Intraocular Lens replacement

[Rigged4Flight]

So I just read that Patty Wagstaff recently had LASIC and IOL surgery on both eyes. My eyes are firmly set in the "must wear corrective lenses" category. They have been for most of my life, and for the last 10 years or so they have also joined the exclusive Presbyopia Club, with all of the privileges and limitations thereof.

I see from the FAA site where monofocal (corrects differently for each eye) and multifocal (corrects far and medium vision) IOL is approved, with 10+ and 90+ day recovery periods, respectively. But I'm unable to find any FAA approval for the premium IOL, which is the presbyopia-correcting near and distance version.

What say you, PoA? Does the FAA approve of premium IOL surgery? Would you consider it if your eyesight required trifocal or progressive lenses?

 

[RJM62]

I have no idea whether FAA approves of premium IOL surgery. That probably can be determined with a phone call to OKC, though.

As for me, I do need progressive lenses to actually see well without fatigue (astigmatism, presbyopia, and a misalignment requiring a prism correction). I actually can pass a vision test with only a pair of cheaters for the near vision part and no correction otherwise, and in the practical sense I could safely fly or drive for hours with no correction at all for distance. But it would be fatiguing. My brain would have to do what the prism correction does.

The answer to whether I would consider the surgery is that I've never even asked whether it's an option for me. In fact, I've never thought about until I read this thread. I guess that sums up my interest in eye surgery for something that can be corrected with a pair of glasses. I've never even thought to ask my eye doctor it.

But as I said, my uncorrected distance vision is actually very good. The astigmatism is so mild that if I didn't also need the prism correction, I probably wouldn't bother with the glasses. I can easily pass an eye test (for distance) without them, and in fact did so recently when I renewed my driver's license just to avoid the "corrective lenses" requirement. If my uncorrected vision were worse, I might feel differently about surgery.

But probably not. My vision has changed enough over the years that I think I'd still prefer glasses and their easily-changed prescriptions over a surgical solution.

Rich

 

[oldShar]

Well, I had IOL implanted 15 years ago -- both eyes.
Nothing fancy, just standard lenses (for distance).
I have routinely passed the class III without correction, tho' it is very tough reading anything closer than about 16", especially without larger print; so I keep a pair of $5.98 WalMart specials with my, for CYA. Don't see the problem. Not really any different from carrying a pair of shades. or a pen. Not a problem

 

[poadeleted20]

You can get a reliable answer to your FAA-related questions from Dr. Bruce Chien, an AME who specializes in difficult aeromedical certifications. He doesn't visit here any more, but you can find him on the AOPA Forums or via his web site.

As to whether I'd do it, the answer is a flat "no", and I do qualify to answer that as I wear trifocal glasses when I'm not wearing my contacts. At this point, even the small risk of losing my FAA-qualified eyesight as a result of such surgery isn't worth the potential return. If this had been an option 43 years ago when I was graduating from college, and 20/20 uncorrected eyesight would have gotten me into military pilot training, I would have done it, but at age 64, there isn't anything much to be gained and a lot to lose, even if the odds are against sustaining that loss.

My current solution of single-vision contact lenses supplemented by reading glasses for close work is doing just fine for me, both on the ground and in the cockpit. Yes, I did shell out $110 to WalMart optical to have a special pair of flying sun/reading glasses (sunshaded zero-correction upper half and clear 1.5 diopter reading lower inserts), but that's a whole lot cheaper than eye surgery, completely risk-free, and it works just fine in the cockpit (driving, too).

 

[ClimbnSink]

Optional eyeball surgery nfw. I keep procrastinating giving this a try http://gettingstronger.org/2014/08/myopia-a-modern-yet-reversible-disease/

 

[poadeleted20]

BTW, when asked about this, Bruce Chien always points out that the guru ophthalmologist of LASIK wears glasses, and has never had the procedure.

