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Monovision plan ?

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claire5773
claire5773

I have cataracts in both eyes and want monovision.  I saw the surgeon again today.  He had earlier said he would set the left for distance, and then we’d discuss the right after the left had healed.  That made sense but seemed pretty wide open.

Today I said, the best case possibility that you’ve outlined – that I’d need glasses for driving, the theater, extended reading, and small print – would be amazing, but I know there is variation.  I then asked how the results on the left would affect the decision on the right.  He said, you’d tell me what you’re missing – computer, or reading. 

I asked about the issue of making the eyes too different and he said he’d make the near eye mildly myopic; not too different. 

I then asked if he thought I’d be able to read my phone (big phone, big font).   He then said I would be able to see headlines (as in print), nothing too tiny. I started sharing results of contact trials and he interrupted me and sternly said he can’t get the precision of contact lenses and his concern was that I would never be satisfied. I was stunned but realize how my approach could have made me seem like the patient who wouldn’t be satisfied. I could get few words out thereafter.

I asked if it would make sense to undercorrect the left to make room for more close vision in the right; and he said that is unwise; a slippery slope.  That made sense to me because you could aim for 20/40 but if you get less, then your distance eye isn’t that helpful uncorrected. 

I am left uncertain as to what he might aim for on the right, and how conservative he would or would not be in terms of “mild myopia.”  Should I know that? 

He would use Technis monofocals:  toric in the left (distance) eye; non-toric in the right.  

Tecnis lenses may be good for monovision.  John R. Wittpenn, Jr. MD used the non-toric monofocal  lenses and  targeted 0.5 to 1.00 diopters in the near eyes of 26 patients.  The patients wound up with good distance and being able to read print; and rarely used glasses. 

My surgery date is set for tomorrow.  If I postpone it would not be until late August. 

I would appreciate your thoughts and comments.   

0 likes, 74 replies

74 Replies

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  • Salty0
    Salty0 claire5773

    Posted

    I don't want to be an alarmist but tread very carefully, this operation and these decisions aren't as simple as the medical professionals would have you think. You will be living with the consequences of these decisions prehaps for the rest of your life. If you aren't completely comfortable with your surgeon & his attitude now think how it will be if you run into after surgery complications. Time is on your side now, you have done the smart thing and reached out to this forum for a reason, think about it.

  • Night-Hawk
    Night-Hawk claire5773

    Posted

    Since the end result can be off by 0.5D from the target just due to the steps the IOLs are available, plus the unpredictability of the cornea healing, its usually advisable to target slight nearsighted for the distance eye. 

    My surgeon had a target of -0.25D for my right eye, but it ended up at 0D or +0.25D plus some residual astigmatism, so I typically get about 20/25 to 20/30 for uncorrected distance vision in that eye but its correctable to 20/20 or better with glasses.

    If I did it over, I would probably have set the target slightly more nearsighted like -0.50D to -1.00D since computer intermediate focus is important to me.

  • barbara96330
    barbara96330 claire5773

    Posted

    Hi, I am very nearsighted and have had one cataract surgery.  I corrected for near and as a heavy phone user am delighted to still have excellent near vision.  My eyes are complicated because my non cataract eye is very very nearsighted so until I get my next surgery the needed prescriptions are  far apart and require tricky glasses.  With that said, I've been satisfied with how glasses correct my left eye for mid/far distances and my right  for reading.  Since I was happy to wear glasses all the time, I am delighted that the result was the ability to read, use my computer, and see distance with only one set of glasses. For perfect distance vision, however, I need to wear a contact in one eye and glasses. (However, I have no need for vision that perfect except at the movies) It's important that you think about how you use your eyes and when you are willing to wear glasses.  My cataract repair eye ended up a little more nearsighted that the doctor intended, but it has not been a problem for me. I agree that doing what is necessary to feel that you have made the right decision is worth it.

