JUST HAD VIVITY LENS IMPLANTED 3 WEEKS

My thoughts since you are already wearing contacts is to try simple mini-monovision using contacts to simulate it. This assumes you have cataracts, but still have good enough vision to see reasonably well?

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The way to do this is fully correct your dominant eye to distance with a contact. Then take the contact power you need for full distance correction in the non-dominant eye and reduce it by 1.50 D to leave you at -1.50 D of myopia.

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One thing to keep in mind is that the Vivity lens gives you about 0.60 D of extra depth of focus vision. Mini-monovision gives you 1.50 D of extra depth of focus, or nearly three times as much a using a Vivity lens set to distance. -1.50 D myopia is not going to give you perfect near vision, but it is pretty good, and good enough for most things, like a phone, computer, and reading normal text without glasses.

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The other thing to consider is that due to the focus extension the visual acuity at the lens peak is reduced with the Vivity, as well as the contrast sensitivity (important for night driving). That cannot be corrected with eyeglasses.

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The common choice with IOL targets for cataract surgery is distance. I believe over 90% choose that. Less common is targeting near vision in the -2.0 to -2.5 D range. That works too, but obviously you need eyeglasses for distance. There would be no advantage to doing that with a Vivity lens though. It would be better to use monofocals. Then your vision can be fully corrected with standard eyeglasses for distance and driving. With your glasses off you will have very good reading vision.

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I seriously considered mini-monovision with a Vivity in the near eye set to -1.0 D, and a monofocal in the distance eye. The surgeon talked me out of it. If you are going to use a Vivity, I think that is the way to do it -- only in one eye, the near one.

Try to understand defocus curves. In https://patient.info/forums/discuss/translating-defocus-curves-from-d-to-feet--803594?page=0 the jimluck post is particularly good. I offer that as a way to understand defocus curves. I am skeptical of the actual curves utilized, since you do lose peak acuity with an extended focus lens.

I would suggest a bit of mini-monovision, but you will probably get to an extent anyway.

I would suggest that you pay attention to your astigmatism, and if you can swing the premium, toric is worthwhile. Where to draw the line? I would say 3/4 D and others might say a little more.

If you could swing to a light adjusting lens, that lets you tune both sph and cyl very close -- within about 0.25 D. Your current surgeon does not offer that product. Big swing. About 4 or 5 extra visits. Higher premium.

I basically want what you do -- intermediate and near. Right now I wear computer glasses pretty much all day other than I take them off to read. Even though my near vision at reading distance is probably a hair less crisp than with them, I am just more comfortable reading without. For me the distance vision I have with the computer glasses is good enough to do things like walk my dogs around my own property, even at night. Super distance vision is strictly something I need to drive, and at this age I only do that a couple times a week and not for that long each time.

However, my decision about what I hope will accomplish that for me is different from what you're contemplating. I've rejected the idea of anything like the Vivity, which nothing I've seen in this forum makes me think would give the kind of near vision I want without also using monovision and will go for monofocals in a monovision setup.

I do want to hear what the surgeon I'm seeing this coming Wednesday has to say about it since I know he has experience with surgery with my kind of targets. I'm finally after several cancellations going to see him this coming Wednesday. I saw one surgeon over a year ago and that appointment did nothing but convince me I needed to know more before making a decision, and to be honest I also didn't click with the surgeon I saw. This one Wednesday I've chosen for a 2d try because, among other things, I know he did surgery for a friend's eye doctor with preference for best vision being near, which means he's not prejudiced against it.

If you want such good near vision, read BookWoman's posts about what she chose and got and how she feels about it. I've seen a good many posts here that say -1.5 is fine for "functional" reading, but the poster reverts to readers for anything more than that, like reading a book for a couple hours. It seems anything less than -2.0 isn't going to get that sort of book reading vision at 15" much less 4. I'm a writer myself, and I read a lot. It's important to me, and I really dislike the blasted readers. My one attempt at progressives was a disaster. But I don't mind glasses for driving at all -- I wear sunglasses when I drive most of the time anyway.

As to making the surgeon upset or angry, I think you need to avoid things like, "I expect. " My plan is more along the lines of "What's most important to me is intermediate and near, with near being comfortable for reading for hours. Would xyz achieve that?" If an approach like that bothers the guy, I guess I'll be looking for a 3d surgeon.

Good luck to us.

What's most important to me is intermediate and near, with near being comfortable for reading for hours. Would xyz achieve that?"

You might want to convert that to distance, because intermediate does not mean the same to everybody.

What you could say is that you would like to focus similarly to what you get now while wearing your computer glasses. If you know what Diopter the computer glasses add, say that. If not, bring the glasses and his tech can measure the strength. I presume the doctor will know your latest prescription, and then adding the computer glasses effect, he will have your target.

Very interesting. Have you ultimately had the surgery and has it worked out as you hoped? (I haven't read this entire 12-page thread, maybe that has been covered.)

Sorry this followup is going to be fairly long.

