Cataract Surgery: Which Intraocular Lens to Choose? A Complete Guide for Patients

0:01 Dr. Filipe, can you explain to me exactly what this whole thing about intraocular lenses and cataract surgery is? My doctor said I have cataract that I'll need surgery and offered me a type of lens, but this lens is expensive. My insurance won't cover the full cost and I'm feeling unsure about which type of lens is best for me since I don't really understand the difference between them and I'm feeling insecure. So, can you help me understand this a little better? Of course. My name is Philipe Lucato and I'm here once again on the channel discussing topics about cataract surgery and retinal surgeries. And the goal of this video today is to help you and your family members better understand the different types of intraocular lenses available for cataract correction. Also to understand based on your needs whether it's worth investing in a better

0:47 lens, one that will improve your quality of life or if not whether it's worth it at all. First of all, we're seeing more and more young patients undergoing cataract surgery. Sometimes in the office, people say, "Wow, I already have cataract, but my mother only had surgery when she was 90 years old." The thing is nowadays exams, diagnosis, technology, and the safety of the surgery have advanced so much that we are performing cataract surgeries on younger patients. We don't wait for it to get as hard as a rock anymore because when it does get as hard as a rock, the chances of having some kind of complication, something going wrong, the chances of the surgery not going as planned are higher. And when we generalize and say, "Oh, my neighbor had cataract surgery or my father had cataract surgery," it seems like it's always the same thing, like

1:32 it's all the same. Actually, it's not quite like that. There are different types of cataracts. There are peculiarities in the anatomy of each eye. Sometimes the eye is small, sometimes it's large, sometimes the cataract is soft, sometimes it's hard. And there are also peculiarities in our habits, in the things we do in our daily lives. These can influence the choice of intraocular lens. But in the past, we used to remove the cataract which is a natural lens that was once transparent and with age becomes cloudy simply to restore its transparency so that light could enter the eye better and vision would improve. And there wasn't much interest or technology available to achieve precise correction of refractive errors. But nowadays, more and more with our increasingly advanced exams, we've

2:17 been able to calculate what is the lens prescription that we need to place in your eye to correct it. Whether it's for distance vision, intermediate vision, or near vision for reading. So technology has advanced a lot and this has allowed us to recommend surgery earlier and with greater safety. Now the goal is not just to restore transparency but also to improve quality of life by reducing your dependence on glasses. So here we start talking about premium surgeries about premium intraocular lenses. What does that mean? These are lenses designed to improve your quality of life and how can we improve a person's quality of life? By reducing their dependence on glasses whether for distance, intermediate or near vision. This improves quality of life because there are people who really struggle with having to use correction with wearing glasses, right? And it also

3:05 allows people suddenly to take up new activities. Someone who is nearsighted and has very strong prescription glasses might not practice certain sports because it's hard to do them with with glasses like running or basketball, soccer, whatever it may be. And also for autonomy and safety. So when we talk about cataracts, especially in the elderly, we're not just talking about improving quality of life, but also thinking a bit about safety, about preventing falls. Since we know that falls in the elderly can have a huge impact on a person's quality of life and health, I'm going to show you the different types of lenses here. Among the lenses currently available for us to choose from on the market, there are the monopocal ones, and then I'll explain. Each of them includes advanced monopocals or monop focals plus. We have

3:52 bif focals, edolf lenses which are extended depth of focus lenses and we also have tri focal lenses. And for all these options we also have toric lenses which means the intraocular lens will also correct a stigmatism because there are people who only have myopia or others who only have hyperopia but the vast majority of people have this associated with a stigmatism as well. And we have a calculation. We input all your exam data into a special calculator and this calculator will tell us whether the aigmatism also needs to be corrected with the lens or not. Notice that the toric lens has a marking on it and any of the lenses from the list I mentioned earlier can be combined with a toric lens to correct a stigmatism as well. So let's go. First very common question, what is the insurance covered lens?

