Author's disclaimer: This article discusses intraocular lens implants (IOL) as a treatment for cataracts based on my own mixed personal experience. There are multiple IOL types, brands and technologies. Individuals have had success -- and problems -- with each and every type. As for myself, as a photographer and a tennis player, picking the right IOL turned out to be non-trivial since each type could conceivably be useful for one or more of my interests and requirements.
Each individual is different, so my experience is not applicable to everyone, and it should it not be taken as guidance as to what any individual should do. Anyone considering cataract surgery should consult a qualified ophthalmology surgeon and should make themselves fully acquainted with all aspects of the process and the products -- especially the down side of each choice.
For those short on patience, the bottom line is that my initial choice, of a diffractive optics multi-focal IOL implant (MF), proved unsatisfactory -- for me. Despite the risk involved, I chose to have it removed and replaced with a simple single focus (SF) implant instead, bypassing the more expensive astigmatism correcting (AC) single focus IOL. I can only say that I wish that the post below, by a practicing ophthalmologist, had been available when I made my initial, fateful decision. The text, which recommends against current multi-focal technology for many situations, with explanation of why, is self-explanatory, although the entire thread is worth following.
If you are interested in my own whys and wherefores, read on. For the impatient, skip to the three week post-surgery update. . .
The Eyes Have It. . .Or Not!
Aging brings changes for the photographer, not the least of which is vision. While many older photographers rightly look for lighter gear and more sedate and knee-friendly subjects and locales to ply their hobby (or trade), advancing problems with eyesight can be equally concerning. Among these, the yellowing and loss of visual acuity that results from cataracts is one of the more deleterious. Not only do routine activities such as reading camera settings and imaging software adjustments become more difficult, but the very colors one perceives in images are no longer accurate, leading to all sorts of problems in post processing.
Cataract implant surgery with intraocular lenses (IOL) can greatly ameliorate vision problems that come with cataracts. But, when one begins to consider IOL surgery one is immediately confronted with the dilemma of which IOL to choose; as it turns out, there are several. And, the choice can greatly depend on lifestyle, preferences, expectations and task-based requirements. By no means are all choices equally suitable in all situations.
Which brings us to my situation. As both a photographer and a tennis player -- as well as a technically oriented engineering professional who wants to know why -- the choice tuned out to be confusing and fraught with the possibility of error. Therein lies the motivation behind this article.
There is plenty of descriptive information available on IOLs, so we'll only mention briefly for completeness the three main types, there being many manufacturers for each as well as various optimizations and technological refinements. They are:
Once one is confronted with these choices, one is left to best match the choice with one's own preferences and needs. As a photographer and a tennis player, this turned out to be non-trivial since each type might work albeit with different pluses and minuses.
My vision had been deteriorating for years. The left eye, especially, became more difficult to correct with glasses, and there was a distinct yellowing of vision, first noticeable when calibrating my monitor setup. Pure whites on the final test pattern of a calibrated monitor had a distinctly yellow cast. Finally, the left eye reached a point where vision was 20/70, with or without glasses; i.e. no significant correction was possible optically. Everything was a blur through the left eye. In particular, depth perception suffered while playing tennis. It was at last time to consider IOLs.
During the pre-op exam, I carefully explained my concerns over the perceived contradictory vision demands of my two hobbies, tennis and photography, and my assessment of their differing requirements. As a lifelong wearer of glasses, I was willing to go with the SF or AC implant and continue with glasses (progressives) after the surgery. The ophthalmologist made sure to explain the benefits of each type of IOL, and I initially chose the AC version since I've also experienced significant astigmatism.
Nevertheless the allure of multi-focal correction beckoned. I envisioned the approach of a tennis ball, with me having to tilt my head back more and more with the near vision correction of progressive glasses as the ball got close in order to continue tracking it. Searching on a tennis forum, I found a discussion wherein a couple of players who also claimed to be ophthalmologists, stated that they had gone with the multi-focals, with great success. So, my final choice was made, and I proceeded to have a very expensive MF IOL implanted.