  • Guest
    Guest claire5773

    Posted

    Wondering if Claire5773 cancelled or went through with the scheduled surgery.
  • claire5773
    claire5773

    Posted

    Thank you all so much for posting.  Quick update:  I thought through everything the doctor said and realized it all made sense.  I really had to cut through my anxiety to think about the information he was giving me.  He never once said anything that could be an overstatement and I realized I appreciated his conservative approach.  I had done extensive research on my own and had multiple consults.  I went ahead with the surgery on the first eye and could not be more thrilled with the results.  Now I am focused on relaxing and healing.  The information I have found here has been very helpful and I appreciate everyone here.
    • at201
      at201 claire5773

      Posted

      Am really happy for you. Great that your surgery on the first eye has gone very well.
  • Guest
    Guest claire5773

    Posted

    Thanks for the update. There is a point where you eventually do have to take the plunge and not look back. All the best on your recovery!
  • claire5773
    claire5773

    Edited

    Thank you all for your posts.  I’m a week out after surgery on the Left eye with a Tecnis toric monofocal lens set for distance.  Covering the right eye, my distance vision is great.  My computer vision (about 26” – 30”) is good and I only use readers for detailed work with numbers.  At 18” to 24”, holding things near my lap, I can read 12 point font (though would use readers if I were reading a whole page).   

    What I need glasses for is: smaller fonts, and reading at book reading distance (I seem to hold books at around 15”). 

    I’m very happy with the results on this eye.  

    I will be seeing the surgeon tomorrow to discuss the right eye.  As I understood him, targeting 12 – 14” was doable with mild myopia and not too big of a difference between the eyes.   I need to make sure I understood this correctly, and understand what the tradeoffs might be.  But I’m hoping that this is doable. 

    I will appreciate your comments.

    • Sue.An
      Sue.An claire5773

      Posted

      Claire - sounds like your surgeon did an excellent job and results are what they should be with technis toric monofocal lens.   I would give yourself an extra 2 or 3 weeks for healing and settling of that IOL so that your surgeon can make any adjustments for the other eye.  His plan to make it slightly more myopic at .50 to .75 diopter is a good one.  If distance vision is great through newly operated eye you’ll do fine and won’t need any glasses while driving etc.   Having the other eye targeted slightly nearer will benefit your reading distance and likely you will not need readers for anything except really minuscule print on pill bottles etc.

      Best of luck to you.

    • Night-Hawk
      Night-Hawk claire5773

      Posted

      You got an excellent result with a Tecnis toric monofocal IOL with good distance and intermediate vision!

      I also have that IOL in my right eye only set for distance vision, the target reached was within 0.25D but with some residual astigmatism so I get about 20/25 uncorrected.  However for computer intermediate vision (24-30"wink I need to add about +0.75D or so for clear vision at that distance.

      Perhaps your eye pupils are relatively small, mine are larger than expected for my age, smaller pupils could increase depth of focus.

    • at201
      at201 claire5773

      Posted

      Great that you have been able to achieve very good results for your left eye.

      As Sue.Ann suggested, targeting the right eye for slight myopia (about -0.5 D or -0.75 D is a good idea). However, targeting for 12 to 14" is not a good idea (you may not have understood the surgeon correctly). You (as anybody) will have a very hard time dealing with that much of a difference between the 2 eyes with no apparent benefit.

    • claire5773
      claire5773 at201

      Posted

      I appreciate the caveat.  I will check.  
    • claire5773
      claire5773

      Posted

      Update:  Two weeks ago I had cataract surgery, with a Tecnis toric monofocal lens put into my dominant Left eye.  That eye can see well from distance, all the way up through being able to easily read 12 point font at about 18” – 24”.  I’m so happy with the results. 

      I wake up and still look for my glasses out of a habit borne of perhaps 50 years, before I realize I don’t need them.  If I need to read something small on-the-fly, such as ingredients on a package in the store, I can hold my arm out and not search for the readers.  It helps that I have long arms. 

      I tried popping out one lens of my glasses for the interim but the eyes are too different.  I can use a contact in the right but I’m really minimizing that before the upcoming surgery (4 weeks after the first) as the contact irritates the eye so much.  I’m able to get around, though I have to be careful. 

