Now with two Eyhanced eyes; mini-monovision; for me, so far a "wow" result.

I won't know where I ended up until I see the optometrist in four weeks. That said, the targets in rounded figures were -2.00 D in my nondominant eye, with a +14 D IOL, and -1.00 D in my dominant eye, with a +13.5 D IOL.

Thank you.

Yes, in round numbers, -2 and -1D.

Keep in mind that this is not really true mini-monovision. Mini-monovision targets very good distance as well as near vision. In ideal cases you want 20/20 distance vision and J1 or J2 near vision. The whole point of mini-monovision is to be eyeglasses free.

.

I would describe targets of -1.0 D and -2.0 D as near/intermediate blended vision, but not mini-monovision. Those targets represent a significant compromise to distance vision.

@RonAKA confuses the most common approach to monovision, namely, targeting one eye for emmetropia, that is, with distant objects being in sharp focus, and the other eye for a myopic target, with the various versions of monovision, which, going by different names, are distinguished by the amount of anisometropia or difference between the two eyes in refractive power.

.

He also is arbitrary in asserting that "The whole point of mini-monovision is to be eyeglasses free." On the one hand, if that's the definition then he is an example of failed mini-monovision because, as he has told us, he sometimes wears glasses for driving under certain conditions or for near reading. And on this definition I am so far is a case of successful mini-monovision because, with the visual acuities that I've described above, I currently am entirely glasses free. (I'll add that earlier today I easily read the small print on a CVS prescription label holding the container at a comfortable distance.)

.

On the other hand, I suggest defining mini-monovision inflexibly in terms of complete spectacle independence is not particularly helpful and doesn't reflect the views of most ophthalmologists. It certainly doesn't reflect mine. In my experience and based on what I've read, the aim of mini-monovision is to reduce spectacle dependence without unduly compromising stereopsis or incurring other negative side effects, such as headaches. Ideally, a successful result more-or-less eliminates the need for glasses for two of the three visual zones: distance & intermediate or near & intermediate. Getting substantial spectacle independence for all three zones is a bonus.

.

Finally, it's not as though I have idiosyncratically low standards in thinking 20/25 distance vision good enough to qualify for successful mini-monovision. Apart from the fact that what matters should be our own individual needs (and I fully accept that 20/25 probably would not have been good enough for, say, Ted Williams), if 20/25 is good enough for Dr. Graham Barrett, developer of the Barrett Universal II formula for IOL power calculations, then it's good enough for me. And it is. See Drs. Andrew Turnbull, Warren Hill, and Graham Barrett, "Accuracy of intraocular lens power calculation methods when targeting low myopia in monovision", Journal of Cataract & Refractive Surgery (2020). If, like me, you don't have online access to the article itself, a review published by the American Academy of Ophthalmology states that the cut-off they used for offering monovision after surgery on the first eye was 20/25 or better uncorrected distance visual acuity in the first eye. Dr. Bryan S. Lee, "Comparison of IOL power calculations for low myopia in monovision" (August 20, 2020) (an "Editor's Choice" article).

The other point to be aware of is that I believe some surgeons intentionally under correct to leave you more myopic with the Eyhance lens than they normally would for a monofocal. I am suspicious that one of the reasons they do that is to ensure that the patient gets the nearer vision that the Eyhance promises in their sales material. A large study done by Alcon found that if you correct this under targeting so the lens is brought back to emmetropia the promised depth of focus advantage of the Eyhance over a monofocal like the Clareon becomes insignificant. You can find a video on that study by searching for this. The critical information is the comparison of the defocus curves starting at the 4:06 point.

.

alcon science Head-to-Head Comparison of Intermediate Vision of Two Monofocal Intraocular Lenses 8 May 2023 Morgan Micheletti, MD

.

I remain convinced that to get the most out of mini-monovision the correct targets in spherical equivalent for the distance eye should be -0.25 D, and for the near eye -1.50 D.

This seems to be Clarion-inspired if not Clarion produced study.

Distance-corrected intermediate acuity was similar in both groups (Eyhance vs Clareon) with only a 2.5 letter mean difference.

I was thinking 2.5 letters sounds like a lot. There are what-- 5 letters per line?

Also, I was wondering if the lack of toric Clarion enhanced its apparent intermediate performance, since there is some suspicion that astigmatism may widen the intermediate performance.

I am still thinking to target -0.375 in the dominant eye give or take, and to go about a -1.875 in the near eye.... Still thinking and studying.

The study evaluated 620 eyes of 310 patients (155 Clareon and 155 Eyhance) who had undergone successful, uncomplicated cataract surgery at least three months prior and had post-operative best-corrected distance visual acuity of 20/25 or better after cataract removal.