4:39 Here's the thing. All health insurance plans in Brazil are required to cover one type of lens, but they do not cover the more advanced lenses, special lenses, or the more expensive ones. So, this will obviously depend on which insurance plan you have and obviously on which clinic you go to. This varies from one clinic to another, but usually the lenses that insurance covers are simpler lenses which don't have as much technology or the other options that I'm going to talk about here. So most of the time the plan's coverage will be for a spherical mon focal intraocular lens. What does a mon focal intraocular lens mean? It has a single focus. So it will only correct your vision at a specific distance. For example, we do exams before surgery. And one of these exams, one of the most important ones is

5:24 biometry. Biometry tells me what lens power I need to put in your eye to get it as close to zero as possible or to achieve the prescription we expect. Usually we test which is the person's dominant eye or the eye with the most cataract and that's the one we operate on first. First we decide to set it to zero for distance vision or as close to zero as possible for distance since sometimes it needs correction. A stigmatism as well and a spherical monopocal lens does not correct the stigmatism unless it is a toric lens. But anyway, if we operate one of the eyes and leave that vision good for distance, so the person can be more independent from glasses to watch TV, to drive, to go to the theater, to go to the movies. When I talk about distance vision, I mean beyond 6 m. In the other

6:10 eye, when we go to operate on the second eye, we usually do a calculation called mono vision. Mono vision means I will also put in the insurance covered lens monocal. But this time, instead of correcting the prescription for distance, I will intentionally leave a little bit of myopia. The myopia will help the person read some things up close. It won't make you completely free from glasses for distance and near in all situations, but when you have one eye corrected as much as possible for distance and the other eye corrected a little for near, this already gives you some independence from glasses as well. Even though it's a simpler lens, the insurance covered lens, you can use this tactic, this strategy called mono vision. And it can also improve your quality of life. So, what are the advantages of this? It's a cheaper

6:56 option since if you have health insurance that covers this lens, you won't spend any extra money with cataract surgery. It's predictable and works well for many people. And it also provides good quality vision. And what is the disadvantage? Well, you won't have binocular vision. One of your eyes will be better for distance, the other eye will be worse for distance, but it will help a little with near vision. But for things like, for example, professional drivers, someone who drives a truck or drives a lot, sometimes depth perception comes mainly from stereopsis, usually because binocular vision is working. And this mono vision option with a monocal lens won't give you good depth perception. It won't give you perfect binocular vision. And it also ends up being an option that won't leave you completely free from glasses. You

7:43 may still need multif focal glasses after the surgery or at least a pair of reading glasses because it helps with near vision but it won't be enough for reading, not those tiny little letters. And then you might ask, "Doctor, I got a quote for a monop focal, but my insurance wouldn't cover the full amount." Why is that? Well, there are simpler monopocal lenses which are the spherical ones and those are usually the ones covered by insurance. And then there are a spheric lenses. Look at this diagram here. The spherical lens. It tends to have some distortion at the edge of the lens. This doesn't happen with the aspheric lens. The aspheric lens has a system that corrects this distortion a bit in the peripheral part of the lens. So, it's a monocal lens. It will also have the same

8:28 limitations as a monop focal lens, but it offers better visual quality. It has slightly better technology and that makes the lens a bit more expensive. Besides that, your doctor may have suggested a monopocal lens for you, but a toric monocal lens because you had a stigmatism. And to achieve good distance vision or to have good quality near vision, it's always ideal to treat a stigmatism whenever it's necessary to address it. So this can make a difference in cost since insurance won't cover either a spherical monop focal lens or a toric monop focal lens. All right. But then you might say, "Oh, Dr. Filipe, that doesn't work for me." You said that when we have cataract surgery, we're going to put a lens inside the eye, that it's going to stay there for the rest of my life, that this lens won't be replaced, and you said that

9:15 I'll probably have to keep spending money every year on glasses again. That's a huge expense every year. changing lenses, changing frames. So, I'd like to know about other options because I really don't want to have to depend on glasses after the surgery. So, let's look at the other options. All right, I'll start by talking about a lens that we used a lot in the past, but nowadays I don't really like to recommend, which is the bif focal lens. Actually, we used to call it the multif focal lens. It's not because it's a bad lens that I don't use it anymore. It's because new options have come up, options that are better than it. Actually, it gives you two focal points for vision. Even though it's called multif focal, it actually has two good focal points for vision. One for distance and one for near. So, the same lens at the same time will work for distance and for near vision. So,