      The doctor said he would do mini-monovision and target the Right eye so it would see, as a ballpark estimate, between 15 inches and 10 feet.  He said the Right should improve my intermediate vision and help some with near.  And I should expect to wear glasses for tiny print, extended reading, and driving.  The lens for the Right will be a Tecnis monofocal, non-toric. 

      I asked the doctor if the results on the Left could change so much that it would change the decision on the Right.  He said it was unlikely.  I bought eye charts online for both distance and near so I can check at home, for my peace of mind.   

      So that’s my update.   I appreciate the support of this community and welcome your thoughts.

    • Night-Hawk
      Night-Hawk claire5773

      Posted

      The vision should get pretty stable after about 2 months, so the end result could change a little for you in the coming weeks.

      Are you getting 20/20 at distance with the toric monofocal IOL?

    • claire5773
      claire5773 Night-Hawk

      Posted

      I got 20/20 at the doctor's, the day after surgery.  At home, I was two letters shy of 20/25, ten days out.  (But the difference could easily be due to different lighting, etc.) 

       

    • at201
      at201 claire5773

      Posted

      "The doctor said that ...target the Right eye so it would see, as a ballpark estimate, between 15 inches and 10 feet. " is unfortunately a somewhat meaningless statement giving a wide range of possible achieved vision. Even "see" is a somewhat meaningless term in this context. For example, seeing 20/100 is not the same as seeing 20/20.

      Any way, he should say something like I am going to target for the best vision at 40 inches (-1.D) or 32 inches (-1.25D). If he does achieve the target of the best focus at 40 inches, you should be able to see 20/25 or better between 26 inches and 80 inches. Similarly,  If he achieves the target of the best focus at 32 inches, you should be able to see 20/25 or better between 23 inches and 53 inches

    • claire5773
      claire5773 at201

      Posted

      Thank you, at201.  I understand that diopters to inches is a calculation, but how do you get the range?  (Eg a range of 26” to 80” for one diopter).  

      Also, since my distance eye sees well starting at roughly 18” – 24” out, how does this affect the situation? 

    • at201
      at201 claire5773

      Edited

      Typically (although not always), a monofocal lens can provide 20/25 vision at distances +- 0.5 D from the nominal best focus value. That means that if one needs a correction of -1.D to see the best at far distance, one seems best (say 20/20) at 40 inch (40/1) distance. However, for this example, he/she should be able to see 20/25 or better between (40/1.5 or) 26 inches and (40/0.5 or) 80 inches.

      Similarly, a monofocal lens can provide 20/40 vision at distances +- 1.0 D from the nominal best focus value. That means that if one needs a correction of -1.D to see the best at far distance,  he/she should be able to see 20/40 or better between (40/2.0 or) 20 inches and (40/0 or) far distances.

      If one has astigmatism, the vision at the best focus without a correction for astigmatism won't be as good as otherwise, but one can see less-than-best over a wider range.

      Also, when the light is bright, the pupil is smaller and that results in more extended range of focus (that is as true of eyes as it is of cameras).

    • Night-Hawk
      Night-Hawk claire5773

      Posted

      I also got a Tecnics toric monofocal (in my right eye) and the vision varied quite a bit the first month or so.  I was getting 20/25 or 20/30 most days after 2 weeks but a few days it was worse and a few days got 20/20.  Now after 8 months since the surgery it doesn't vary as much but still can be 20/20 for awhile some days but usually 20/25 to 20/30.

      In my case from an optometrist refraction exam recently my right eye has -1D astigmatism and is within 0.25D of plano power. Correcting that with glasses I can get 20/20 or even better.

