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Blended vision laser eye surgery?

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 Postmanpat 13 Sep 2021

  I have a 60 year old friend who has worn long distance glasses/contacts all her life and has decided to have corrective laser surgery. The surgeon (who comes highly recommended) is very keen to do blended vision surgery so that she will not need glasses for anything. She is concerned about the quality of sight (v short and v long distance), longer recovery time and potential complications from this compared to monovision surgery.

  Has anybody got any experience or insights into the blended vision option?

In reply to Postmanpat:

No experience in that, but I thought corrective eye surgery was moving towards total lens replacement rather than reshaping with laser?

Post edited at 18:07
 Postmanpat 13 Sep 2021
In reply to Ridge:

More expensive I think.

 Jon Stewart 13 Sep 2021
In reply to Postmanpat:

Laser surgery (on the cornea) isn't usually offered to anyone at 60, they'll be offered lens exchange surgery. This is the same procedure as cataract surgery - the natural crystalline lens inside the eye is removed and replaced with an artificial intraocular lens (IOL). Laser surgery is for young folk, lens exchange for oldies.

The options for anyone having lens exchange surgery (or for that matter bilateral cataract surgery) relate to what type of IOLs they get. It should make no difference to recovery times what type of IOL is used as the procedure is the same. The options are:

1. Distance vision (both eyes). Standard option, good vision for walking around, driving, watching TV, but reading glasses are needed. Reading vision with glasses on is also good.

2. Monovision (one eye distance, one eye reading). One way of not needing glasses after surgery, and works well for some people. Best done for people who've used this technique with contact lenses and adapted to it. One advantage of this technique is that if you don't like it for all tasks (e.g. night driving or long periods of reading) you can equalise the two eyes with glasses.

3. Multifocal IOLs (I think this is what you're calling "blended vision"). These can work well, by combining a distance prescription and reading prescription in each lens (in concentric rings). A bit more expensive, and do get pretty good results. Personally, I wouldn't go for this, because it's a compromise to both distance vision and reading vision. It's great if it works, you don't need any glasses, but if you're not happy with the vision, it can't be corrected by wearing glasses over the top: the damn things (the multifocal IOLs) are inside your eyes. If you're used to having good distance vision, multifocal IOLs aren't going to deliver what you're used to - not great if you do a fair bit of driving at night, for example. I don't want to bad mouth multifocal IOLs because I have seen good results with them, but anyone choosing this option needs to understand that they're compromising clarity of vision for convenience of not wearing reading glasses. 

If I was having lens exchange surgery (I wouldn't actually bother, I'd wait 'til I was getting a bit of cataract rather than remove a perfectly good natural lens) then I'd either get normal distance vision, or "partial monovision" where the non-dominant eye is left just a little bit short sighted so you can check your phone or read a kindle with large font, but you'll still need reading glasses for any detail. But the best option is dependent on lifestyle and priorities.

 Babika 13 Sep 2021
In reply to Postmanpat:

Jon Stewarts reply is spot on. 

I had laser in my 20's and last September I had IOL - replacement lenses as further laser was no longer possible. 

I considered the monovision v blended vision at length and opted for monovision in the end as I was adamant I didn't want any reading glasses at all. 

It does depend on your friends needs and expectations of results. Personally I'm thrilled with the outcome - I can read maps, phones and GPS devices in pouring rain, snow whatever without struggling to clear a pair of glasses.

My long distance vision is very good but maybe not 20-20. You can't have everything so you need to know what you want most.  

 Postmanpat 13 Sep 2021
In reply to Postmanpat:

Thanks for the feedback. I'll pass it on. 
I don’t think she can afford lens exchange but wants not to need glasses at all.
 

  As I understand it she is referring to what seems to be the most recent version of laser surgery. This one, I think https://www.oclvision.com/blog/getting-used-to-blended-vision-how-long-does-it-take/

Her main concern seems to be recovery time and risk of something going wrong.

