Experience with Eyhance, Rayner EMV, Vivity?

thank you. did both of you use eyhance? not sure how i feel about mini monovision since i have not tried it. i wear progressive eyeglasses now but take it off when i read or on the computer. wonder how i'll feel about needing glasses for intermediate or can i get distance and intermediate with eyhance? also if you are in the US, did you find it hard to find a doctor that offers it?

Both my wife and I have Eyhance IOLs.

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Regarding mini-monovision, while I'm a strong proponent I strongly encourage anyone considering it to trial it twice with contacts: once with contacts in both eyes before the first surgery; again with a contact in the unoperated eye between surgeries. That said, a 0.50 or 0.75 D refractive difference between the eyes, that is, micro-monovision, most likely safe for most everyone.

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Like you, I wore progressive lenses for many years. I was myopic enough that without my glasses I couldn't see my computer monitor or read printed matter without holding it very close to my eyes. For computer work and reading I wore Shamir Workspace lenses, a modified form of progressive lenses with wider intermediate and near zones and a small, but for me very effective, distance zone at the top. Hoya and Zeiss, among others, make similar lenses.

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My wife has both distance and intermediate with her Eyhance IOLs at -0.50 D. As has been said, however, we are each unique. That said, defocus curves can be useful in indicating mean results at different focal distances, recognizing that visual acuities make up a normal distribution so that one should regard reported results suggestive and that you could end up with better or worse vision than the curves, which graph the mean results.

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Looking at the average of defocus curves from four studies I found online that show binocular results, the mean binocular visual acuities at distance and intermediate (66.67 cm / 26.25") are:

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0.0 refraction: distance, 20/19; intermediate, 20/28

-0.25 D refraction: distance, 20/21, intermediate, 20/25

-0.50 D refraction: distance, 20/22, intermediate, 20/23

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I'm in eastern Massachusetts. Without any difficulty, I found three surgeons who implant the Eyhance IOL. Of these, the surgeon with whom I've ended up uses it preferentially as his monofocal lens; another had started using and recommending it within the preceding six months or so; and a third used it but not preferentially (he was pushing the Light Adjustable. Bear in mind that many surgeons have relationships with, or at least strong preferences for, particular companies. Someone with ties to Alcon may not even offer the Eyhance, just as someone with ties to Johnson & Johnson, which makes the Eyhance, may not offer the Vivity.

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If the particular IOL to be implanted in your eyes matters to you, I strongly suggest using a surgeon with considerable experience with that IOL. The primary reason is that the IOL power calculation formulas require both biometric data and what's called an "a constant." While each manufacturer recommends a constants for its lenses, best practice is for each surgeon to personalize the a constant for each IOL in light of their patients' results. Obviously, the more surgeries a surgeon does with a particular IOl the more data they have with which to personalize their a constant. For example, Johnson & Johnson recommends an Eyhance a constant of 119.3 for use with the Barrett Universal II formula (widely considered one of the best); my surgeon's personalized a constant is 119.4. (Ask, they should tell you, and then with your biometric data, which they also should give you, you can do your own power calculations online.)

thank you for the extensive reply. sounds like you did extensive research. how did you get comfortable with using eyhance given that it is relatively new? how long has your wife had her eyhance and did she experience any side effects? did both if you choose distance as target?

Let me take your questions in order. First, I got comfortable with the Eyhance IOL for several reasons including its substantial similarity to the well-established Johnson & Johnson Tecnis 1 monofocal IOL; prior use outside the United States and peer-reviewed studies based on that usage; endorsement by the first surgeon my wife and I saw (with whom she stayed), who described himself as being neither the first nor the last to adopt new technologies; and its preferential use as a monofocal by the surgeon with whom I ended up.

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My wife had her eyes done in late December and early January of 2022/2023. She was comfortable relying on the surgeon's recommendation after rejecting multifocal IOLs and the Vivity because she did not want to risk negative side effects and was willing to wear readers for close-in reading.

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She has not experienced any side effects.

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My wife accepted her surgeon's targeting recommendation of -0.50 D on the basis that these targets promised first class vision from distance through intermediate (computer), which in fact is what she has. IIRC, her distance vision is 20/25, which she experiences as excellent, not needing glasses to drive at night or in bad weather. She's also very comfortable working for long stretches at her MacBook Air laptop. But she does need readers for reading at near.