    • claire5773
      claire5773 at201

      Posted

      Thank you so much.  That is so helpful.  And what should be the range at plano, which I think is zero diopters ?  
    • claire5773
      claire5773 Night-Hawk

      Posted

      Thanks, that helps.  It’s interesting how your vision varies.  With astigmatism and dry eye, I certainly got used to that with contacts and glasses.  I think it’s harder to correct for astigmastism in general so I’m pleased with my results.
    • at201
      at201 claire5773

      Posted

      For a eye with a plano prescription (and 20/20 vision at far distance), on average with a monofocal lens, one can expect to see 20/25 at about 80 inches, about 20/40 at 40 inches, 20/63 at 26 inches etc.

      Of course, there are people who have better distance range (just like others have worse range). For example, with the plano prescription, 13% of people will have better-than-average vision of 20/20 at 40 inches and 30% of people will have worse-than-average vision of  20/50 -  20/80.

    • at201
      at201

      Posted

      Sorry. The numbers in the second paragraph above were not quite right.  It should have said"

      Of course, there are people who have better distance range (just like others have worse range). For example, with the plano prescription, 5% of people will have better-than-average vision of 20/20 at 26 inches and 30% of people will have worse-than-average vision of  20/50 -  20/80.

    • at201
      at201

      Posted

      Am not sure why the message above got sent while I was still correcting it.

      Sorry about that.

      It should have said   '

      "Of course, there are people who have better distance range (just like others have worse range). For example, with the plano prescription, 5% of people will have better-than-average vision of 20/20 at 26 inches and 43% of people will have worse-than-average vision of  20/50 -  20/80.

    • claire5773
      claire5773 at201

      Posted

      Thank you.  You were right, I misunderstood and that was not his plan.  The plan for the right is minimonovision. 
    • at201
      at201 claire5773

      Posted

      Am glad to know that. That is a good plan.
    • claire5773
      claire5773 at201

      Posted

      Thank you, at201.   You wrote: “For a eye with a plano prescription (and 20/20 vision at far distance), on average with a monofocal lens, one can expect to see 20/25 at about 80 inches, about 20/40 at 40 inches, 20/63 at 26 inches etc.”

      How far is “far distance”?  Also, for plano, what is the “nominal best focus value”?

    • Sue.An
      Sue.An claire5773

      Posted

      Hi Claire - Distance is officially 20 feet or futher for IOLs set for plano (and if achieved as they can shift .25 either way in healing process.) However the ability of the eye to get some "pseudoaccommodation" (false focusing) due to pupil constricition usually give decent vision 10-15 feet and further. No one can give you an exact measurement - too many variables in my opinion.

    • at201
      at201 claire5773

      Posted

      As Sue.An has already mentioned, "far distance" can be considered to be 20 feet or beyond.

      It is usually considered better to aim for slight myopia (-0.25D) since small amount of myopia is better than ending up at any farsightedness. Any way, since you will be setting the right eye for best focus at 32 or 40 inches, you don't have to worry about that part any more.

    • claire5773
      claire5773

      Posted

      Update on my DIY at-home vision check: 

      Vision in the left operated eye set for distance with a Tecnis toric lens is unchanged vs. the last check 8 days ago.   Far vision:  Missed two letters on the 20/25 line.  Near vision:  J3 on the Jaeger chart.      

    • Sue.An
      Sue.An claire5773

      Posted

      Will you be seeing your surgeon for an official checkup?   I know some will see you in a week.  My own did 24 hour check and 6 week checkup.  Unless I called in with an issue that necessitated an appointment sooner.
    • Night-Hawk
      Night-Hawk claire5773

      Posted

      Your current result of between 20/25 and 20/30 distance vision is much like I got at the 2weeks after surgery with my right eye toric monofocal IOL.  Though my vision would vary day to day for the first month or so but 20/25-20/30 has been my typical average uncorrected result with that eye even now after over 8 months since surgery.  In my case a refraction eye exam indicated I have about 1D residual astigmatism and if that is corrected with eyeglasses I can get 20/20 or better then.

      So might be similar for your eye - after a month or two you can get an optometrist eye exam to determine your new eyeglasses Rx too.

    • claire5773
      claire5773 Sue.An

      Posted

      Yes, I saw the surgeon after 1 day and 1 week; and will see him again after 4 weeks when I'm done with the drops. 

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