10:03 what's the problem with it? Take a look at this chart here. It has a peak that shows vision is good at a distance. And this focal point here is good for near vision right where it's circled. But in the middle between those two points, it delivers a result that's not satisfactory. In other words, intermediate vision, that is vision for things a little farther away, like using a computer, cooking, or reading sheet music, something that's just a bit farther away, doesn't have a good effect. So, sometimes the patient puts on the bif focals and they can read everything up close. And during the exam, when you give them the near vision chart, they can read all of it, too. But they say, "Doctor, your face isn't very clear. You're just a little farther away, and I can't see very well at that distance." And later I'll talk about when I still use bif focals, but I won't

10:48 mention it now so as not to confuse you too much. But its disadvantage is this intermediate vision. Nowadays we use intermediate vision a lot and it doesn't provide such a good effect at that distance. Another important detail, this lens is of the defractive type. What does that mean? Look at its design. It has these rings around it. Look at the lens on the right side of your screen which is a monop focal lens from the same brand. And look at the bif focal on the left. The difference is these rings here. Light passes through these rings and part of it focuses in one place while other rays that pass through another part of the lens focus at a different point. And that's why it provides good vision both at a distance and up close at the same time. And not all patients can have defractive lenses implanted. That's why we do all those tests at the clinic

11:35 before surgery. But look, dry eye, significant blepheritis, changes on the ocular surface, the size of each patient's pupil, possible retinal changes, any more significant or serious opthalmological condition. All of these are contraindications for this type of lens. If we're not careful with the indication, the patient might spend a lot of money on this lens and end up dissatisfied with the quality of their vision. They might not like the visual effect very much. Another thing, sometimes defractive lenses can cause side effects like halos and glare. For example, when you look at a light source, you might see a halo around it. The changes you see in the image here illustrate what that looks like. This happens more at the beginning, right after surgery. Our brain learns to suppress these halos. This tends to

12:21 improve over time. We experience neuro adaptation, but for that we depend on having perfect ocular health. That's why from time to time we don't recommend defractive lenses when the patient has a more serious condition. If there are no contraindications, the patient might experience light and glare at some point, but it's usually a temporary effect. Another important detail, these defractive lenses work better in a bright environment with plenty of light. Because they split the light, the light energy that passes through the lens, part of it focuses in one place and another part focuses elsewhere. So the effect in a darker room in dim light is not the same as when the environment is well lit. So notice that all the lens options I present to you have some advantages and disadvantages. None of them have the same quality as our

13:07 natural lens when we are young. But there are patients who prefer to prioritize quality of light. And independence from glasses even if it means sacrificing a bit of visual quality. Of course, it's not the same visual quality, for example, for distance as a monop focal lens, but it provides excellent distance vision and gives you more independence from glasses. Bif focal lenses still have their place, especially when we want to combine technologies. Sometimes we put a lens from a certain brand or type in one eye and based on the result in that eye, we notice that the vision turned out well. For example, for distance and for intermediate distances, but it's not so good for near vision. We can then choose to put a bif focal lens in the other eye aiming to improve the person's near vision as well. I think that's currently the main scenario where it's indicated.

13:54 But I'll show you the other options for you to understand. The third option I'm going to show you is also a defractive lens. Take a look in this video at the rings of defractive lenses I mentioned as an example for you. So it also requires perfect ocular health, a good surface, and a healthy retina. This lens I'm going to talk about now also splits light and it works better in a well-lit environment than in a dark one. It can also cause halo effects and glare just like I mentioned with the bif focal. But tri focal lenses for those who have no contraindications are very good. They're excellent for those seeking independence from glasses. This lens provides good distance vision for driving, going to the movies or theater. It gives excellent intermediate vision and also at a distance for cooking, for reading

14:40 sheet music and it also provides excellent near vision which is for reading your phone, a book, a magazine or for sewing. So it's called tri focal because it gives excellent vision at these three distances. Then of course it also requires some care on our part to choose the right case to see if the person's eye health allows them to have a tri focal lens. It may be the most expensive option among all intraocular lenses, but even though it's the most expensive option, it's not the best option for everyone, you know. So, sometimes your doctor might not even have offered it to you, especially if you have any condition, for example, an epetinal membrane, macular degeneration, diabetic retinopathy, or very severe dry eye. Why? because you would be investing a lot of money in a lens and could end