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I have not chosen to target distance, a preference formed before meeting with my eventual surgeon. After having biometric measurements taken and discussing what I find important in living in the world visually, my surgeon recommended targeting my first, nondominant eye anywhere from c. -2.00 D to -2.50 D. I should learn tomorrow, five weeks after that surgery, where it's settled. This information will help decide the particular target for the (more distance-oriented, but not plano) dominant second eye.

what does -2.00 D mean?

Let's start with the basics, and please forgive me to the extent that I cover ground with which you're already familiar.

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Diopter, or "D", is a unit of measurement for the optical power of a lens, defined as the reciprocal of the focal length in meters. So, a -2.00 D lens has a focal length of 1/2 meter.

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What's important to us either as eyeglasses wearers or in thinking about what power intraocular lenses to get is that diopters measure the degree to which an eye's focusing ability departs from normal. This difference is the refractive error. The most common refractive errors are myopia (nearsightedness), hyperopia (farsightedness), and astigmatism. If, as I do, one has myopia, light rays entering the eye are focused in front of the retina instead of on the retina, resulting in distant objects appearing blurry. If you are myopic and look at your prescription from an optometrist, the minus sign indicates myopia and the number is the amount of myopia. Similarly for hyperopia, except with a plus sign. Having astigmatism means the the light rays do not focus on a single point, resulting in blurry vision for both far and near objects.

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Ignoring astigmatism for the time being, to target -2.00 D means to aim for a refractive error of -2.00 D, which is somewhat myopic. All else being equal, if the target is reached exactly, one can expect very good near and intermediate vision. From defocus curves for particular IOLs we can get more information regarding the quality of vision (visual acuities) likely to result from different IOLs and particular refractive errors.

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Defocus curves graph the visual acuities measured for a particular IOL at different refractive targets (or focal lengths). Generally, they are centered on 0.0 D, that is, no refractive error, with minus refractions to the right and positives to the left. One can shift a curve to the right, for example, to see what the curve would look like with a different refractive error. So, if one shifts the curve 2 diopters to the right, one then has a defocus curve for a refractive error of -2.00 D.

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In my own research in deciding what IOL to choose and what refractive errors to target, I found on the web a number of defocus curves from peer-reviewed studies involving the Eyhance IOL. These curves actually graph the mean average visual acuities (and sometimes also show the range encompassing one standard deviation in either direction). (While it would be nice also to know the median visual acuities, none of the defocus curves I found provide that information.)

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Because studies generally involve a limited number of eyes and I don't begin to know enough to evaluate the quality of individual studies, I decided to adopt a "Nate Silver" approach to the curve by aggregating the visual acuities at each refractive point and then dividing by the number of studies. If you will, this gave me an average of the average refractive results / visual acuities.

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Looking at the average of the Eyhance defocus curves at a -2.00 D refractive result, here are some of the average mean visual acuities I calculated:

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1m (39.37"): 20/30

66.67cm (26.25"): 20/26

50cm (19.69"): 20/21

40cm (15.75"): 20/22

33.33cm (12.12"): 20/25

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Please bear in mind that even if the surgeon hits the refractive target exactly, there's no guarantee that any particular patient will have these visual acuities. At each distance, the numbers show the average of numbers that are themselves the mean average of each particular study. What we can say is that the likelihood is that a patient's results will be within one standard deviation. That said, I think this information useful in indicating the range of likely visual acuities for a particlar IOL at different refractive targets.

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You'll probably have noticed that mean visual acuities for intermediate vision, from c. 20" (c. 50cm) to c. 40" (c. 1m), range from 20/21 to 20/30. If you want indicatively better results with the Eyhance at 40" then you either need to target closer to 1m (-1.00 D) or, as I did, opt for mini- or micro-monovision. Subject to tomorrow's eye exam for my operated eye, the target next week for my second eye is likely to be c. -0.75 D to -1.00 D. For simplicity, let's say -1.00 D and assume that my surgeon hits it exactly. Here are some of the average mean visual acuities in that case:

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66.67cm (26.25"): 20/22

80cm (31.5"): 20/21

1m (39.37"): 20/21

2m (6.6'): 20/25

distance: 20/32

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As stated, there are no guarantees as to a surgeon precisely hitting the targets or of the visual acuities one gets if the targets are hit precisely. What I can say in my case is that, when examined the day after surgery on my first eye, in that eye I read J1 (the equivalent of 20/20) at near and was 20/60 at distance. For me, in the real world, that's just fine. So, if my target achieves analogous results by targeting -0.75D to -1.00 D in my second eye, I expect / hope to be a happy camper.

