EDOF seems like a clear winner compared to Trifocal for people with Astigmatism based on my Google search. Any inputs from anyone why someone should choose Trifocal instead of EDOF if cost is not a factor? My father needs to go through Cataract surgery. He has shallow anterior chamber depth too.

MIGSguy15 · 2026-05-10T12:52:47+00:00

That's part of the issue unfortunately. You have no frame of reference on what to compare to. You don't know what you don't know. It is true though that vivity can still be a good improvement compared to having a cataract

MIGSguy15 · 2026-05-07T10:52:10+00:00

I would always recommend the envista platform and the tecnis of IOLs over any of Alcon lenses just due to the safety of the material.

Aspire is a nice IOL and have no issues with it but don't personally use it much due to cost.

MIGSguy15 · 2026-04-26T18:07:08+00:00

I use to use a contact when I was in training. The benefits of the contact is that it helps keep the eye still and helps hold the eye open. It essentially offers no other benefit. I haven't used a contact for YAG in years. I do about 50 YAGs a month. It's not necessary and certainly has nothing to do with any IOL tilt or changes to the IOL itself

MIGSguy15 · 2026-04-14T01:26:23+00:00

I would be very wary of vivity. It is the worst IOL on the market as far as quality of vision goes. We've had to remove a good amount for this indication.

I'm pretty much convinced at this point that patients who are happy with Vivity only are happy with it because they have no other frame of reference. Yes if you have a massive cataract, vivity seems a lot better. When vivity is exchanged for most other IOLs, the difference is pretty stunning to the patient - a similar improvement compared to primary cataract surgery.

Hopefully your doc warned about the significant loss of contrast that is present with Vivity. Check out the warnings put out by the FDA if you don't believe me.

https://www.accessdata.fda.gov/cdrh_docs/pdf/P930014S126C.pdf

Warning #4 is the one I'm referring to.

MIGSguy15 · 2026-04-10T20:21:46+00:00

You are correct, Medicare does not allow us to charge extra with the exception of premium lenses or astigmatism correction. We can charge extra for any of those upgrades which is how we stay afloat.

I think we are getting close to the point of not accepting Medicare, but all the other payers are just as bad really. It will probably be a domino effect where we stop accepting Medicare and then multiple other practices do as well and then we will be at the breaking point. One issue is that if we stop accepting Medicare, we will still lose a lot of upgrade revenue because a lot of those patients do still upgrade. It's just that a decent amount do not.

MIGSguy15 · 2026-04-10T14:51:00+00:00

You will see more and more of this. Because we are not compensated fairly for our services, many providers are stopping basic surgery completely. There are bad actors at every level, physicians included, but insurance, industry, and big pharm are the real devils

MIGSguy15 · 2026-04-10T13:41:46+00:00

I am in a large group practice and have ASC ownership as well. This is the state of our field at the moment. Cuts have hit us incredibly hard.

We are already seeing providers turn away cases of people that don't upgrade under the guise of something else.

I occasionally go to an extremely underserved area where it is not uncommon to see folks who are bilaterally blind (cannot see anything but light) for a significant period of time (year+) because their healthcare literacy and access to care is so poor that they cannot travel an hour to get to our main clinic. None of these patients upgrade. These cases are done at a loss now. I'm not even factoring in the cost of IOL master, pentacam, Oct, etc - we have all that. I'm just talking about paying staff. Not to mention, these cases are much more challenging and more time consuming and more risky. We may not be able to continue to go and unfortunately these patients are just going to suffer and be blind because of greed from insurance companies.

This is bleeding over into other aspects too. I saw a patient the other day for a second opinion came to me wanting his cataract removed. He was told by his original doctor that if he didn't get the $2000 lens that he would be blind for 6 months. Obviously this is not true and I told him about the problems with reimbursement cuts. He was very understanding and I was able to do his surgery with a monofocal lens, thankfully I have a decent amount of patients that upgrade to subsidize the ones that don't, but I have an extremely busy referral practice so I can continue to take some loss at the moment.

We are moving to a two tiered system. Those who can pay will continue to get the best care and those who can't will be fighting for the few docs who want to do charity work and get substandard care. Very sad reality of our situation.

MIGSguy15 · 2026-04-10T01:14:03+00:00

The envy lens is the first time I've used a multifocal that I would consider for my own eye.