 

[azure]

Optional eyeball surgery nfw. I keep procrastinating giving this a try http://gettingstronger.org/2014/08/myopia-a-modern-yet-reversible-disease/

Eye exercises for myopia have been around for years. I tried a variant of "active focus" back nearly 40 years ago. I don't think there's any scientific evidence that it works to reverse or even retard the progress of myopia. IMO, at best you can maybe stretch your range of accommodation slightly. Might help someone in the -1.00 to -1.50 range stave off the need for glasses for a year or two. Once you're into presbyopia, the issue isn't muscle strength but lens rigidity. OTOH, seems a lot of people's eyes change in the plus direction as they age, so myopia might be at least partly self-correcting in some cases, but that's not necessarily a desirable outcome. (Hint: being farsighted AND presbyopic can be quite miserable.)

Disclaimer: I'm not an eye care professional, nor do I play one on TV. I did, however, stay at a Holiday Inn Express a few years ago.

 

[FORANE]

The procedure of intraoccular lens implantation is done routinely with very low complication rates. In most cases it is completed in under 10 minutes under topical or retrobulbar block anesthesia with a mild sedative.

Perhaps the most important factor to consider is the phrase in the guide below which states: "freedom from any glare, flares or other visual phenomena". The multifocal lenses are known for a high incidence of this sort of effect such as halos. An initial incidence approaching 100% which tends to become less noticeable with time.


https://www.faa.gov/about/office_or...am/ame/guide/dec_cons/disease_prot/binocular/

Guide for Aviation Medical Examiners


Decision Considerations
Disease Protocols - Binocular Multifocal and Accommodating Devices

This Protocol establishes the authority for the Examiner to issue an airman medical certificate to binocular applicants using multifocal or accommodating ophthalmic devices.

Devices acceptable for aviation-related duties must be FDA approved and include:

• Intraocular Lenses (multifocal or accommodating intraocular lens implants)
• Bifocal/Multifocal contact lenses

Examiners may issue as outlined below:

• Adaptation period before certification:
  • Surgical lens implantation - minimum of 3 months post-operative
  • Contact lenses (bifocal or multifocal) � minimum of one month of use
• Must provide a report to include the FAA Form 8500-7, Report of Eye Evaluation, from the operating surgeon or the treating eye specialist. This report must attest to stable visual acuity and refractive error, absence of significant side effects/complications, need of medications, and freedom from any glare, flares or other visual phenomena that could affect visual performance and impact aviation safety
• The following visual standards, as required for each class, must be met for each eye:
  Distant:
  First- and Second-Class
  20/20 or better in each eye separately, with or without correction
  
  Third-Class
  20/40 or better in each eye separately, with or without correction
  
  Near:
  All Classes
  20/40 or better in each eye separately (Snellen equivalent), with or without correction, as measured at 16 inches
  
  Intermediate:
  First- and Second-Class
  20/40 or better in each eye separately (Snellen equivalent), with or without correction at age 50 and over, as measured at 32 inches
  
  Third-Class
  No requirement

Note: The above does not change the current certification policy on the use of monofocal non-accommodating intraocular lenses.

 

[weilke]

My wife is a trained lasik surgeon. She wears glasses :wink2: .

While some surgeons advocate 'refractive lens exchange', (iow 'cataract surgery without cataracts'), this is certainly unusual in the US. While replacement of the human lens is a very safe surgery, few opt to have their eyeballs opened without a pressing need to do so.

As for cataract surgery, in the US market, there are basically three kinds of 'premium' IOLs:

- toric lenses that allow the correction of regular astigmatism (different optical correction in two planes). The toric IOL is very similar to a standard acrylic IOL except that the curvature is not the same in the X and Y axis. If inserted in the correct position, this allows for correction of the astigmatism and a patient who would otherwise require glasses for distance after surgery can go without. The toric lens is still a monofocal IOL, so you can be corrected for either distance or near but not both. A patient corrected for far would typically require readers to look at charts, ipad or the numbers on the instruments.