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A concluding note on astigmatism. Depending on the IOL being used, if your astigmatism is about a certain level your surgeon is likely to recommend correcting it with a (more expensive ) toric lens. Whatever you choose, to use the defocus curves you need to combine 1/2 the predicted post-operative (residual) astigmatism and the targeted refractive error to get what's called the spherical equivalent and then use that result. For example, if the target is -1.00 D and the predicted residual astigmatism is 1 cylinder (how astigmatism is measured), the spherical equivalent is -1.50 D. In looking at defocus curves for a particular IOL targeted at -1.00 D you'd want to look at results for -1.50 D rather than the target.

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I hope this helps.

thank you for taking the time to explain. much appreciated. everyone here is very helpful.

RebDovid,

I'd love your thoughts on what might be best for me. I'm 73, very myopic, with lots of corneal astigmatism (-8.25 cyl -3 sphere right, -2.25 cyl -5 sphere left).

99% of the time I wear glasses that are 0.75 D undercorrected, which gives me my best vision for using the computer (26 to 30 inches distance) and adequate for driving, using the smartphone and TV watching. When I need to read really tiny print or examine something small really closely in my workshop, I use the left eye with no glasses (-5.0 sphere, -2.25 cyl). I'm still working (self employed), and use the computer a lot and do precision metal work that requires accurate near vision.

I have reading glasses that are 2 D undercorrected , which are best for 17-inch distance. I rarely use them. They don't work for seeing the computer screen, for me. They are only good for reading a book or magazine.

I've probably seen at least one of the same eye docs you have, since I too am in eastern MA and I sought out what I believe to be the only practice in the area that has the LAL, as far as I know and another that will soon have it (or maybe does by now,; that was months ago). Interestingly, however, they both recommended Eyhance rather than the LAL.

One can't get high enough cyl in an IOL in this country to fully correct the right eye, or even half correct it. So, I have made a tentative plan to have the right eye done in Toronto with a Zeiss monofocal that has enough toricity.

Another option, however, that I would like to entertain in this post with you would be to just accept that the right eye will always need glasses for the astigmatism correction, and get the Eyhance for both eyes anyway.

I don't mind wearing glasses, but I want it to be just one pair of glasses that I wear 99% of the time and that gives me good intermediate vision and decent distance vision. So the trick is to get all three distance ranges (far, intermediate and near) with only two ways of seeing (with glasses and without). I don't want progressives, bifocals or mini monovision. I wore progressives for 20+ years and am very glad to have discovered that 0.75 undercorrection eliminates my need for them. They really didn't work well for me. I tried mini monovision with scleral contacts and it was okay, but I didn't like it.

So let's say I get toric Eyhance in both eyes targeting -2. That would give me good near and very-near vision in the left without glassses and probably good enough near vision in the right without glasses to eliminate the urge to close the right eye. (With my present vision, I reflexively close the right eye when I take my glasses off to see very near, because the extreme astigmatism of the right is too distracting. It would be nice to have at least a little bit of binocular near vision without glasses).

The glasses could target -0.5 and, because of the EDOF of Eyhance, that should give me good intermediate, pretty good distance, and some near.

I wouldn't have to do my surgery in Canada and I would get the EDOF benefits of Eyhance in both eyes instead of just one. The toric Eyhance would take care of all of the astigmatism in the left and about a third of it in the right. The glasses would do the rest. What do you think?

The docs say my cataracts look bad to them, but with glasses I can still get to about 20-30 and night driving is not a problem, so I'm in no hurry for surgery.

Please take these thoughts as tentative. First, however, the ophthalmologist I saw who pushed the LAL was Dr. Samir Melki in Brookline. Based on the referring ophthalmologist and limited research, I'm sure he's quite competent. But I found him brusque and somewhat peremptory regarding both the IOL he wanted to use--the LAL- and his target--0.0 D. I left feeling that were I willing to place myself entirely in his hands I'd get a technically proficient result but not necessarily one that matched my own preferences, and that he wasn't willing to put in the time to explore my preferences and either explain why I should go along with what he wanted or adjust his own recommendation in light of my preferences.