Post edited at 23:07
In reply to Jon Stewart:

I’m now wearing one lens in my dominant eye to correct my short sightedness and no lens in the other eye for close vision. A bit strange at first, but totally comfortable with it now and no reading glasses required. Do you come across this approach much?

 Jon Stewart 14 Sep 2021
In reply to Postmanpat:

Thanks for posting the link. The "blended vision" laser procedure for presbyopia isn't a commonly practiced, tried and tested thing, so you might struggle to get any independent feedback.

Is it that much cheaper than lens exchange? Thing is, once you're 60, you're going to get changes to the lens as cataracts start developing, which might be in 2 years, or 20 years or any time in between. It's not possible to predict, which is why lens exchange is standard - it lasts. Laser surgery for presbyopia has been possible for decades but basically no one bothers, because before too long you'll probably need cataract surgery anyway. May as well get it all sorted early and be done with eye surgery for good.

I think I can see what they're up to with the procedure (making aspheric corneas like a multifocal soft contact lens, I'm guessing). Gut reaction: not my bag. Your friend could try multifocal contact lenses for a while to get some idea of what to expect before committing to anything irreversible. All round, without understanding a lot more about it, this doesn't sound like an option I'd be very keen on trying! 

 Jon Stewart 14 Sep 2021
In reply to paul__in_sheffield:

> I’m now wearing one lens in my dominant eye to correct my short sightedness and no lens in the other eye for close vision. A bit strange at first, but totally comfortable with it now and no reading glasses required. Do you come across this approach much?

Yes, all the time. For those with the right prescription for it, this is a cheap and simple option that can work really well.

 nikoid 14 Sep 2021
In reply to Jon Stewart:

Interesting post. Someone I know had lens exchange surgery and seemed surprisingly blasé about it (at least to me). He certainly did not seem to have looked into the risks.  Do have any data or can you point to any studies on the risks for this procedure?

 Jon Stewart 14 Sep 2021
In reply to nikoid:

Can't quote you any data off the top of my head (easily googled), but I do post-ops for NHS cataract surgery every day and it's a doddle. Hardly ever any complications to deal with. The complications I do see every now and then are dealt with by prescribing anti-inflammatory eye drops and then they settle down. Not seen a serious complication like retinal detachment (or god forbid an  infection of the internal eye) yet.

I would promote a blasé attitude to cataract/lens exchange surgery. Really routine and low risk. But on the other hand, I'd only have an operation on my eye (except maybe laser in my 20s) if there was something I couldn't fix with glasses or contacts since I don't find them a hassle. 

In reply to Jon Stewart:

Interestingly, my dad had his cataracts fixed 3-4 years ago, after a lifetime of being extremely short sighted. I assume they did a lens replacement. He was warned that his short sightedness might return, and indeed while at first he needed no glasses for the first time in his life, but the need for glasses rapidly returned over a few months, albeit to a much lower prescription. Is this a regular occurance?

Post edited at 10:34
 Jon Stewart 14 Sep 2021
In reply to Alkis:

Not really. After cataract surgery, the prescription doesn't generally change much at all (but sometimes it does, it's interesting that the surgeon could predict this for your dad). Lots of people do still need distance glasses after cataract surgery though, because on the NHS they won't fix astigmatism with the IOL. 

In reply to Jon Stewart:

Well, he told him he could correct his eyesight at the same time but that it's going to stabilise higher than it starts with, which is what happened. I am ignorant as to the procedure, so I can't provide any more info unfortunately.

