation? It would be nice to watch TV, golf, drive and see the gauges, read labels in a grocery store (except for the small print), and so on without glasses. I guess this is intermediate to far distance? What about using my computer?

I am very confused and, to a certain extent, disappointed because I initially thought Crystalens would return my freedom from glasses again until talking to the local doctor.

Any recommendations on what I should do?

Thank you for your time.

Mike

[John C Hagan III, MD, FACS]

I would advise any patient with your history of RK to avoid any multifocal IOL.  An spheric Technis is among the finest IOLs now in existance.

Modified monovision would mean generally that one eye would be corrected to maxium vision without glasses at distance (with a little built in undercorrection in case the IOL power calculations do not apply to your eye). The other eye would be left mildly myopic so that you would have middle vision (computer, shop, speedometer, etc) and with good light and good printing reasonable reading vision.

The post op refractive error would be   -0.25 or -0.50  distance  and the other eye -1.25 to 1.75.


Some people (like me) would rather have good reading vision and mid vision without glasses. In that case the post op refractive error would be

mid vision -1.25
reading vision -2.50

In either case glasses in a progressive bifocal form would balance the eyes out so that when worn both eyes would help for distance , mid vision and near vision.

With my patients that fall into this catagory I just tell them to wear the glasses when they feel it helps them. Some chose to wear them all the time and others just for things like sporting event/night driving or prolonged very small print reading.

Again I would avoid any multifocal IOL.

JCH MD

[MikeV99]

Thank you for the response. It makes me feel much more comfortable with what I am being told and is very helpful.

If I understand it correctly, RK (as I remember, mine is an eight cut) results in a cornea that is uneven in how it has been flattened. Hence, it is more difficult to get an accurate mapping of the cornea than would be the case with someone that has not had RK? Given that a whole bunch of boomers have had RK and will be wanting cataract solutions that do not require glasses one would have thought those measurement issues would have been resolved by now?

Why are measurement errors less of a problem with monofocus lens compared to multifocus? Evidently the multifocus lens requires much more accurate measurements, but at first thought one would think the nature of the multifocus flexibility would have more measurement error tolerance?

Why is it claimed that Crystalens can be used with patients that have had a previous RK? This would imply that Crystalens apparantly has more measurement error tolerance than the typical multifocus IOL (at least based on their claims)?

Even though the surgeon that did my RK (at a large eye clinic in Texas) says he would use Crystalens, the comments of my local doctor, you, and the problems discussed in this forum raise a very large red flag. I did a search in the literature and could not find any studies that specifically reported success/failure rates for the Crystalens after RK. I found a couple that discussed their approach to doing the surgery.  

Very educational. Changing my direction from thinking that a 4th or 5th generation Crystalens would offer more benefits over the traditional blended approach has not been easy. Given the flood of boomers with cataracts, I suspect doctors will hear such questions and comments more frequently in the future. My aplogogy for so many "why" questions, but your comments are very helpful.

Thank you for taking the time out of your practice to help educate us!

Mike

[John C Hagan III, MD, FACS]

1. The problem with IOL power determination is based on the fact standard formulas are based in virgin cornea not the RK scarred flattened cornea. That said enough RK people have had surgery that special formulas for IOL power in RK patients are available. Much better than years ago but not as accurate as the virgin cornea.
2. Reason 1 aside I do not recommend multifocal IOLs in RK patients because the main complaint about multifocal IOL is dysphotopsia (flare, glare, ghost, rays, halos, starbursts, arcs, moving dark or light spots) and night blindness. Since RK Scars can cause the same thing there is a double dose of optical abberations.
3. It is true that a Crystalens or any other type of multifocal IOL can be inserted in an eye that has had RK the question is SHOULD IT BE DONE?

JCH MD

[MikeV99]

Thank you. Blended tecnis it is.

Which tecnis IOL should someone that has had RK be considering (1-piece, acrylic, or CL - silicone) and why? The 1-piece looks very different than the other two.

The RK surgeon will have my original cornea numbers before RK (I just signed a release for the local surgeon to get the records). Will the local surgeon use those along with the RK modified formulas to determine the power of the lens? All three of the above lens vary in 0.5 diopter increments.

The RK surgeon that did my procedure is in a large well known eye clinic in Dallas. The local surgeon (Little Rock metro area) is well thought of also but will not have the same patient traffic load. I do not know how comparative is their equipment and other resources. Certainly the 5-6 hour trip to Dallas would be inconvenient. Are there any benefits of using the original surgeon that would justify the inconvenience?

Thank you again.

Mike