ReStor lens for cataract surgery

[ilanh]

Regarding JMBeam and his problems following the Restor lens. Some of your complaints are due to a misunderstanding of what the lens is supposed to do, but some may indeed be due to a basic weakness of lens design itself. The Restor lens does do a good job at correcting near vision and generally provides a high near add in the range of +2.5. Consequently, intermediate vision is not ideal with this lens even though it is a multifocal lens. People who see ideally for a particular range of vision before refractive surgery must always be prepared to possibly lose this postop. For example, the -3.00 myope who sees perfectly at near without glasses prior to Lasik may lose this ability postop if they're in the presbyopic age range. Therefore, they've traded perfect uncorrected distance vision at the expense of uncorrected near vision. The Restor lens is also in the same category. People with good intermediate vision preop may lose some of that postop. However, distance vision is a different problem. If you have a resultant postop refraction and are able to see well at distance with that refraction then it is true that a Lasik "touch up" will solve the problem. However, if you are unable to see well at distance no matter what prescription you wear then the problem will be one of three things. You could have a capsular membrance behind your lens implant which will need removal with a Yag laser (a quick and easy procedure). You could have cystoid macular edema or some other retinal problem which is limiting your vision. Or you could have a problem with the multifocal lens itself ie: the concentric zones are decreasing contrast sufficiently to affect you. The first two conditions are easy to rule out. If the third is the case then you will have to have the Restor lens explanted and replaced with a monofocal lens. You will not be the first to have this done (it's unusual but it happens). Good luck,

Ilan

[acredhead113]

Just wanted to thank the forum participants for this thread. As a cataract surgeon who is not currently using the restor, I am struggling not to get caught up in the excitment. If someone is paying 1900 to 2000 dollars more for the procedure with a multifocal/pseudoaccomodating intraocular lens (IOL) we need to be careful that the results support the cost/effort.

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TO date in my own practice, i target between -1 to -2 in the non dominant eye with a monfocal implant to provide the patient with solid near. The dominant eye is targeted for plano. Even patients that settle in the lower myopic range ---0.5 to -1.0 can read a clear j3 on the near card. -1.50 to -2.0 will net j1+. A little trial with monovision contact lenses if the cataract is not too bad is helpful. I have also suggested some trials with multifocals in select patients but my colleagues do not necessarily agree that this is a good test model. Some patients LOVE multifocal contacts, others do not. If in the best hands the acceptance rate is 75 to 80%, how could it be any higher with a multifocal IOL?

Today oct 2005 for my eyes i would still lean towards a mild mono in the non dominant eye and perhaps a wavefront (low spherical aberration) optimized IOL for the dominant eye. I would wear a nice light single vision for night driving and extreme visually demanding distance tasks. If i were retired like most of my patients who only day drive and rarely night drive, i would rarely wear glasses at all.

THis discussion is probably the most honest, straightforward, optically based information exchange I have read to date on this IOL.

Sam

Optical sam:

I had my left eye operated on about a month ago. The MD told me I could have either. It was my choice. The MF cost more. After looking on this board and reading more about it on the internet I told him I wanted the standard IOL implant. I am 57. I still work. I still drive at night. I still do all the things that most people like to do. My Dad is 82 this month. He has had implants in both eyes. He agrees with me. He wants to be able to see the best that he can for at least 18 more years. He said new is great as long as it takes into consideration the needs and wants of the patient. You see my Dad thinks he is still young and wants the same as us younger people, just plain good vision for everything. If this new Restor lens does not meet all his requirements they need to improve it instead of trying to sell people on a bad idea.

[fjpod]

FWIW...I'm an OD with 27 years experience of managing post-op cataract care. Compared to the days when we fit aphakic spectacles and CLs, today's posterior chamber IOL patients generally get 20/25 BVA with no glasses...and if we can get one eye to come out at -.75, the patient has J2 + near VA with no spectacles at all.

Most patients (who had cataracts bad enough to warrant surgery) are THRILLED with this. Of course if their VA wasn't so bad in the first place, ( and this is a big if) and their IOL calculations or lens placement is off a bit, they can be very unhappy.

I really don't see what all the "excitement" is over accomodating IOL's.
I haven't had a patient complain to me yet about having to wear glasses for reading or driving after surgery.

I saw one patient recently that I did not comanage. He was a 58 year old who had a unilateral cataract removed and replaced with an accomodating IOL. He was upset that he had to still wear reading glasses for the other eye which was no where near developing a cataract. He was wondering ( and so was I) why he was talked into it in the first place.