15:27 up with poor visual results or at least not get the benefit that this lens is supposed to provide if your eye were completely normal though. But for those who can invest and have no contraindications and have normal visual function, it's a spectacular lens. And now let me talk about two options that I really like and that have changed my recommendations recently. Since I am a retina specialist and I follow many patients who could not have a defractive lens such as a bif focal or tri focal lens, but who would also like options to maintain more independence from glasses or to improve their quality of life? First, I'm going to talk about the advanced monopocal lens or monopocal plus. These lenses, they don't have rings. They're not defractive. They don't have those rings that cause halos,

16:12 glare. Look at their design here. They're practically the same as a monop focal lens, but in the center of this lens, there's a small adjustment, a technology that gives it excellent intermediate vision without affecting distance vision. So, take a look at that graph. The blue line is the bif focal, which I showed earlier. The purple line is the triocal, which provides good vision at all three distances, far, intermediate, and near. And look at this green line, which is the monopocal plus. See how it gives good distance vision. It doesn't provide good near vision. I mean, an excellent near vision, but it really helps with intermediate vision. You can see on the graph that it's even above the other two there. So, it's good for driving. It's good for cooking, for using the computer. It doesn't cause those halo

16:58 and glare phenomena, but it's not 100% for tiny print like the small print on medication leaflets. But look at what we do here as well. When we operate on the first eye and we manage to achieve exactly the result we wanted, we get good distance vision in the first eye and for intermediate vision the patient is happy with that result. We corrected the aigmatism, implanted an advanced monopocal toric lens was corrected perfectly. We can input the data into this calculator and correct the other eye adjusting the vision a bit to improve near vision. So we do this and create a mini mono vision. That's exactly what it's called. We call it mini because the amount of myopia we leave in this eye with the advanced mon focal lens is smaller than the amount of myopia we used to leave in mono vision when we used a standard mon focal lens.

17:45 So with the advanced monop focal lens sometimes we leave the first eye as close to zero as possible. In the second eye we leave it there 0.75 one diopter of myopia and this will provide good vision excellent vision both for distance and intermediate and often vision that allows the person to be free from glasses for near as well. We never promise that you'll be completely free from glasses because vision is something very personal. It may be that the person is able to read there in the office, but even so, they might feel the need for a little correction for a certain activity they do. So, they might need glasses for near vision after surgery. But the vast majority of patients do well with this option both for distance intermediate and with this near adjustment, they do very well too. And the great thing about the monopocal plus and that's why I've

18:31 been implanting it a lot in patients I follow for retina issues is that the indications are much more straightforward. We can use it in cases of mild retinal changes. Sometimes in patients who have dry form of macular degeneration or a mild epetininal membrane or diabetic retinopathy that doesn't cause significant changes. We can safely use this lens and achieve a good result. The last option I want to talk to you about is the EDOF IOL, which are the extended depth of focus lenses. These lenses were developed to provide good vision for both distance and intermediate ranges. Depending on the brand of EDOF, it can be defractive and have those rings. Or currently, more recently on the market, we have an option for a EDOF lens that is not defractive. And that's nice because it

19:17 doesn't cause halo or glare phenomena. It doesn't have all those problems of the defractive ones and at the same time it provides excellent distance vision, excellent intermediate vision and also delivers a lot of near vision. So it's an excellent lens. We are able to recommend it in many cases where we previously wouldn't have recommended a defractive lens and achieve excellent results making the person much more independent from glasses than before. So I hope that with this video I've managed to clear up most of your questions. My name is Philipe Lucato. If I can help with anything else, answering your questions either in the office or right here on the channel, you can leave your comments here and as much as possible. Of course, there are details I can't know without having examined the person. I won't be able to answer everything, but whatever questions I can help with,

20:04 general, leave your comment here. Also, follow the doctor on Instagram. And I'm always talking to you here about relevant and interesting things about cataract surgery and also about retinal surgery. I strongly believe that information is part of your treatment. When you go into surgery knowing better what you have, what your options are, and what the limitations of the procedures are, that's when it already starts. The surgery is already starting to go well, even before it even begins. So, a hug to everyone. I hope you enjoyed it and see you soon.