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Regarding your situation, on the one hand you mention wanting good intermediate vision and decent distance vision. On the other hand, you discuss targeting both eyes for -2.00 D. Also, you're willing to wear one pair of single vision glasses (you said not progressives or bifocals). And unless you go to Canada for the higher cylinder correcting Zeiss IOL, you're interested in the Eyhance IOL.

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On this basis, I suggest two approaches for consideration by you and your surgeon. One, which you've presented, is to target -2.00 D on a spherical equivalent basis in both eyes. Assuming your surgeon hits the target, you should expect to need glasses to drive. For intermediate and near vision, based on averaging defocus curves I've found online for the non-toric version of the Eyhance, the mean visual acuities are 20/25 at 31.25", 20/19 at 19.69"; and 20/25 at 12.11". Of course, these are mean averages and your actual results could be better or worse. But if I understand your priorities correctly, it seems a very reasonable approach. You'd then need single vision glasses for distance. (I don't know how such glasses would affect your ability to see the dashboard of your car. You might want to look into eyeglass lenses such as the Shamir Relax and Essilor Eyezen. They come with a small amount of add in their lower area. If this doesn't take you into uncomfortable progressive lens territory, it might help with seeing the dashboard.)

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The alternative would be to aim for intermediate and distance without glasses and use readers for near vision. With this approach, you could target -0.75 D, for which the mean visual acuities are 20/25 at both distance and 19.69"; 20/35 at 14.31"; and 20/43 at 12.11".

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With either approach, my concern would be the uncorrected astigmatism in your right eye. Have you and your surgeon considered limbal relaxing incisions? My general understanding is that they are most effective at correcting low to moderate levels of astigmatism and that they can be combined with toric IOLs. With the maximum correcting Eyahnce toric IOL of 6.00 D, it looks like you'd have 2.25 cyl. of uncorrected astigmatism. If all or most of that can be corrected with LRIs, then you're good to go.

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If without going to Canada for the Zeiss IOL your right eye astigmatism can't be corrected beyond the maximum toric Eyhance correction of 6.00 D, I've no idea how disconcerting you would find 2.25 cyl of uncorrected astigmatism. Unless you have good reason to be confident it wouldn't be a problem for you, I give Canada renewed consideration

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Good luck.

Thanks. A few points:

1. 99% of the time I will wear glasses, regardless. So, if I target -2, I am not going to see distance poorly, because 99% of the time I will have glasses on. And I won't have trouble driving and seeing the dashboard because the Eyhance has EDOF and the glasses will have shifted the defocus curve up to include distance and intermediate. The reason to target -2 is so I can also have near and very near just by taking the glasses off. My proposed strategy is to get Eyhance for the sake of EDOF and to shift my defocus curve in and out by wearing or not wearing my one pair of monofocal distance/intermediate glasses. I don't want readers and I don't want progressives or bifocals.

2. Cylinder at the IOL plane is not equal to cylinder at the corneal plane. -6 at the IOL plane corrects only -4 at the Corneal plane. So I can expect a -6 cyl Enhance to bring my -8.25 at the corneal plane astigmatism down to about -4 at the corneal (or spectacle) plane. But 99% of the time I will have on my -4 cyl glasses so for distance and intermediate the residual astigmatism will not be fully corrected. The trade-off is that for near and very near I will have astigmatism in my right eye vision because that's when I won't be wearing glasses. I am thinking that I am willing to make that trade-off in order to get the EDOF of the Eyhance. Remember, Eyhance has the same desirable defocus curve shape through spectacles as it does without spectacles, just shifted.

Typo: I meant to say the residual astigmatism WILL be fully corrected. That "not" should not be in there!

Why do those two practices recommend the Eyhance over the LAL? this is very important to me. Thank you.

You make a cogent case for your approach, which might have been mine had I not chosen mini-monovision. Indeed, it's possible we'll end up in very similar places.

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My first eye, done in late June, already enables me to read comfortably books, magazine, my cellphone,etc. in the "near" zone and to work comfortably with text on my desktop computer monitor. At distance, it was last measured as 20/60, which obviously isn't good enough to drive, watch movies or television, etc., but is quite comfortable about the house and the neighborhood before I put a distance-correcting lens in my unoperated eye.