- Fresnel based multifocal IOL (e.g. ReStor from Alcon, Tecnis from Abbot). These IOLs are aspheric and have something similar to a Fresnel pattern in the center creating more than one focal point. If properly measured and fitted, this allows a post cataract patient to be able to have both good near and far vision. The way the lens does that is by projecting several images onto the retina, the brain is smart enough to filter out the sharp image while ignoring the overlaid blurry image. The physics of this approach dictate that the optical quality of either image (near or far) will never be as good as the quality of the image from a monofocal lens. Most patients who opt for this are so deliriously happy that they dont need glasses that they are able to ignore the slight blurryness created by the Fresnel pattern. As mentioned, the other issue is that at night and with point light sources (like oncoming headlights), there can be a halo pattern created by the lens itself. Also, the way the lens is shaped, in the dark (when the pupil is wide), the near vision will be worse than in bright light. Most (>90% patients who decide on one of these IOLs are very happy with the outcome. Some are absolutely miserable because they hate the halos and slight blurriness. We will not put these into engineers .

- 'Accomodating IOLs' (e.g. Crystalens). While regular IOLs are kind of stiff, this implant is designed to flex and move based on the contraction of the muscles that used to provide accomodation. The result of this is some maintenance of the ability to accomodate. To get the lens to work, everything has to get in exactly the right spot. If it doesn't, the lens behaves like a monofocal IOL.



In all three cases, the lens itself costs more than a standard IOL and there are additional steps required during the surgery. As a result, typically there would be an upcharge in addition to the standard cataract surgery charges. If you need cataract surgery and you have some astigmatism, there is no real downside (beyond the cost) to getting a toric IOL. Whether the multifocal or accomodating options are worth the added expense is a personal decision.

 

[Hank S]

Multifocal lenses work very well, and can have up to a dozen different focal rings. But the do not provide as sharp of an image as a mono focal,lens with or without toric correction.

Many DOs will not recommend (or actively recommend against) multifocal IOLs for pilots, engineers and perfectionists. Despite working in the industry for a decade, I am not a candidate because all three describe me . . .

For whatever reason, three different DOs have told. E that I am not a candidate for contacts, so I wear glasses and swap out for prescription sunglasses when driving, flying or being outdoors (and yes, it's a pain).

On the other hand, how many ophthalmologists wear contacts? All of mine as I've moved around the country wear glasses. Draw your own conclusions, my own is to be happy with glasses.

I'll consider surgery when cataracts become a problem, but will probably go monofocal for a crisp, clear image. YMMV.

 

[noobJohn]

My optometrist keeps bringing up the "clear lens replacement" option for me because I'm very nearsighted with astigmatism and NOW barely squeaking by the FAA's never vision test. I'll soon have to start toting around reading glasses.

He keeps saying the surgeon would fix me up and I wouldn't need glasses or contacts for anything.

I remain skeptical. I'm pretty happy with my contacts for now.

My wife is a trained lasik surgeon. She wears glasses :wink2: .

While some surgeons advocate 'refractive lens exchange', (iow 'cataract surgery without cataracts'), this is certainly unusual in the US. While replacement of the human lens is a very safe surgery, few opt to have their eyeballs opened without a pressing need to do so.

 

[weilke]

I remain skeptical. I'm pretty happy with my contacts for now.

There is your answer.

One thing to keep in mind with optometrists recommending surgery is that frequently there is a way for them to benefit financially from referring you for surgery through a concept called 'co-management'. This is a setup where the OD receives a portion of the surgical fee in exchange for assuming the post-operative care of the patient. As there is considerable expense to a clear lens exchange with a premium IOL, the cash value of that share can be an incentive beyond being payment for the work of providing post-op care. And yes, this is legal.

 

[Hank S]

Premium lenses can carry a $ignificant upgrade charge that may not be covered by your insurance, even if the procedure and mono vision lens is. Just make sure that whichever IOL you select has UV filtering to protect your vision afterwards.

 

[Everskyward]

Eye exercises for myopia have been around for years. I tried a variant of "active focus" back nearly 40 years ago.

I did this back around 1990 and it was a total waste of money for me.

 

[Rigged4Flight]

Tons of great feedback in this thread. Thanks!

The procedure of intraoccular lens implantation is done routinely with very low complication rates. In most cases it is completed in under 10 minutes under topical or retrobulbar block anesthesia with a mild sedative.