I really don't feel that it's OK to tell these accomodating IOL patients, "well, you have to be ready for a little LASIK if the IOL isn't perfect"

[ilanh]

Most people who get the Restor lens done are encouraged to get it done on both eyes. It works best that way. The few that I have seen so far are literally thrilled. I examined a 75 year old patient a few weeks ago who saw 20/20 for distance and J1 for near, all without correction. He never wears glasses anymore for anything. He had previously been a hyperope and had spent his entire life in glasses. I am 45 years old and do not have the uncorrected vision that this elderly gentleman has. I do not want to go on record saying that everything is perfect with this lens because we are still working on some issues. For example, there is still the glare at night issue which appears to trouble some people. The official word from the company is that this occurs in about 5% of people. Other studies have shown that initially it may occur in a lot more but that it comes down significantly once the brain has adapted to the concentric zones and apodized surface. Also, the vast majority of patients are experiencing excellent uncorrected distance vision, but there are some who have unexplained loss of best corrected visual acuity (some of these patients have had the lens explanted). Overall, you have to view this a little bit like Lasik. Most Lasik patients are thrilled but there are definite side effects that causes some griping in the minority.

-I think that we need to pick better candidates ie: no lasik patients, unilateral cataracts etc.
-We need to inform patients that distance and near vision will be better than intermediate (ie: eliminate folks who depend a lot on interm vision)
-Eliminate truck drivers and other night vision dependent people (ie: people whose job depends on night driving and may suffer as a result).
-For now don't do this on pilots, police officers, fire fighers etc

I believe that the future is rosy for this lens but would still counsel nervous nellies to wait another year before getting it.

[fjpod]

Usually you do have to dilate to get a good perspective on whether there is a secondary cataract, and to what extent it may be causing a reduction in VA. The density of the cataract and the VA reduction must make sense. You also have to rule out any other potential internal problems before engaging in the treatment such as macular edema and optic atrophy.

[acredhead113]

Usually you do have to dilate to get a good perspective on whether there is a secondary cataract, and to what extent it may be causing a reduction in VA. The density of the cataract and the VA reduction must make sense. You also have to rule out any other potential internal problems before engaging in the treatment such as macular edema and optic atrophy.

I have a question: I had cataract surgey one month ago on my left eye. I think at the same time he did lasik surgery to correct for my astigmatism. I have had two appointment or consultants with him and he keeps telling me he is going to remove the stitch from my eye. I feel something in my eye. It feels like water or just something is there. What is it?

[ilanh]

I have a question: I had cataract surgey one month ago on my left eye. I think at the same time he did lasik surgery to correct for my astigmatism. I have had two appointment or consultants with him and he keeps telling me he is going to remove the stitch from my eye. I feel something in my eye. It feels like water or just something is there. What is it?

What you had was a limbal relaxing incision (LRI) which is often done at the time of cataract surgery. Relaxing incisions are made using a diamond blade at the steep meridians of the eye to decrease astigmatism. Usually the relaxing incisions cause a foreign body sensation that lasts a few weeks. Although many of us do sutureless cataract surgery it is possible, however, that your surgeon used a corneal suture and that indeed may be what you feeling. If he told you that he placed a stitch then it's most likely that the sensation that you are experiencing is the suture and it will go away as soon as he removes it.

[acredhead113]

What you had was a limbal relaxing incision (LRI) which is often done at the time of cataract surgery. Relaxing incisions are made using a diamond blade at the steep meridians of the eye to decrease astigmatism. Usually the relaxing incisions cause a foreign body sensation that lasts a few weeks. Although many of us do sutureless cataract surgery it is possible, however, that your surgeon used a corneal suture and that indeed may be what you feeling. If he told you that he placed a stitch then it's most likely that the sensation that you are experiencing is the suture and it will go away as soon as he removes it.

Thank you for the explanation.

What type of procedure is required to remove the stitch? Does it hurt? How long does it take?

[jasonmiller]

Check out http://AccommodatingIOL.com

Has some decent info about the topic

[jsan123]

I am a 58 Y/O myopic male and with an immature cataract in the left eye. I am considering the Restore procedure, with refractive correction for the right eye.

While I am not a fighter pilot or a truck driver, one of the reasons I am doing this is for sailing/cruising. I need to have 20/20 acuity. I have worn monocular contacts for most of my life but as I age I find that my acuity has been reduced.

My OD says that it may require post op lasik to get to 20/20 which he is willing to do as part of the (considerable) price. Does anyone have comments on the success of this, please?

[QDO1]

I am a 58 Y/O myopic male and with an immature cataract in the left eye. I am considering the Restore procedure, with refractive correction for the right eye.

While I am not a fighter pilot or a truck driver, one of the reasons I am doing this is for sailing/cruising. I need to have 20/20 acuity. I have worn monocular contacts for most of my life but as I age I find that my acuity has been reduced.

My OD says that it may require post op lasik to get to 20/20 which he is willing to do as part of the (considerable) price. Does anyone have comments on the success of this, please?

be prepared to wear spectacle while it all gets sorted out - post op, pre lasik. This procedure potentially seems quite surgical. the last laser clinic I worked in listed recent ophthalmic surgery ad a contra indication to Lasik...

[chip anderson]

I know I am gonna get accused of O.D. bashing again but last I heard they couldn't do catract surgery or lasic at any price.

[Happylady]

My Mom who had Restor lenses put in when she had catarat surgery is not thrilled with her close vision. If the light is great and what she is looking at is dark letters against a light background then she can read with no glasses.

If the light is poor or the reading material doesn't have good contast then she needs glasses. Her progressives have a +2.50 add but the other day in a restaurant she had to use a magnifying glass to see a menu with poor contast. even wearing her glasses.