I need to clarify some of what you're suggesting. I'm used to thinking of diopters only in terms of my prescriptions, and I'd find inches easier to understand.

I guess 0.60D must be arms-length (since Vivity offers arms-length and you say Vivity provides 0.60D), and 1.50D must therefore mean reading distance - or something close to it, since you say it would be good in most situations but not all.

Maybe in actual practice it works well, but my concern is it sounds to me like it means a bit of a strain for reading under many conditions, along with the need to sit forward a few inches at the computer. Splitting the baby in half and ending up with nothing that comfortably works, except distance (and even that requiring adaptation since it's monovision).

What about placing Vivity in one eye to cover full distance through arms-length, and a monofocal in the other set to a more perfect reading distance? I guess that would come with a pretty high risk of a gap between reading distance and arms-length depending on how much near the Vivity actually provides the individual.

You proposed doing the opposite, but you were talked out of it - using Vivity for near, and monofocal for far. I guess that suggestion would be for Vivity to handle intermediate through reading, and also seems like a bit of a gamble - in this case, the risk of a gap between Vivity's furthest point, and monofocal distance. You'd need to prescribe the Vivity for far enough out to make sure there's no gap out there - several feet, probably - and then the near vision would be unpredictable. I think one could probably state that for any given person, they would have more usable near vision with a Vivity prescribed for less than full distance than with one prescribed for full distance - but that it might still not be enough to avoid reading glasses.

It strikes me that either hybrid solution of EDOF + monofocal risks an intermediate gap. As does any solution of two monofocals. It still seems to me that the strongest case for no gap is mini-monovision with two EDOF lenses. The result would be "clean" - a continuous range of vision with no gap, with the knowledge that reading glasses will probably be needed under some, many or all conditions, depending on the individual. But that's clean - you can't really correct for a gap hanging out at some random location in space several feet away. You can easily correct for a shortfall in reading, or a shortfall in distance.

Interestingly, beyond all of the other problems posed by MF lenses, the gaps between the 3 focal points also would bother me - and those gaps are inherent in the design. Any time you have monofocals involved, you introduce almost unavoidable gaps.

(If a person has some accommodative power left, these gaps can be overcome. I don't think I have much if any.)

In conclusion now, I have a friend - a photographer and painter - who got the Vivity with (she thinks) mini-monovision, and superb results. No problem with contrast, and brilliant colors. Has OTC readers for reading menus in dimly lit restaurants, and otherwise never needs them. But she started out with very different eyes than I have. I'm lifelong nearsighted with astigmatism; she had mild astigmatism and needed glasses for reading (so I guess simply astigmatic, or somewhat farsighted). So I take her results as a very encouraging outcome, but not necessarily applicable to me or anyone else.

I'm very interested in further feedback on these areas. And I guess I should go back and read all 12 pages!

Yes, we are pretty similar. I've also cancelled visits to the surgeon a couple of times, as I felt I needed to do more research, plus I was afraid of being overwhelmed by it all. I'm very comfortable hanging around with my computer contacts all day long, and going outside and even shopping with them in. Sometimes it bothers me that I don't see people's faces outside till I am nearly on top of them, and then I pop on my driving glasses.

My appointment is also this Wednesday!

Unlike you, I haven't had that first visit to any surgeon, and don't personally know anyone who has had surgery in my town, let alone know a surgeon who works well with someone with my perspective, so I'm just meeting with the surgeon in the large ophthalmology practice I use, who also has served on the faculty of a local residency program (though not this year).

I don't even know if he works with Vivity. His web site mentions Panoptix, and that's a non-starter for me. But it doesn't look like the web site is a priority for them.

Good luck!

One option you may want to consider is a 1.5 D split in near vision. Perhaps -1.0 D in one eye and -2.5 D in the other eye. I would not call that monovision as it sacrifices good distance vision, but it should give a good range of vision from reading books with small print to doing everyday activities around the house. It may give enough distance vision for TV if you have a large screen not all that far away.

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Your surgeon sets the target for each eye in diopters. So there is no confusion between you and your surgeon about what you want I would suggest becoming familiar with the diopter scale. To convert to distance just divide 1 meter (about 3 feet) by the diopter target. -1.0 D would give peak vision at 3 feet. -2.5 D would peak at about 16". But each of those would give quite useable vision on either side of those peaks. +2.5 D Add is the normal correction applied to prescription bifocals or progressives to give good reading vision.