Perhaps the most important factor to consider is the phrase in the guide below which states: "freedom from any glare, flares or other visual phenomena". The multifocal lenses are known for a high incidence of this sort of effect such as halos. An initial incidence approaching 100% which tends to become less noticeable with time.


https://www.faa.gov/about/office_or...am/ame/guide/dec_cons/disease_prot/binocular/

I wouldn't consider multifocal lenses. I've tried multifocal contacts, and I apparently don't have the ability to adapt sufficiently to them to use them without resorting to cheaters. And even though the halo affect is said to diminish over time, I would hate to put something permanent in my eyes that is known to cause issues like that.

My wife is a trained lasik surgeon. She wears glasses :wink2: .

Gotta admit - that tendency by doctors involved in the procedure does give me a moment of pause.

As for cataract surgery, in the US market, there are basically three kinds of 'premium' IOLs:

- toric lenses that allow the correction of regular astigmatism (different optical correction in two planes). The toric IOL is very similar to a standard acrylic IOL except that the curvature is not the same in the X and Y axis. If inserted in the correct position, this allows for correction of the astigmatism and a patient who would otherwise require glasses for distance after surgery can go without. The toric lens is still a monofocal IOL, so you can be corrected for either distance or near but not both. A patient corrected for far would typically require readers to look at charts, ipad or the numbers on the instruments.

- Fresnel based multifocal IOL (e.g. ReStor from Alcon, Tecnis from Abbot). These IOLs are aspheric and have something similar to a Fresnel pattern in the center creating more than one focal point. If properly measured and fitted, this allows a post cataract patient to be able to have both good near and far vision. The way the lens does that is by projecting several images onto the retina, the brain is smart enough to filter out the sharp image while ignoring the overlaid blurry image. The physics of this approach dictate that the optical quality of either image (near or far) will never be as good as the quality of the image from a monofocal lens. Most patients who opt for this are so deliriously happy that they dont need glasses that they are able to ignore the slight blurryness created by the Fresnel pattern. As mentioned, the other issue is that at night and with point light sources (like oncoming headlights), there can be a halo pattern created by the lens itself. Also, the way the lens is shaped, in the dark (when the pupil is wide), the near vision will be worse than in bright light. Most (>90% patients who decide on one of these IOLs are very happy with the outcome. Some are absolutely miserable because they hate the halos and slight blurriness. We will not put these into engineers .

- 'Accomodating IOLs' (e.g. Crystalens). While regular IOLs are kind of stiff, this implant is designed to flex and move based on the contraction of the muscles that used to provide accomodation. The result of this is some maintenance of the ability to accomodate. To get the lens to work, everything has to get in exactly the right spot. If it doesn't, the lens behaves like a monofocal IOL.

In all three cases, the lens itself costs more than a standard IOL and there are additional steps required during the surgery. As a result, typically there would be an upcharge in addition to the standard cataract surgery charges. If you need cataract surgery and you have some astigmatism, there is no real downside (beyond the cost) to getting a toric IOL. Whether the multifocal or accomodating options are worth the added expense is a personal decision.

I wonder (and as I type this I know that the correct action would be to talk to a trained LASIK doctor) what it would take to correct my astigmatism AND my near AND my far distance issues. I've had astigmatism and nearsightedness for my whole life, and I've also developed the normal presbyopia as reached my second adulthood (the part where I understand that I'm not as smart as I thought I was when I reached my first adulthood). I think it would take a combination of premium IOL and LASIK or PRK to give me as close to "normal" eyesight as possible. Here's a good link I just found, based on questions your post brought up for me: http://eyeworld.org/printarticle.php?id=6285

On the other hand, how many ophthalmologists wear contacts? All of mine as I've moved around the country wear glasses. Draw your own conclusions, my own is to be happy with glasses.

True story. I think almost every DO I've ever gone to had either glasses or contacts.

I'll consider surgery when cataracts become a problem, but will probably go monofocal for a crisp, clear image. YMMV.