 Jon Stewart 14 Sep 2021
In reply to Alkis:

I'm sure it would have been ordinary cataract surgery with IOL, there would just be something particular about your dad's eyes which would mean they'd settle down to a more myopic end point some time after surgery. This isn't something most people would need to consider. For the vast majority of people, they measure you up, put in the appropriate IOL and pretty much straight after surgery you get as close as possible to optimal distance vision, give or take any astigmatism, and that's how it stays. (There is a bit more to it than this, and there's certainly no guarantee of ending with a close to zero prescription, but this is basically how it goes in uncomplicated cataract surgery).

 mountainbagger 14 Sep 2021
In reply to Jon Stewart:

This is really interesting. My myopia is improving slightly with age (I'm 46) and I've been told to expect to have to use reading glasses as I get older. Does IOL surgery stop that improvement/deterioration from continuing somehow? That is, can most people expect a fairly static situation following the surgery.

FYI, my 75 yr old mum had IOL earlier this year. She had cataracts but also had her myopia corrected at the same time. I believe she was told she'd need some bog standard reading glasses off the shelf afterwards. She was very nervous but absolutely ecstatic with the results... miraculous she said.

In reply to Jon Stewart:

Nice to see a discussion going on where someone knows about topic in hand!

How do you feel about lens replacement for very short sighted people in their forties? Do you see people like that coming through in your work? 

(Standard laser surgery wouldn't do it and not at the best age anyway. Vision well corrected by hard lenses just now, glasses in comparison a poor solution given the prescription. She's thinking about getting a consultation at one the hospitals in Sheffield.

 Jon Stewart 14 Sep 2021
In reply to mountainbagger:

> This is really interesting. My myopia is improving slightly with age (I'm 46) and I've been told to expect to have to use reading glasses as I get older. Does IOL surgery stop that improvement/deterioration from continuing somehow?

Lens replacement surgery would take you from the beginning of presbyopia at 46, where you're just starting to need different prescriptions for distance and near vision as the natural lens loses its flexibility, to the end point (that of a 60 year old) - in the space of 10 minutes rather than 15 years. At the moment, you just need one prescription for myopia, and you can still read with you glasses on (and probably if you take them off too, depending on how myopic you are). After lens exchange surgery, you would have good distance vision, but you would need the same strength reading glasses as a 60 year old, so 46 is not a good time to do it.

You're really at the totally unsweet spot for surgery: too old to have laser and not need glasses, but too young to want to get rid of a very usefully flexible natural lens in favour of a totally rock hard plastic one that only focuses at one very specific distance (unless it was multifocal, but that's a big step down from a natural one that's still got a few yeras of decent flexibility left).

> That is, can most people expect a fairly static situation following the surgery.

Yes, it's a fairly static situation.  Much more static than where you are at 46 where your eyes can still focus dynamically at every useful distance with the use of a single prescription!

> FYI, my 75 yr old mum had IOL earlier this year. She had cataracts but also had her myopia corrected at the same time. I believe she was told she'd need some bog standard reading glasses off the shelf afterwards. She was very nervous but absolutely ecstatic with the results... miraculous she said.

That's the standard procedure, and it's brilliant.

On a side note, private providers are doing a lot of this work for the NHS and it's working out absolutely great for cataract patients. You get seen in a little private hospital in a business park on the edge of town, usually (where you can park, believe it or not), it's a chilled out and friendly but professional atmosphere - the staff aren't stressed - and a top surgeon does a massive list of 20 or so totally routine piss-easy surgeries and then clocks off early. 

Post edited at 13:28
 Jon Stewart 14 Sep 2021
In reply to Swig:

See above. 40s is not the best time, but if you're highly myopic, there's still something to be gained.

[Edit: you said laser won't do it - too much cornea needs burning off I guess].

If I was you I'd stick with RGPs - optimal distance vision, still got your flexible natural lens for a few years yet. You can change to monovision or multifocal RGPs when your near vision starts to suck. If you find RGPs a bit annoying, you could try soft lenses (they come in all presecriptions now), but I tend to encourage RGP wearers to stick with them.

Post edited at 13:27
In reply to Jon Stewart:

Thanks for all your input on this thread.

I've alway been short sighted since I was a kid, wore glasses all the time, then started taking them off to read, then started to have to hold the book closer and closer to my nose, and in my late 40s had to switch to varifocals to work effectively in the office.