We are going to do a refraction on her this week and I think a stronger add will make her happier.

[fjpod]

I know I am gonna get accused of O.D. bashing again but last I heard they couldn't do catract surgery or lasic at any price.

Maybe jsan is mistaken and means OMD. Or maybe his OD performs pre and post operative care which is within his scope of practice.

Why assume that an OD is performing cataract surgery illegally?

Someone's gotta keep you honest, Chip.

[chip anderson]

The patient pretty well stated the O.D. was going to do lasik "at a conciderable fee."

My biggest problem is that I am honest.

[fjpod]

The patient pretty well stated the O.D. was going to do lasik "at a conciderable fee."

My biggest problem is that I am honest.

Doesn't matter whether he is charging a fee or not, the patient may be mistaken, or the OD may be in partnership with an OMD, and just like an optician who owns an optical practice may say " We can examine your eyes" when he really means that the OD he employs can examine his eyes, the OD may have been referring to his OMD partner or employee.

Why do you automatically assume the OD is practicing illegally?

I think your biggest problem is you think you are the only one who is honest.

[chip anderson]

I didn't I assummed the patient didn't know the difference between an O.D. and an Opthalmologist.

Twas you who assumed the worst.

[fjpod]

I didn't I assummed the patient didn't know the difference between an O.D. and an Opthalmologist.

Twas you who assumed the worst.

Ah! So you were couching your thoughts and hiding your true analysis of the subject.

Sounds a little dishonest.

By now the whole board is annoyed with us for carrying on off the topic. So, why don't we move any further discussions like this to threads with appropriate titles like honesty, ethics, situational analysis, etc.?

[jsan123]

You are quite right, I did not understand the distinction. This particular Dr. is a board certified Opthamologist with a specialty in cornea issues I believe.He comes highly recommended. Regards this error, my old boss used to say "Do not rule out the possibility of incompetence."

But back to the point of my initial inquiry. After the Restore implants and the Lasik "touch up" am I going to see 20/20 at distance to see that bouy at the channel entrance?

[fjpod]

But back to the point of my initial inquiry. After the Restore implants and the Lasik "touch up" am I going to see 20/20 at distance to see that bouy at the channel entrance?

jsan,

Really only your eyecare professional, in this case your ophthalmologist, can give you assurance. Make sure he/she is someone you have used in the past, and someone you trust. But, I don't think anyone can "promise" you 20/20. They would be foolish to do so.

[jsan123]

The Doc was pretty clear in setting my expectations. He indicated that the results have been 20/25 to 20/40 but then said that with Lasik should be able to get to 20/20. I am looking to find out what others, either professionals or patients have experienced with this new technology. As I said before if I am going sailing, I need to hve good vision, both near and far.

[chip anderson]

JSAN: No one can predict with 100% certianty the out come of any surgery.

As to sailing just remember what a cute little little redhead once told me: "You don't have to see to have fun."
Of course, I never got to find out exactly what she ment.

[Robert Martellaro]

I am a 58 Y/O myopic male and with an immature cataract in the left eye. I am considering the Restore procedure, with refractive correction for the right eye.

While I am not a fighter pilot or a truck driver, one of the reasons I am doing this is for sailing/cruising. I need to have 20/20 acuity. I have worn monocular contacts for most of my life but as I age I find that my acuity has been reduced.

If updating the Rx and/or lens design proves unsatisfactory, I would strongly consider a fixed focus monofocal IOL. I've heard of very good results with Tecnis's prolate silicone IOL- good vision and contrast sensitivity. Most folks would agree that multifocal and accommodating IOLs at their best can only approach the quality of distance vision of traditional IOLs.

My OD says that it may require post op lasik to get to 20/20 which he is willing to do as part of the (considerable) price. Does anyone have comments on the success of this, please?

In some cases 20/20 says more about the quantity of vision and less so for the quality of vision.

Regards,

[ilanh]

The Restor IOL should only be used on patients who place a high premium on getting around without glasses. In my practice I would not even offer it to anyone who is happy with their reading glasses or "feels naked" without glasses. This lens is for highly motivated people only. It will get about 80% away from glasses as advertised. There may be some adjustments to make ie: near vision may require you holding the print a little closer than you are otherwise used to (since the add power is somewhat strong). Also, intermediate vision is not stellar with the lens and may require additional glasses just for the computer (or adjusting your distance from it). Finally, there may be slight halos at night around lights (although the majority of patients have not complained too much about this). In fact, most cataract patients have suffered from halos around lights just due to the cataracts (Restor halos are milder). About 5-10% of people may require a lasik touch up following the procedure to take care of residual astigmatism or to finalize the prescription. Some surgeons are bundling this in with the cost of the procedure. There is nothing wrong with this and it is logical. The bottom line is that the vast majority of patients will be very happy with their final vision and will not regret having gone this route. If you want to play it absolutely safe you can wait for another few years until the technology is perfected (then again, you can say this about a lot of things.)

Ilan Hartstein, M.D

[ecsoptical]

Very well put, thank you