Hi I’m Dr. David Malitz, a board-certified ophthalmologist. I am going to discuss the most important decision you need to make after deciding to proceed with cataract surgery or a refractive lens exchange -Which lens should I choose for optimal visual performance and minimal side effects?
The best lens has features that mimic the healthy natural lens. It should be clear, and allow you to see near, distant, and intermediate ranges. It should correct astigmatism if present and protect you from ultraviolet light and it should have minimal if any unwanted visual images. Unfortunately, there is no perfect lens but the technology is amazing and can restore these functions with a high degree of accuracy with the aid of a talented surgeon, excellent equipment, excellent measurements, and advanced formulas to select the lens power customized for the size and shape of your unique eye. We now live in an era where it is no longer necessary to place an appliance on your face in order to see (glasses) or a plastic object in your eye (contact lenses) in order to see clearly and to enhance the quality of your life. In youth, 20s-early 40s, an implantable contact lens, or laser LASIK or PRK is an ideal procedure to reduce or eliminate your need for glasses. In your 40s, you lose your accommodation requiring reading glasses even if you see perfectly in the distance. If you don’t see well in the distance bifocals or trifocals are necessary or multifocal contact lenses. Unfortunately, these options often distort images and are a nuisance. With modern technology, although off-label, a clear lens exchange (ClearLex or PreLex) replaces your tired natural lens with an intraocular lens designed to optimize and restore vision and reduce or eliminate glasses or contact lenses.
Cataract surgery is the most common surgery in seniors with over 3 million procedures done in the USA each year. The Clear Lens Exchange is virtually identical but done on an elective basis for vision correction. Using only eye drops to numb your eye, your lens is broken up into tiny fragments using sound waves with a procedure called phacoemulsification. The fragments are carefully suctioned out of your eye and a new lens is placed to enhance and restore your vision. Now we come to the critical decision, which lens should you pick? There are now five main classes of lenses that I’ll touch on today. Each type has advantages and disadvantages.
Lens technology is always evolving new designs allowing us many options. We are extremely fortunate to live in an era where we can correct virtually all distances and provide an excellent range of clear, unaided vision. and there will be new lenses and features available by the time you see this video that might not be available at the time of filming, Make sure you evaluate your visual needs and budget and discuss your individualized lens choices with us prior to making your decision. After your research, if you have questions, your surgeon is the best person to address your questions or concerns.
The oldest technology is a mono-focal lens. There are over 40 brands of mono-focal lenses available in the USA. Your surgeon generally has a preference. We only use only FDA approved high-quality, acrylic, aspheric one piece, foldable monofocal lenses. Make sure your surgeon is choosing a high-quality monofocal lens if this is your choice. The optics of a monofocal lens can vary as can the material and manufacturer. Most manufacturers only offer 1/2 unit sizes. We have picked lenses that are available in 1/4 steps to optimize the customization for your eye and unique needs. Monofocal lenses are designed to create clear vision at just one distance (distance, intermediate or near). Although not an exact science, you should express your preferred distance for unaided vision. If you are older and do a lot of reading, or have been nearsighted your whole life, you may select clear unaided near vision and choose to wear glasses for distance (driving or TV) viewing. You may also choose the opposite but you are highly likely to be dependent on glasses for fine-tuning for some or all distances. This lens is covered as part of the cost of cataract surgery by all insurance plans including Medicare and will restore clear vision at one distance. As this lens does not correct astigmatism, you will most likely need to wear glasses for your best distance, intermediate, and near vision after surgery.
If you have regular astigmatism and you want the option to be glasses-free for some activities, you can have your astigmatism corrected with incisions in your cornea (AK/LRI) or a “toric” lens. This lens has two powers built in to neutralize your astigmatism. For low astigmatism we prefer a limbal relaxing incision (LRI) for moderate astigmatism an astigmatic keratotomy (AK) can be used but a toric lens reduces the need for corneal incisions.
With a mono-focal lens or a toric lens, you can decide for each eye to aim for distance vision, which is helpful for driving or watching TV, intermediate vision, like for computer vision, or near vision for reading fine print or nutrition labels. You might also want to consider monovision or mini-monovision, where one eye is set for distance and the other eye is set for intermediate or near vision to give you a range of vision.
This is not ideal for everyone, but if you have been successful with monovision in the past with contact lenses or refractive surgery, this is a viable option. The third and more advanced technology categories are multifocal lenses and extended depth of focus lenses. These lenses are designed to provide clear distance, intermediate, and near vision. This is a great option if you desire to be liberated from glasses and these can even correct astigmatism if necessary..
Vision-correcting lenses are not covered by insurance but you can use funds from a health savings account if you have one to pay for this enhanced technology. These lenses provide the greatest range of vision but may have unwanted visual phenomena like rings or halos or streaks around light sources. Almost always, with neuroadaptation, you will learn to adapt to these lenses and our patients that have selected freedom from glasses or contact lenses are among the happiest patients in our practice. In the rare event that the patient cannot tolerate the unwanted visual side effects, the lens can be replaced. If the power is off (more likley with eyes that have had previous surgery) the lens can be replaced, another lens can be placed on top of this lens (piggy-back) or the outcome can be fine tuned with laser vision correction. We find these options necessary less very rarely in our practice. These lenses are not ideal for age-related macular degeneration or corneal irregularity or advanced glaucoma. For these eyes we find the Eyehance or Vivity lens or possibly the IC-8 may be better suited.
Here are 5 questions that will help you figure out which lens choice is right for you. Are you okay with wearing glasses? If you are, then you might just consider a standard monofocal lens and match your two eyes so they work well together.
You will definitely need reading glasses for fine print with these lenses, and if you have significant astigmatism, you might just need progressive or bifocal glasses that you would need to wear at all times. Do you have significant astigmatism? If you have astigmatism in your glasses and/or your doctor tells you that you have astigmatism based on your tests, you might want to consider a toric lens to help correct that astigmatism.
Are you okay with wearing reading glasses? If so, then you can have both eyes focused at distance so that you maximize 3D vision. If you hate the idea of wearing ANY kind of glasses, you might want to consider monovision or multifocal lenses. Have you done well with monovision contact lenses or did well with monovision LASIK or PRK? If so, you should consider replicating this with your intraocular lenses.
Alright, so do you hate the idea of wearing glasses or is the idea of monovision unpalatable? The last type of lens you should consider is a multifocal intraocular lens, which typically has multiple rings with various powers within the lens to help focus light at various focal points within the eye. This lens gives you a larger range to see distance, intermediate, and near without glasses.
But a word of warning – if you are interested in a multifocal lens, you need to ask yourself if a low amount of constant glare during the day and more intense nighttime glare is going to bother you. This can be a really difficult question for most people to answer, and this is an impossible question for your eye care provider or your surgeon to answer on your behalf, so I advise you to ask your family members or friends if they think you are detail-oriented.
While many are happy with their choice to go forward with a multifocal lens, there are definitely those who are not and once the lens is in the eye, it can be quite dangerous to take it out and there is not much we can do besides changing out the lens to help with quality of vision. If you were having cataract surgery today, which lens options would you choose? I’m going to leave my answer in the comments below, and you should too! If you enjoy this video, please like and subscribe to my channel and I’ll see you at my next
If you have further questions, just call or make an appointment. We have patients from all over that choose to optimize their chance of success by selecting a surgeon with exhaustive experience with virtually all lens options.
David Malitz, MD