That crisp, clear image - without a need for cheaters or other external devices - is my holy grail of vision, and I would give anything to be able to know before going under the knife that I would end up with exactly that.

One thing to keep in mind with optometrists recommending surgery is that frequently there is a way for them to benefit financially from referring you for surgery through a concept called 'co-management'. This is a setup where the OD receives a portion of the surgical fee in exchange for assuming the post-operative care of the patient. As there is considerable expense to a clear lens exchange with a premium IOL, the cash value of that share can be an incentive beyond being payment for the work of providing post-op care. And yes, this is legal.

I had a DO that always pushed the benefits of LASIK whenever I went in for an updated eyeglass Rx. He never failed to hand me the business card of a practicing LASIK surgeon. I immediately disregarded his advice as being financially motivated.

Premium lenses can carry a $ignificant upgrade charge that may not be covered by your insurance, even if the procedure and mono vision lens is. Just make sure that whichever IOL you select has UV filtering to protect your vision afterwards.

Thanks again for all of the valuable feedback, everyone.

 

[weilke]

Btw. A DO is a doctor of osteopathy, an alternate way to obtain a degree to practice medicine. An OD is an optometrist, a specialist in vision care.

 

[Circuit Flyer]

Btw. A DO is a doctor of osteopathy, an alternate way to obtain a degree to practice medicine. An OD is an optometrist, a specialist in vision care.

Further complicating the reading on the subject is that OD also stands for right eye ("oculus dexter" in Latin). OS is left eye ("oculus sinister"). OU ("oculus uterque") is both eyes. I've seen some eye-related medical records starting to use LE (left eye, not law enforcement) and RE.

 

[Hank S]

I wonder (and as I type this I know that the correct action would be to talk to a trained LASIK doctor) what it would take to correct my astigmatism AND my near AND my far distance issues. I've had astigmatism and nearsightedness for my whole life, and I've also developed the normal presbyopia as reached my second adulthood (the part where I understand that I'm not as smart as I thought I was when I reached my first adulthood). I think it would take a combination of premium IOL and LASIK or PRK to give me as close to "normal" eyesight as possible.

It's possible to get a multifocal lens with toricity for your astigmatism. MF should correct for both near and farsightedness. Readers can be avoided by getting an "add power" lens. Not sure if the Toric + Add Power combo is available on a monofocal lens. Either way, it's a $ignificant up charge.

Good luck with your research! Keep us posted on your findings, as we are all aging and new developments are always appearing.

 

[weilke]

I wonder (and as I type this I know that the correct action would be to talk to a trained LASIK doctor) what it would take to correct my astigmatism AND my near AND my far distance issues. I've had astigmatism and nearsightedness for my whole life, and I've also developed the normal presbyopia as reached my second adulthood (the part where I understand that I'm not as smart as I thought I was when I reached my first adulthood). I think it would take a combination of premium IOL and LASIK or PRK to give me as close to "normal" eyesight as possible.

Wavefront lasik alone may be sufficient to correct both your myopia and astigmatism. Depending on how thick your cornea and how high your correction, there are limits of what either prk or lasik can achieve.

Youcan also wait until you get cataracts and go with a toric lens. It all depends on the details.

 

[Rigged4Flight]

Btw. A DO is a doctor of osteopathy, an alternate way to obtain a degree to practice medicine. An OD is an optometrist, a specialist in vision care.

Doh!

It's possible to get a multifocal lens with toricity for your astigmatism. MF should correct for both near and farsightedness. Readers can be avoided by getting an "add power" lens. Not sure if the Toric + Add Power combo is available on a monofocal lens. Either way, it's a $ignificant up charge.

Good luck with your research! Keep us posted on your findings, as we are all aging and new developments are always appearing.

I've tried multifocal contacts and just could not get them to work with my brain. I know the brain is supposed to adjust and adapt to them, but it never happened with me even after over a month of wearing them.

I'm planning on spending some time with an eye doctor when I get back home this Fall, and I'll be sure to update this thread or create a new one with more details, questions and options as I find them.

Wavefront lasik alone may be sufficient to correct both your myopia and astigmatism. Depending on how thick your cornea and how high your correction, there are limits of what either prk or lasik can achieve.