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My second eye, to be done this Tuesday, is the unknown. While targeting c. -1.00 should cover and reinforce my intermediate vision, in the nature of things I can't know whether it will give me good enough distance vision to drive legally and, if so, to be comfortable driving at least in daylight and good weather. If not, then, like you, I'll be content to wear glasses for driving as well as movies, etc., but wouldn't expect to need glasses otherwise.

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One more point, we started with the eye with the more myopic target because if hadn't produced the intermediate and near vision I wanted we would have had a second chance with the second eye. Because it takes time for an eye to "settle", this can be a reason to separate the operations by at least six weeks even if mini-monovision isn't on the agenda.

thank you. how is your near and intermediate distance with monofocal? do you use progressives but take it off for distance? did you get monovision?

Aspen

I didn't go with monovision. I asked my cataract surgeon to target intermediate vision for both eyes, and the result surprised me and her.

My distant and intermediate vision are excellent. I use readers for sustained close reading. On rare occasions, if I am driving on a country road late at night, I will use Rx eyeglasses for distant vision. I have had no halos, glares or any other unwanted visual phenomena.

thanks for taking the time to reply. why did you target intermediate? i'm confused what to target. i am nearsighted so i dont use glasses for the computer or my phone but wear glasses all day for everything else. if i target intermediate, will i have 2 glasses - one for walking and driving, one for reading?

"No two eyes are the same, and results with same lens and even with the same surgeon may vary from person to person."

If there is one thing I have learnt on this journey, it's this ^. There are many who love their Vivity lenses, but more me they're intolerable.

Lense choice really is a bit of a gamble. I think the safest choice is probably the proven monofocal lense.

Aspen88 -- You ask "If I target intermediate will I have 2 glasses -- one for walking and driving and one for reading?"

Short answer: No. Reading glasses alone would be sufficient if you get average results. But eyes vary. You may have sharp vision at a greater-than-average range of distances or a less-than-average range of distances due to pecularities of you corneas and other factors.

Longer answer:

If you target intermediate with a monofocal and get average results, you should be 20/32 for distance which is good enough to pass a drivers license test anywhere and is really fine for driving. But for best distance you would need glasses. However, without glasses you'll see the dashboard better (unless the glasses are multifocal) so you might prefer no glasses.

Your best vision would be around 3 feet (how long are your arms?) , vision at 26" should still be good and it would be borderline at 20". At 16" (which is about where I like to have a book or smartphone), vision would be like 20/50 and that's not very good, so for extended reading you would want reading glasses.

If you target intermediate (-1.0) with Eyhance and get average results, you will have the same 20/32 at distance but better results for reading than with a monofocal. You would have quite good vision down to 16" and acceptable acuity at 13".

Very Long answer:

Here is how I get the above results:

I googled (without quotes) "defocus curve for Eyhance" and chose the hit that came up on ResearchGate.net for Tecnis Eyhance vs. Tecnis Monofocal. Then I re-labelled the X and Y axis in scales that are easier for me to understand: The Y axis is scaled in logMAR but I relabelled that in 20/20, 20/30, 20/40 terms using the chart in Wikipedia that converts logmar to that more familiar scale. Then I drew a heavy black horizontal line at logMar .30 (20/40) to remind myself that above that level is decent acuity and below that line is fuzzy acuity.

I relabelled the horizontal axis in feet and inches, using the formula that distance in meters = 1/diopters and 1 meter is about 39 inches. So, 0.0 diopters is infinity. 0.5 diopters is 78 inches (6 1/2 feet). You can ignore the signs -- they don't matter for this exercise and we are mostly interesting in the part of the horizontal scale with negative numbers. Continuing with the re-labelling, -1 diopter is -39", -1.5 is 26", -2.0 is 20", -2.5 is 16", and continuing beyond the reach of that diagram, -3.0 would be 13" and -3.5 would be 11".

To better understand what I was looking at, I googled (without quotes) "how to interpret a defocus curve" and chose the hit from MillennialEye.com called "Understanding the Defocus Curve."