Unfortunately, the full consequences of each choice, and especially the technological why behind each, was not sufficiently clear to me relative to corresponding benefits. The key technical details that would have been a tipoff were missing -- see the link above for those explanations. This insufficiency, turned out to be crucial for what came next.
Multi-focal Implant Experience
After the implant, the true nature of the diffractive optics IOLs became immediately evident. The diffractive optics halos that surround bright objects at night were very pronounced from the beginning and never got better. I had been told that compared to my pre-operation eye, if the blurring and halo phenomenon was an eight on a scale of ten, then an SF or AC implant would be a two and a MF implant would be a three -- virtually no difference and a great improvement in either case. This was not even close to my experience.
The degree of vision correction was disappointingly poor, and further, I could never quite master the technique of shifting from far to near. It just didn't work for me. Worse, the loss of contrast was startling. The problem was most evident when looking at an object having some degree of structural detail and strongly illuminated from one side. The brightly lit side had no detail -- the entire illuminated portion was simply a white glare. Meanwhile the shadowed side, rather than shading smoothly from light gray to almost black, was a uniform shade of featureless gray.
It became evident that the choice of MF for the IOL was intolerable as a permanent solution. Following consultation with the performing ophthalmologist, I was referred to a specialist skilled in removing implants and inserting new ones -- a doctor who also took the time to fully explain what went wrong and, for my technically oriented way of thinking, the all important question of why. The bottom line is that the MF IOL was removed and replaced with a simple SF IOL.
Results So Far. . .
The SF IOL performance to date is encouraging. Vision was better from the beginning, although there is more work to be done. First, I am told that there was more "scarring" than usual for the two procedures, leaving vision improved but still not as expected. Also, some loss of contrast remains, but this could easily be due to residual astigmatism. The scarring can be removed by laser polishing. There then remains the fitting of progressive glasses with astigmatism correction. Only then will the final level of vision be known.
Meanwhile, the choice of going ahead with the replacement is, I believe, right for me -- although I emphasize once again that this path is not without risk and should only be considered as a last resort. Better to have made a fully informed choice initially. To that end, everyone considering an IOL should educate themselves fully. Ophthalmologists can help by explaining the negatives as thoroughly as the benefits.
Initial results following the replacement of the multi-focal IOL with a single focal version were encouraging, but progress was slow. Vision remained blurred, this time with an intruding ghost image offset from the main subject. Colors remained disappointingly muted, as if seen through haze or fog. While Internet by no means replaces sound medical diagnosis and advice, a search nevertheless turned up the possibility that the ghost image resulted from astigmatism, a defect that both eyes possessed before surgery on the worst one. In fact, without glasses, the other eye also exhibits ghost images as well.
Having no choice, I waited for my three week post surgery exam before panicing. The result was better than expected. Everyone is familiar with the standard alphabet chart, a row of letters rendered in decreasing size until one can no longer make out the letters. This time, I was given the pinhole test. In this test, one eye is covered as ususal, but rather than the eye to be tested being completely open, the tested eye is blocked with an insert that has a scattering of pinholes. The theory is that the pinholes restrict the incoming light rays to a small part of the eye's lens, thus minimizing the effect of any aberations.
To my surprise, the test chart letters were sharp and clear, rather than blurry blobs, down to a 20/20 vision level! The doctor laughed and said, "Your vision is perfect, you just need new glasses. Needless to say, this was excellent news.
He was not optimistic about the loss of color contrast. As a photographer this didn't sit well. So, I turned to Internet again and found a possible explanation from the Americn Adademy of Opthamology, to wit, the posterior capsule (membrane behind the implant) can become hazy from cell growth. This is treatable with YAG laser polishing, a simple in-office procedure, and one that is often needed to remove post surgery scarring anyway.
So now we await new glasses and laser polishing in a much more optimistic frame of mind!
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