Looking for advice on cataract lens choice

Very interesting article. Thank you.

Glad you found the article helpful. Probably the most important parts of the Barrett article are that it shows getting to mini-monovision successfully is a process, rather than a one time decision. You need a plan... The important parts are do the distance eye first, if you can, and then test to determine the optimum myopia in the near eye.

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Probably the most helpful article I have seen on mini-monovision is this one below. Unfortunately the complete article has been taken down, but you can click on each of the figures in this link and expand the comments below each figure to get a lot of the information. You can also click on the PubMed button to get an abstract. The basic process was to take people that had monofocals in both eyes set for distance (they averaged 20/19 for vision), and then add -1, -1.5, and -2.0 D of myopia to the non dominant eye to simulate the various degrees of monovision. -1.0 is at the top end of the micro-monovision range of -0.75 to -1.0 D. The -1.5 is in the middle of the mini-monovision range of -1.25 to -1.75 D range. The -2.0 D is at the bottom of the -2.0 to -3.0 D full monovision range. All the graphs and the expanded notes below them are worth reading. The summary in the abstract kind of puts it all together.

"Conclusions: Pseudophakic monovision with anisometropia of 1.50 or 2.00 D provides useful binocular visual acuity from far to near. However, because stereopsis with 2.00 D of monovision is substantially impaired, approximately 1.50 D of anisometropia is thought to be optimal for successful monovision."

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Semantic Scholar Optimal amount of anisometropia for pseudophakic monovision.

Ken Hayashi, Motoaki Yoshida, +1 author H. Hayashi

Published in Journal of refractive surgery 1 May 2011

Medicine

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Another article which is not quite is good but useful is this one. It is helpful in that it reports satisfaction with monovision, and that over time satisfaction increases from 90% after one year to 100% after 10 years. It may be that as the pupil size decreases with age the effectiveness of monovision improves. It also raises the option of using an EDOF lens in the near eye, and call it Hybrid Monovision. I considered it with a Vivity lens in my near eye, but rejected it when it came time to make the final decision. The benefits vs the additional risk just did not seem worth it. You can get very satisfactory results with a standard monofocal lens like the B+L enVista and Alcon Clareon. I chose the Clareon.

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Clinics in Surgery

1 2018 | Volume 3 | Article 2027

Monovision Strategies: Our Experience and Approach on

Pseudophakic Monovision

Misae Ito CO, Shimizu K. PDF

Be careful! There are some people that try to make mini-monovision way more complicated than it needs to be, and end up making a mess of things. Keep it simple and use monofocal lenses set to the standard -0.25 D SE target for distance, and -1.50 D SE for near. There is no reason that correctly targeted mini-monovision cannot be just as successful with IOLs as with contacts. There are three independent but somewhat related objectives to keep in mind for successful mini-monovision.

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1. You want to be as close to plano as possible without going into the plus far sighted zone for the distance eye. This means setting a target at -0.25 and not plano or -0.50 or less.
2. You want to minimize the myopia in the near eye, but still be able to read comfortably. Some will be happy with -1.25 D, but I suspect more will like -1.50 D.
3. You want to minimize the differential between the eyes to maintain good intermediate vision and depth perception. If you follow points 1 and 2, that is automatically accomplished with a differential of 1.25 D.

Paraphrasing my jurisprudence professor, Roberto Mangabeira Unger, we should aim to make things as simple as possible, but no simpler.

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Because people have different visual priorities, when talking about monovision it's important to recognize that a guideline that works most of the time for, say, a priority on distance vision may not work for a priority on near vision. That said, one guideline that I think generally applies in both cases is that, if at all possible, one should trial monovision--ideally both before surgery on the first eye and again during the interval between the two surgeries--rather than rely on the likelihood that most people accommodate to a 1-25 D difference between the two eyes. Why? For the simple reason that you may not be most people, and you'll be very unhappy if you end up with more monovision than you can tolerate comfortably. (But maybe you're a gambler. In that case, why aren't you considering a multi-focal IOL?)

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For those who prioritize distance vision, and assuming successful trials of, say, 1.50 D of monovision, then it makes sense to begin by targeting the distance eye at the first minus at or below -0.25 D SE and to target the second eye at -1.25 or -1.00 D SE less myopia than the refractive result in the first eye. Granted, this is a more complicated way of stating the guidance than simply saying -0.25 D SE and -1.50 D SE, but, first, the IOL power calculations may not let you choose -0.25 D SE. Second, your surgeon may not hit the target. Not only is this a reason not to target plano, it's also a reason not to blindly target the second eye without regard to the actual results in the first eye. Third, even though your trials of monovision may show, as mine did, that 1.50 D of monovision is well-tolerated, because absolute accuracy isn't guaranteed it makes sense to target a smaller amount of monovision in case the result is more myopic than planned: 0.50 D less if you're more risk averse (that's me); 0.25 D less if you're less risk averse.