I ended up with a AcrySof IQ monofocal which is currently at -0.375 spherical equivalent (SE) in my distance eye. SE is sphere plus 50% of the cylinder. My near eye is at -1.625 SE with a Clareon monofocal. I do not observe any gap in vision between the two eyes. I can see my car and motorcycle instruments equally clearly with both eyes. Not everyone gets the same near vision with a monofocal, but I seem to have come out on the fortunate side. With a bright computer monitor I can start to read text at about 18" with my distance eye. Peak vision with different diopter levels can be determined by dividing 1 meter (40 inches) by the diopter. So my near eye peaks at 40/1.625 or 24". However, vision does not drop like a stone on either side of that peak vision distance. I can see a computer monitor down to about 8" before it starts to get too fuzzy to read. And, I could watch my 65" HDTV at 8-9 feet with reasonable clarity with my near eye. When doesn't it work? Like your friend I can get in trouble in dim light. I have to reach for +1.25 D readers when the print is very small and light is not ideal. I have had issues reading menus in dimly lit restaurants especially when they are not simple black letters on white background using readable fonts. That said I do not bring readers when going out shopping or even to dine at a restaurant. I can manage with the flashlight on my phone if I have to. The extra light makes it easy to read without readers.

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The reason I suggest using a monofocal in the distance eye instead of the near eye is that a monofocal gives you lots of coverage from being able to see the moon clearly down to 2-3 feet. Getting a wide range at near distance is more difficult, and an EDOF lens can help get from 2-3 feet down to 1 foot or so. Not that wide a range but is necessary. But, that said correctly targeted monofocals can do it too. My suggestion would be to get a good understanding of what the Vivity and cannot do is to look at this FDA document from Alcon. Look at Figure 4 which shows a graph of the MTF Contrast sensitivity vs distance in Diopters. the SN60WF is the AcrySof IQ monofocal that I have in my distance eye. The contrast sensitivity at distance (0.0 D) is almost twice as high as the Vivity. For that reason I think it makes more sense to have the monofocal in the distance eye for night driving. It makes up for the significant loss with the Vivity EDOF technology.

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Next look at Figure 5 which shows visual acuity (logMar) vs distance in Diopters. At 0.0 D or distance the standard monofocal achieves a bit better than a logMar of 0.0 which is 20/20 vision. The Vivity falls a touch short of 20/20. At about 0.5 D for distance (18") the visual acuity for both is about equal. At 1.0 D or about 3 feet the Vivity starts to out perform. A logMar of 0.20 is an accepted benchmark for good vision with a Snellen of about 20/32. As you can see the Vivity extends this visual acuity level from 1.0 D to 1.5 D, for an increase of 0.5 D, which is the minimum required to be sold as an EDOF lens. In inches this extension is from 40" to 27". This is with both lenses targeted to 0.0 D. When you target something to the right the whole curve sides to the right. With a -1.0 D target with the Vivity you would get peak visual acuity at -1.0 D and if you do the mental gymnastics with the graph you will see the visual acuity at distance drops to a logMAR of 0.3 or 20/40 the legal driving limit in many jurisdictions. I would suggest that is the main benefit of using a Vivity lens in the near eye. The distance vision will be better in that eye. I am at about 20/65 at distance with my near eye offset to -1.50 D. However, the binocular benefit of distance gained with the Vivity eye when the other eye is already at 20/20+ is very small.

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Google this: "Vivity P930014 Package Insert"

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Another site I have found useful for monofocal mini-monovision is this one. It combines the curves for different offset targets for the near eye and displays the combined visual acuity in Snellen units and the distance in meters which is easier to read. Unfortunately the complete detailed article has been taken down and all that is left is the figures. If you click on each one there is more detail at the bottom however.

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Google this:

Optimal amount of anisometropia for pseudophakic monovision.

Ken Hayashi, Motoaki Yoshida,

PanOptix is the multifocal made by Alcon the same company that makes the Vivity. Surgeons typically are "in bed" with a certain manufacturer, so if they offer PanOptix they will most certainly offer Vivity. The surgeon I went too offers both, at the same premium ($2,200 CDN over a monofocal) per eye.

Another thing to consider in getting cataract surgery is the overall process. Some surgeons push to have both eyes done within one or two weeks of each other, or even both at the same time. I think that is a poor practice as one of the biggest issues with cataract surgery is the accuracy in predicting outcomes in refraction. It is in the +/- 0.5 D range, not +/- 0.25 D like with eyeglasses. For that reason it is worth waiting 5-6 weeks after the first eye is done to get a full phoropter refraction done to see where you really landed. That is most helpful, providing the surgeon considers it, in choosing the power and getting improved accuracy on the second eye.

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And the second part of the process if you are considering monovision is to allow time to test drive it with contacts, before and after the first eye is done. And, also allow for a decision point as whether you really want to do it or not. The article below is by a Dr. Graham Barrett which is a world known opthalmologist that has developed one of the most accurate formulas for IOL power calculation. He is also a proponent of mini-monovision. This article is about his method of doing it. I agree with it all except that at the midpoint I concluded I needed -1.50 D rather than the -1.25 D that he recommends. In any case worth a read. And be aware that all ophthalmologists are non on board with monovision and instead prefer to promote the use of premium priced lenses.

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CATARACT SURGERY | OCT 2009

My Standpoint on Monovision as a Cataract Surgeon

The success of monovision depends on the level of targeted myopia for near vision.

Graham D. Barrett, MD, FRACO