I get really good results using a distance contact lens in my dominant eye and leaving the other one uncorrected, and it's now my preference for walking or running when it's misty or raining, (and swimming).

Sounds like the 'partial monovision' option would be worth me considering when I retire and (hopefully) spend more time outside and swimming in the lakes.

 Jon Stewart 14 Sep 2021
In reply to Ridge:

> Thanks for all your input on this thread.

No problem. It's a procrastination displacement activity while I should actually be doing something for work!

> in my late 40s had to switch to varifocals to work effectively in the office.

> I get really good results using a distance contact lens in my dominant eye

This is exactly the combination of solutions I would recommend to most people aged 50+ with office jobs and outdoor/sporty hobbies.

 Jim Fraser 14 Sep 2021
In reply to Jon Stewart:

> 2. Monovision (one eye distance, one eye reading). One way of not needing glasses after surgery, and works well for some people. Best done for people who've used this technique with contact lenses and adapted to it. One advantage of this technique is that if you don't like it for all tasks (e.g. night driving or long periods of reading) you can equalise the two eyes with glasses.

I know someone who has had this method with laser and she seems really happy with it. 

This method works with corrective surgery and with contact lenses but not with glasses. I use it regularly with contact lenses and it's great even though I do not use it all the time. A few minutes after I put the lenses in my brain is like 'I've got this!' and I have seamless all-distance vision. I have tended to go for a near-eye prescription that is not so near because that gives an advantage for driving but I shall probably try to have two options in future with one for closer work.

 Jon Stewart 14 Sep 2021
In reply to Jim Fraser:

> I know someone who has had this method with laser and she seems really happy with it. 

Looking again at the link the OP posted, I think the "blended vision" option might just be monovision done with a laser rather than anything fancier. It'll work OK for many people, but if I was 60 I'd go for lens exchange (or wait 'til I got cataracts and go NHS) instead.

> This method works with corrective surgery and with contact lenses but not with glasses. 

Yes, in glasses you end up with different sized images, which the brain doesn't like much. But I have seen patients using exactly this option (in one case by accident as their prescription had changed in a coincidental way; when I prescribed something much more sensible which I expected to be a vast improvement they didn't like it at all...).

 nufkin 14 Sep 2021
In reply to Jon Stewart:

>  monovision done with a laser 

I seem to recall reading, quite a long time ago now, that laser-corrected vision might go squiffy at altitude (presumably as pressure changes altered the shape of the eye). Do you know if that ever was actually the case, or have I just spent the last couple of decades plodding around with un-lasered eyes on the off-chance I might get an invite to try a new route in the Himalaya?

(which of course I haven't, inevitably)

 mountainbagger 14 Sep 2021
In reply to Jon Stewart:

> You're really at the totally unsweet spot for surgery

🤣 Good to know! I'll stick with contact lenses for sport and glasses the rest of the time (interestingly I have no issues reading with my glasses on, but the lenses are a bit squiffy...I am well overdue an eye test which I'm about to book so we'll see what that's all about) until I'm older.

Thanks for your informative and helpful replies though, very kind of you.

 Babika 14 Sep 2021
In reply to nufkin:

My personal experience is laser in my 20's, many trips at altitude over the years.

No problems at all.

 Sealwife 14 Sep 2021
In reply to nufkin:

It is mentioned in one of the books about the Everest disaster (maybe Into Thin Air).  Beck Weathers was reputed to have had problems with his sight owing to altitude affecting his eyes following laser surgery.  

 Jon Stewart 15 Sep 2021
In reply to nufkin:

> I seem to recall reading, quite a long time ago now, that laser-corrected vision might go squiffy at altitude

This a down to a couple of case reports, one published in Into Thin Air, where the patient had an older and more dramatic form of cornel surgery, not modern laser surgery. No evidence of problems following laser at altitude as far as I know.


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