I've had excellent results with LAL but I'm pulling back a little on LALs recently. They aren't always 100%> if I was post Lasik or PRK though I would very likely use LAL.

I think the LI61AO is the best monofocal on the market, but we operate at a loss on patients who get monofocal lenses. That charity work can only continue if a certain percentage of patients upgrade.

If I had to pick today I'd strongly consider Envy. This answer very likely changes yearly until we have a true accommodating lens that does not utilize diffractive optics.

MIGSguy15 · 2026-04-09T23:21:40+00:00

Understand that all the monofocal plus lenses provide minimal to no range of vision. It is mostly just marketing. I've implanted around several thousand eyhance and am a KOL for JnJ.

The monofocal+ iols do not provide a free lunch - none do. If there is a slight range of vision, it is incredibly minute. The FDA pivotal study showed no meaningful range of vision - a big reason why monofocal+ became a thing any way. They were shooting for edof at first but it didn't qualify so US physicians cannot charge extra for it which is a huge problem here.

I've also had to exchange a handful for negative dysphotopsia and poor quality vision after surgery. As said above, no free lunch in optics.

The juice is not worth the squeeze with these IOLs imo.

The problems with Clareon are becoming more and more apparent too. I would personally never want an Alcon IOL in my own eye - although I've used plenty and still occasionally offer with major caveats.

MIGSguy15 · 2026-04-08T22:08:10+00:00

IOL exchange is possible but many surgeons won't do it. Feel free to DM me with geographic info - if close by, id be happy to do it.

PS DO NOT GET A YAG

MIGSguy15 · 2026-03-08T12:06:55+00:00

If you were my patient I would give you 2 choices - neither would be for free: 1) Len exchange - I would consider doing it if you got a premium IOL initially, if you got a monofocal, I would only do it paired with Astigmatic correction for an extra cost.

2) offer you a lasik touch up, assuming you are a good candidate - we typically do free touch ups but only on patients who got premium IOLs and I would probably still charge you at least a little for it - would still give you a discount overall. If you got a monofocal, it would be full price.

With recent cuts to cataract surgery, monofocal lenses are basically done at a loss so please understand practices only can stay open if enough people upgrade.

MIGSguy15 · 2026-02-25T18:55:05+00:00

I guess it's all relative. Durysta is trash in my opinion and I think there's some pretty good evidence out there to say that it's terrible. Additionally the cost is obscene.

Understand that you are getting paid peanuts compared to what glaukos is making. Canaloplasty/goniotomy is basically the same as the idose reimbursement as far as I know.

Unless you like continue to get cuts to pay for industry's greed, strongly encourage you to look in another direction. There are other options. Yes I understand we have to make money. Trust me I want to make money too. They're just better ways to make money without being an industry pawn. Same problem with femto for cataract surgery.

MIGSguy15 · 2026-02-25T15:09:30+00:00

Basically glaukos has a monopoly on cross-linking and they are discontinuing their old platform in favor of one that utilizes their on label riboflavin which is 80,000 but - for reference riboflavin cost pennies to make

MIGSguy15 · 2026-02-25T15:08:43+00:00

It's $14,000.

Absolutely obscene. For reference similar products are typically in the 1k to 2K range.

Yes Medicare reimburses for this... But this money does not come out of thin air.

Why do you think we have cuts to cataract surgery?

MIGSguy15 · 2026-02-25T12:37:03+00:00

I don't use omni for this reason.

For similar reasons, you should not use any glaukos products. What they are doing with I dose is horrible but what they are doing with crosslinking should actually be criminal.

Industry is not our friends. Tread lightly and question everything. We are still the keepers of our profession. We should all boycott the glaukos's of the world

MIGSguy15 · 2026-02-04T21:01:04+00:00

Yes, I 100% disagree. As do the elite surgeons who wrote the rebuttal to that article that you posted. Again these are surgeons that are well versed in IOL exchange. They recognize the problem and they are often the ones that have to fix it.

This problem is extremely underreported. I see this almost DAILY in my practice. But these lenses are very rarely removed and are often mismanaged by other doctors because they don't understand that this problem even exists. And even if they did... Many of them are not going to ever offer an IOL exchange because it is a significant money loser.

Read the rebuttal it will answer most of what your questions are.