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Finally, however, it doesn't always make sense to begin by targeting the first eye for distance. If it's more important to you to nail near vision, then you'll want your first surgery to do your "near" eye. If the result is unsatisfactory, you get to decide whether to try again for near vision or settle for what you have and go for less myopia in the second eye.

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Alas, it's neither simple nor self-evident. You need to think for yourself, assisted by your surgeon and your own research.

I will definitely report on what I decide. I already have something to report, which is that this discussion here is amazingly helpful. I really feel empowered with the knowledge that is being shared here.

I did read other threads before I posted my question but I'm finding this thread the best so far of what I've read. Obviously because the answers are directly in response to my question. I think this forum in general and this thread in particular are great resources for me.

In situations where reading is marginal due to the font size or light, I just put on some mild OTC readers of +1.25 D. I almost never read books, so I can comment on that, but I may use these readers as well if I were to read a book. Most of my reading is on the computer, and I do find with my -1.6 D monovision for sites like this, vision is just fine. No need to increase font size. It just works. Before I got into this I wondered if I would have to buy two pairs of readers and put different lenses in for each eye. That has not been necessary even though my near eye will be getting more of a boost than my far eye. It will be like a person plano in both eyes without glasses having readers with +2.85 in one eye, and +1.65 in the other. I guess I could find readers that have frames where the lenses could be easily popped out, buy two pairs, and match up the eyes to leave me closer to the typical +2.5 D add that one would get with progressives, but for the amount of time I use readers, it doesn't seem to be worth it. This was a problem that I kind of overthought and turned out to not be a problem at all.

Maura wrote: Most people nowadays probably don't read for hours every day. I do.

Ron wrote: I almost never read books

And therein lies the disconnect. For those of us, like Maura, who spend hours a day reading printed material and prefer to read 'naked', so to speak, putting on readers is not only inconvenient but also less comfortable visually. For someone else who doesn't read in that way and might instead spend hours, say, golfing or driving, then of course having to wear readers would be a minor issue. It's a really individual choice.

Yes, but I spend hours a day reading a computer monitor, and have no trouble with that. A computer monitor is backlit though which makes it easier than text on paper, especially in poor light.

I also spend a lot of time on the computer but (in my case, anyway) the large monitor is about 2 feet away from my eyes and I can see everything just fine. When I read a book, we're talking about 12-18" away, depending on where I'm reading and the size of the book and the typeface. Those extra 6-12" make a big difference in visual acuity, especially as I want the text to be completely crisp and clear.

My computer does not have a super large monitor, and is only 24", so I sit closer, and about the same as your book reading distance of 12-18". I don't like glasses because I "multi-task" and often look up at the TV at the same time. It is about 10 feet away. I consider putting on and taking off glasses to be a major inconvenience. For the few times I use readers, I take them off immediately before getting up. Walking around the house with them on, makes me feel nauseous. I do not like the feeling of everything beyond 2-3 feet being a blur. In recent years but before cataracts my vision was in the -2.5 D range on a spherical equivalent basis. I used to be in the -4.0 D range but for reasons I do not understand it slowly improved as presbyopia developed. In any case with this amount of myopia I would put on progressives as soon as I got up in the morning, and not take them off until I went to bed. I could not stand the fuzzy vision.

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I think some people prioritize eyeglass free close vision with their IOLs, and some prioritize distance. My priority is both. Yes, near and far are slightly compromised, but I consider that as a good tradeoff for being eyeglasses free at essentially all distances.

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I think that is why IOL selection is a personal decision and everyone will not go the same way. But, that said, I think everyone should consider all options before jumping in.

This conversation illustrates nicely the reason for my interest in the Light Adjustable Lens.

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-1.0 D? -1.5 D? -2.0 D? -3.0 D? What will work best for my situation, lifestyle, and preferences?

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I already have and like monovision. I have to get my first artificial lens in my near-vision eye, because that's where the cataract is. I'm guessing that a result of -2.00 D to -2.25 D is likely to be most satisfying for me - I have always had good near-vision in at least one eye, and I hope to be able to see small print/details even in old age. But I am not a fanatic about it, and I also hope to retain decent mid-range and long-distance vision with my other eye, or with both eyes together.

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The adjustable lens is expensive, but if it gives me the best chance of avoiding refraction error plus an opportunity to fine-tune to the best result for my needs, it will be worth it.

