This article discusses my personal mixed experience with intraocular lens implants (IOL) as a treatment for cataracts.  It all came out well in the end, but it was a tangled and confused journey along the way.

Disclaimer:  Each individual is different, so my experience is not applicable to everyone, and it should not be taken as advice 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.

I can only say that I wish that the post below, by a practicing ophthalmologist and surgeon, 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.

There are multiple IOL types, brands and technologies, each with their advantages and disadvantages.

  • Single focus (SF) - these may provide best focus for either near or far but not both.  Glasses will be required for the opposing focal distance.

  • Astigmatism correcting single focus (AKA "toric") - these single focal point IOLs additionally correct for astigmatism.

  • Multi-focal (MF) - the multi-focals use (in most cases) diffractive optics to allow for shifting vision from near to far, thus enabling many users to dispense with glasses.

Multi-focals do have potential negatives as well as the positive of alleviating the need for glasses.  The diffractive optics design reduces the light available at each of the distances provided by the lens.  MFs may cause halos around lights at night which some find objectionable.  Older patients sometimes lack sufficient eye muscular strength to achieve close focus.  Unfortunately the very real impact of these negatives is not always clear beforehand.

Individuals have had success -- and problems -- with each and every type.   As for myself, as both 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.  For those short on patience, the bottom line is that my initial choice, of a diffractive optics multi-focal IOL implant proved unsatisfactory -- for me. Despite the risk involved, I chose to have it removed and replaced with a simple single focus lens  instead, bypassing the more expensive toric single focus IOL.  For the record, here are the takeaways, in succinct form, from my own personal experiences with cataract surgery.

  • Cataract surgery replaces the discolored material inside the eye capsule with an implant.

  • My first choice, a multifocal lens, proved to have inherently have less contrast than single focus lenses (SF), see the above link.

  • It also proved difficult to adapt to the multi-focus capability of the MF lens, resulting in blurred image formation.

  • I eventually chose to have the MF lens replaced with an SF lens by a specialist, a very risky procedure but one that, fortunately, worked out for me.

  • There may be aftereffects from the surgery. There may be residual capsule opacity which obscures clear vision.  There may be scarring at the incision.  The capsule may shrink to conform to the lens, in which case there will be a series of creases or wrinkles, much like the wrinkles when one wraps an irregular shape with shrink/cling wrap.

  • The opacity, scarring and creases can produce various visual abnormalities, including blurred vision and loss of contrast (muted colors, looking through haze, etc.).

  • Laser treatment ("polishing") can alleviates both problems. After the procedure, colors are vivid and high contrast again, and visual acuity increased significantly.  However, it is a one time procedure, and further intervention is virtually impossible.

  • With a single focus lens, glasses will still be required. There may also be residual astigmatism, resulting in double vision or blurring. This can be ameliorated with glasses and also with laser vision correction (e.g. LASIK) or other procedures.

  • Often both eyes need cataract treatment, and often surgeons recommend doing the second soon after the first, e.g. two weeks later.  While this may be the right answer for many, it was not for me.  Had I proceeded with the second eye before the status of the first was clarified, I might have been left with limited vision in both.  There's little harm in waiting and a great deal of risk reduction to be gained.

If you are interested in my own long-winded 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.  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.  Part of the problem is that not all doctors are able to articulate the difficulties in terms that provide a deeper technical understanding of how each implant works and what the consequences thereof are.  Once one is confronted with incompletely explained choices one is left to best match the possibilities with one's own preferences and needs.  This turned out to be non-trivial since each type might work albeit with different pluses and minuses.  Therein lies the motivation behind this article. 

Initial MF Surgery

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 astigmatism correcting toric 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 toric 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 -- the link above covers those explanations: less light, halos around lights at night, inability of older eyes to accommodate to close vision.  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 After Replacement of MF With SF

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.

Three Weeks After Second Surgery

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 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.  There was also the scarring and cloudiness possibility.

Having no choice, I waited for my three week post surgery exam before panicking.  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 usual, 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 aberrations.

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 American Academy of Ophthalmology, 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!

Laser Polishing at Five Weeks Out

As we saw at the three week mark, progress, in the form of replacement of an unsatisfactory multifocal implant with a single focus lens, appeared to produce an improvement, subject to needed vision correction and a bit of laser polishing to remove residual effects from the surgery, which seems to have caused both blurring of the image and a significant loss of visual contrast.

Well, we've had another visit, this time to take a look at the remaining problems.  My hunch regarding the prospect of improved contrast following laser polishing (see link to American Academy of Ophthalmology article referenced above) proved correct.  The result was that the laser polishing did improve contrast, as well as overall visual acuity, and lo and behold, the hazy image rendition through that eye has disappeared!!  Hallelujah!  That eye now forms a clear image, albeit still with some double vision attributable to astigmatism.  Colors are finally both vivid and correct.  Whites are now white, blacks are black, each with plenty of contrast in subtle shades, and colors are positively intense.

The end may now be in sight.  We go back once more for a vision exam and possible laser correction to fix the astigmatism and its accompanying ghost images and to get a proper vari-focus glasses lens to add close-up vision to the distance implant.  That suggests that there will, hopefully, be only one more update to this saga and then we'll come out the other side.

After that, we'll work on the other eye.

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