Youcan also wait until you get cataracts and go with a toric lens. It all depends on the details.

Yeah, it seems like a combination of techniques will probably be what I will need. I want to be able to focus on a something up close, then smoothly adjust my focus from near to mid-range and then to far - all without glasses or cheaters, and with as much clarity as possible.

Sounds like I'm going to need to just start throwing money at the doctor until everything looks right!

 

[Hank S]

Note that some IOLs (mono- and multi-focal) are available with Wavefront optics.

 

[NoHeat]

Note that some IOLs (mono- and multi-focal) are available with Wavefront optics.

What's that?

I'm guessing it does not mean just spherical, nor just spherical plus cylindrical correction, but instead a custom shape, made especially for one patient, that is intended to get the best image focus everywhere on the retina?

 

[Hank S]

As referenced in Post #19, it's an aspheric correction that reduces halos and increases image sharpness. It is not customized for a given patient, but is customized for a particular lens model. "Aspherical" just means that the lens is not a section of a sphere, or that the radius of curvature is not constant from the edge of the lens to the center.

 

[NoHeat]

As referenced in Post #19, it's an aspheric correction that reduces halos and increases image sharpness. It is not customized for a given patient, but is customized for a particular lens model.

Ok, thanks. I thought that for LASIK, wavefront correction meant something that was customized for a given patient. The reason I thought that is that when I had wavefront LASIK, while it wasn't explained to me, there was a colorful printout of the focus pattern for my eyeballs that was generated by a machine that imaged my eyes. This pattern looked more complicated than just a round pattern plus a linear (cylindrical) pattern. I assumed that the treatment was customized to correct for this complicated focus pattern of my eye, and not just correcting with a sphere plus cylinder as is typical for eyeglasses.

So does the term "wavefront" get used more loosely for the lens replacements? If they just mean aspherical, why don't they just call it that instead of "wavefront"?

 

[weilke]

So does the term "wavefront" get used more loosely for the lens replacements?

Yes, because it is a buzzword that sells lenses.

 

[Hank S]

"Wavefront" is copyrighted and used across the industry. Wavefront Industries was purchased by someone (I forget which company), so look for generic terminology to appear. But for now, Wavefront has name recognition for practitioners and sounds more impressive to patients than "aspheric" does.

Note that the aspheric is different fron cylinder correction in your glasses / contacts. A spherical lens (all the ones not advertised as aspheric or Wavefront) have radii that are part of a sphere. Draw the optic radius and it can be extended into a complete circle; the radius of curvature is the same for every point.

Aspheric lenses are different, the radius is slightly different at every point. Ask your OD to explain the difference, I can't do it in a simple forum.

 

[SbestCFII]

I think that an individual examiner isn't going to be too picky as long as your vision meets the standard during the exam.

 

[poadeleted20]

I think that an individual examiner isn't going to be too picky as long as your vision meets the standard during the exam.

I think an individual AME faced with an applicant with an intraocular lens replacement is going to follow the protocol in the AME Guide. See here for that protocol.

 

[Geico266]

So I just read that Patty Wagstaff recently had LASIC and IOL surgery on both eyes. My eyes are firmly set in the "must wear corrective lenses" category. They have been for most of my life, and for the last 10 years or so they have also joined the exclusive Presbyopia Club, with all of the privileges and limitations thereof.

I see from the FAA site where monofocal (corrects differently for each eye) and multifocal (corrects far and medium vision) IOL is approved, with 10+ and 90+ day recovery periods, respectively. But I'm unable to find any FAA approval for the premium IOL, which is the presbyopia-correcting near and distance version.

What say you, PoA? Does the FAA approve of premium IOL surgery? Would you consider it if your eyesight required trifocal or progressive lenses?

My wife had premium lens replacement. Both lenses failed after 2 years and they are just the standard lenses now. Come to find out they were defective and recalled. The new lenes are free, but you have to pay for the surgery. Premium leneses are a money making scam if you ask me. IMHO stick with standard lenses. Don't be a guinea pig.