Here's how to use the defocus curve diagram for the Eyhance and Monofocal: Pick a distance on the horizontal scale and go up to the graph for either the monofocal or the Eyhance. When you hit the graph line, go over the left and read the vertical scale to find out how good your vision will be at that distance IF YOU TARGET DISTANCE and you get average results.

Now create a NEW labelling of the horizontal scale that is shifted one unit to the left.

So, the point on the horizontal scale that was labelled 0.00 and which you re-labelled infinity to convert it to inches and feet, is labelled 78" on this new scale, and the point that was labelled +0.5 is now labelled infinity on the new scale. This new horizontal scale will show the average results for someone targeting -0.5 (very far end of the intermediate scale). Using this new scale, we see that the average person targeting -0.5 with a monofocal will have very good distance vision (20/25) and acceptable nearer vision down to 26", using 20/40 (logMAR 0.3) as the cutoff for "acceptable." With an Eyhance, the acceptable range is extended down to 16" instead of stopping at 26" with a -0.5 target.

I then created a whole series of relabellings of the X axis, each one shifted one more box to the left to correspond to targeting -1.0, -1.5, etc.

I will scan and upload my graph.

We're not done. Now let's consider the effect of putting on glasses. If I put on glasses with a prescription of -1.0 diopters sphere in both eyes, it will shift the horizontal scale two boxes to the right. So, if I have targeted -1.0 (intermediate) with my surgery, when I wear these glasses I will see like someone who targeted -0.0 (distance) not just at distance, but at every point along the horizontal axis. So, my reading vision will now be just like the reading vision (16" let's say) of that other person who targeted -0.0, for example. Approximately. The glasses make things a little smaller, where as the stronger IOL does not have that same minification effect.

If I put on +1.0 reading glasses, then it will shift everything 2 boxes to the left (it is 2 boxes because this is calibrated as one box = half a diopter). With the +1.0 glasses on, a person who targeted (and achieved) 0.0 with their surgery, will see like someone who targeted -1.0 in their surgery and who is not wearing glasses. So we can read the result for their vision with +1 reading glasses by using my hand-drawn horizontal scale for the -1.0 target.

I hope this helps. It helped me a lot to write it, proving once again, "To really understand something, teach it to someone else." Thus I suggest taking my graph and try to explain it to someone else!

Thank you for a very clear explanation of how to use a defocus curve to get an understanding of the possible results from targeting whatever IOL is depicted in the defocus curve at a variety of refractive targets. And I was pleased to see that the article you used to understand defocus curves is authored by my surgeon, who is doing my second Eyhance eye tomorrow morning.

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I'd add three points. First, the cut-off for acceptable visual acuity is subjective and may change depending on what one is viewing. When I went through a similar exercise for myself, I used 20/30 because, in talking with my surgeon about refractive targeting I wanted to leave some margin for a result worse than the mean visual acuities shown in defocus curves. As with many, but not all, issues involved with cataract surgery, I don't think there's always a 'right' answer.

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This leads to my second point. All the defocus curves I found reported mean visual acuities. Ideally, they also report, and sometimes depict graphically, the standard deviation from the mean. This is important because it gives some idea of the range of likely visual acuities with any particular refractive result. Personally, I'd also like to know the median visual acuities, what percentage of patients did better or worse than the mean, as well as the modal.

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The uncertainties and small sample sizes in any particular study lead me to my third point, namely, the desirability of looking at data from multiple studies and defocus curves. After finding several studies that included Eyhance defocus curves, I calculated two averages: one an average of the mean visual acuities for monocular defocus curves; the other an average of the mean visual acuities for binocular defocus curves.

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Why two averages? Because I was interested in, and with my surgeon decided to target, mini-monovision. With mini-monovision in the range we're attempting, c. 1.25 D to 1.50 D, there should be neither binocular summation (two eyes working together to produce perhaps a line better vision than either alone) nor binocular inhibition (visual acuities worse than one eye). For purposes of mini-monovision in this range, it therefore seemed to me that monocular defocus curves would be most helpful. As I had the data from binocular defocus curves, I calculated those averages, too, to compare the differences between mini-monovision and equal targets.

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In fairness, my surgeon said I was overthinking it. But using defocus curves helped me feel more comfortable with my choices, which were anyways consistent with my surgeon's recommendations based on listening to what I had to say about my visual preferences/priorities.