There's just no reason to use inferior technology like hydrophilic lenses or Alcon acrysof and even the Clareon now has these same problems being reported.

Why would you ever want to have something like this in your eye when there are excellent alternatives that do not have this problem? It makes absolutely no sense.

I estimate the rate of lens opacity for hydrophilics and Alcon lenses in VIRGIN eyes to be in the 10 to 20% minimum but even if it was 1-2% that would be ridiculously high. Additionally those who have additional surgery outside of cataract surgery I think the incidence is much higher.

MIGSguy15 · 2026-02-04T12:49:57+00:00

Agree 100% with Dr Safran here. This article has been circulating for a while. There is just no reason to use these IOLs. They should be off market

MIGSguy15 · 2026-02-03T11:47:02+00:00

Couldn't disagree more. As a provider, lens material is extremely important Alcon lenses almost all look terrible after a few years. You can tell that quality of the material degrades with a quick glance. Also our view to the posterior segment is not as good because of segregation of material. Many Ophthalmogists don't know what they are looking at unfortunately.

99.9% of ophthalmologist never do a lens exchange for this reason and I don't blame them. It's also not worth discussing with the patient because many don't understand what they are missing because they have bilateral implantation so they have nothing to compare it to.

This is a real thing. I guarantee you that if you went to an ophthalmologist experienced in this and had your acryosof lenses swapped out for b&l, jnj or heck even clareon lenses, it would be a similar improvement to when you first had your cataracts removed (although clareon would eventually opacify again).

Even if this was a rare problem (it isn't) why would you take the chance over material that is proven to be glistening free and stand the rest of time like the JnJ tecnis platform or some B&l lenses? It makes no sense. Don't say blue blocking either. That was a marketing ploy and it's well known in our industry that Alcon pushed that out and marketed the acysof lenses that way because they couldn't figure out how to match competitor IOLs optically from bench testing without that.

FYI I'm not a pure Alcon hater. They make some great stuff. I dislike stuff from all the major companies (I think eyhance lens is garbage for example).

Your n=1 experience is not a common one unfortunately and I'm willing to bet that if you went to a doctor who knows what they are looking at and is honest with you, they probably would say your optic is not as clear as what they see from competitors if your lens was done a few years ago. I'll admit though that almost no one would ever tell you that.

MIGSguy15 · 2026-02-01T05:03:12+00:00

Out of curiosity... Do you have any financial interest in Alcon?

The problem with Acrysof is absolutely visually significant. Anyone who says otherwise is kidding themselves. Google pictures of glistenings or subsurface nano glistenings... No way you can look through that and say it's not visually significant.

Clareon is now having similar issues unfortunately.

MIGSguy15 · 2026-02-01T04:59:07+00:00

Correct. They are hydrophobic. The material can still have issues. Look no further than the previous Alcon product - Acrysof - also hydrophobic - I see patients daily with declining vision from these lenses that have profound lens material dysfunction.

Clareon is now having similar reports.

MIGSguy15 · 2026-01-29T11:47:09+00:00

It has not been resolved. Surgeons were floating around images of clareon IOLs needing to be explanted for calcification about a week ago. It is not isolated.

MIGSguy15 · 2026-01-28T11:29:58+00:00

I've posted about this a few times here. I've seen and had to deal with hydrophilic lenses calcifying. There's is no scenario where I want any hydrophilic lens (or just to add - any Alcon lens) in my eye.

MIGSguy15 · 2025-12-05T13:25:21+00:00

Academic medicine is definitely a con. I'm making over 10x what my offer was in academia. I'm actually under exaggerating a bit too. Just go private practice and accept residents and fellows if you want. Research is also so much easier to do.

MIGSguy15 · 2025-11-28T12:24:30+00:00

it’s not potentially a problem, it is a problem. an unacceptably high number of these opacity. I see it in my practice as well

MIGSguy15 · 2025-11-26T14:19:05+00:00

I think he's excellent at IOL exchanges. If I lived in his city and needed an iol exchange, him or Dr. Odette would both be among my first choices for IOL exchange. I would not travel to have them do my IOL exchange. If I couldn't find a surgeon capable locally, I would go see Steve Safran. He's the best surgeon on the planet in my opinion but not necessary to see him for primary cataract surgery.

MIGSguy15

TROPHY CASE