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BTW, I just now figured out why you guys put those period lines in your posts! 😃

Mini-monovision with standard monofocal lenses works best when the distance eye is done first. This sounds like it may not be a choice for you. But when it is done this way you end up with plano (or close) in the distance eye, and you can used OTC readers to simulate the options for myopia in the close eye. The IOL eye is not impacted with the accommodation effect and gives you a more accurate simulation of what the close IOL eye will be like. For example if you end up at -0.25 D in the distance eye, and use a +1.25 D reader for viewing a Jaeger chart, that will simulate what you will see with a -1.50 D target for the close eye. But, of course if you do surgery on the close eye first, that ship has already sailed!

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One option may be to switch which eye is your close eye. Eye dominance is often used to determine which eye to use, with the convention that the dominant eye be the distance eye. But that is not essential and some studies have found the opposite way works as well or even better. I was in your situation and my non dominant eye had the worst cataract and needed to be done first. The surgeon told me that dominance was not a big factor, and suggested we do it for distance. In the end it worked for me, and I have what is called crossed monovision.

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But if your vision is still good enough you may want to simulate it first with contacts. Correct your cataract eye to plano, and the other eye to -1.50 D, to see what you think.

"One option may be to switch which eye is your close eye."

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Good thought. But I have two problems with that approach. First, it seems risky to turn my monvision upside down after nearly 30 years. Maybe it would be fine, but it makes me nervous. Second, the switch would require me to either a). get lens replacement surgery on my healthy eye that does not need it, perhaps years before I'd really need surgery; or b). go without any near-vision acuity for several years - I'd need to use reading glasses until my second cataract develops and requires surgery for a near-vision lens replacement. I'm 64, so accepting a crummy result for, say, five years in hopes of a good result after age 69 does not sound like a great deal.

Yes, your concerns are valid. I had good vision but with a cataract in early stages detected for my second eye. It was still correctable to 20/20 with glasses. I went 18 months before the second eye was done, and used a contact in my non operated eye to simulate mini-monovision and give me eyeglasses free near vision. Even when I did the second eye, vision was still quite correctable, but I decided it was time to get on with it.

"I think that is why IOL selection is a personal decision and everyone will not go the same way. But, that said, I think everyone should consider all options before jumping in." Yes, and I think this forum helps to do that.

Sadly, it is more complicated. RonAKA's opinion is that "slightly compromised" near and far vision is "a good tradeoff for being eyeglasses free at essentially all distances." To achieve this goal he advocates beginning with the distance eye. He also advises: "if you end up at -0.25 D in the distance eye, and use a +1.25 D reader for viewing a Jaeger chart, that will simulate what you will see with a -1.50 D target for the close eye."

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The first complication is that coming within 0.50 D of the target is considered a reasonable result and does not indicate a lack of expertise or care on the part of your surgeon.

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The second complication is that, even if the surgeon hits -0.25 D SE in your first eye, the simulation works--in the sense of showing your near vision after you second surgery--only if they actually hit -1.50 D SE in your second eye.

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The third complication is that, if the result in your first eye is, say, plano or + 0.25 D SE and the result in your second eye is -1.00 D SE or -1.25 D SE, your near vision most likely will be more than "slightly compromised".

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Hence, even if you're willing to accept "slightly compromised" near vision and the need to put on and take off readers with some frequency, you still need to decide whether, if you don't get the results you want you'd rather have very good (not even slightly compromised) distance vision or near vision. Quite possibly, most people prioritize distance vision, in which case it makes sense to begin with the distance eye, find out the result, and make a final decision on the second eye's target based on that result and (ideally) a post-first-eye trial of a greater amount of monovision than you'll want your surgeon to target.

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But some of us prioritize near vision, in which starting with the distance eye would be a mistake. If the first eye ends up at plano, for example, targeting the second eye for -1.50 D SE increases the risk of ending up with more monovision than you can accommodate; it also may ,more stereoptical vision than you want. In contrast, starting with the near eye gives you the same advantages in achieving very good near vision that starting with the distance eye does for achieving very good distance vision. And this conclusion actually seems simple and straightforward.

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A final suggestion. How do you decide, if it's not obvious to you, whether to prioritize distance or near vision? Consider what you (think you) want in common situations. For example, I just finished reading the New Yokr Times Book Review, pretty much from cover to cover. Holding it at a comfortable distance, about 12" from my eyes, I had no difficulty or discomfort reading any of it's rather small type. Last night I had no difficulty or discomfort watching Oppenheimer at a movie theater last night. As an experiment, I started wearing my glasses about a half hour into the movie. They sharpened my vision just enough for me to leave them on. So, I have, and am happy with, uncompromised near and intermediate vision and slightly compromised (20/25) distance vision. Operating first on my distance eye would have reduced the likelihood of achieving this result as compared with starting, as I did on my surgeon's advice, with my near eye.