Makes me wonder what percent of people did not reach 20/25 BCDV and were therefore excluded from the data.

Let's be clear that so far Dr. Micheletti's claims have not appeared in a peer-reviewed journal.

.

Second, peer-reviewed studies of the Eyhance with which I'm familiar are not based on an intentional under-correction of the Eyhance (except when they report on monovision).

.

Third, in fact it's the Clareon that was under-corrected in Dr. Micheletti's 'study'. His video reveals that the Clareon was target-corrected to -0.25 D while the Eyhance was targeted to plano. See 2:30 and following. Even with that bias in favor of the Clareon for intermediate vision, Dr. Micheletti acknowledged that the Eyhance provided 2.5 lines better intermediate visual acuity.

.

Fourth, Dr. Micheletti is a paid Alcon consultant who did a 'study' paid for by Alcon that Alcon sponsored at a professional conference. His video appears on Alcon's website. In contrast, Springer International Ophthalmology has published an open access preprint by academic investigators who reported having no disclosable financial or non-financial interests. The article is Visual Outcomes and Patient Satisfaction after Bilateral Implantation of an Enhanced Monofocal Intraocular Lens: A Single Blind Prospective Randomized Study. Peer reviews were received by the journal on June 23, 2023.

.

Directly comparing the Eyhance and Clareon, the investigators report (using logMAR):

.

Mean UIVA ± SD was 0.17 ± 0.12 for Eyhance and 0.31 ± 0.09 for Clareon; p<0.001 (0.17 logMAR = 20/29.6; 0.31 logMAR = 20/40.8)

.

Mean DCIVA ± SD was 0.13 ± 0.11 for Eyhance and 0.29 ± 0.09 for Clareon; p<0.001 (0.13 logMAR = 20/27; 0.29 logMAR = 20/39)

.

Mean UNVA ± SD was 0.23 ± 0.11 for Eyhance and 0.33 ± 0.12 for Clareon; p<0.001 (0.23 logMAR = 20/34 ; 0.33 logMAR = 20/42.8)

.

Mean CNVA ± SD was 0.23 ± 0.11 for Eyhance and 0.33 ± 0.12 for Clareon; p<0.001 (0.23 logMAR = 20/34; 0.33 logMAR = 20/42.8)

If one prioritizes distance vision and wants to leave a margin for refractive surprise to avoid a hyperoptic result, then -0.25 D and -1.50 D seem reasonable targets with conventional monofocal IOLs.

.

But as Dr. Micheletti's own Alcon-sponsored video shows, -1.50 D won't get you very good near visual acuity with a Clareon monofocal. He presents a Clareon defocus curve at c. 4:06 of the video. With a plano refraction visual acuity at -1.50 D appears to be about logMAR 0.30 or 20/40. If we shift the curve to the right for a second eye refraction of -1.50, then the visual acuity at -3.0 D or 13.12" is that same 20/40. At least for those of us who prioritize near and intermediate vision, I don't think 20/40 counts as a very good result.

.

BTW, Apple recommends viewing a smartphone from at least 12". -3.00 D is 13.12". So it seems reasonable to look at visual acuities at that distance when evaluating near vision. See Phone's Screen Distance Feature on iOS 17 Can Help Reduce Eye Strain (June 15, 2023).

For sure it was an Alcon initiated and funded study. They said they were investigating why real life experience with the Eyhance was not living up to claims by J&J. I suspect instead of risking a lawsuit by saying that J&J was misleading surgeons and patients, they decided a better thing to do was a study and show everyone the results. These findings were presented at a large conference.

.

I suspect the use of non toric lenses was simply done by eliminating those who needed a toric lens. It should have not swayed the results one way or the other.

.

Yes I believe 2.5 letters means half a line. But I would suggest looking at the defocus curves and how close they are together tells the bigger story.

.

Keep in mind that you when it comes down to the crunch, you can't target a specific diopter target. After you get your eyes measured you need to ask for the IOL Calculation sheet. It will list what your options are for targets. That is when you have to make a final decision. It will usually come down to a choice between two power with one on either side of your theoretical ideal.

.

Eyes that can't be corrected to 20/25 or better after cataract surgery must have other issues. It would make sense to exclude them so it does not skew the results for reasons that have nothing to do with the lenses used.

They specifically said that some with the Tecnis Eyhance got toric.

My 0.375 number is really me on the fence as to whether to go for 0.5 or 0.25. With the RxLAL I could try each in theory. I am not sure what resolution the LDD can deliver. I think I read that it could be set in 1/4 D steps, although I don't see why they could not aim for something between steps.

I certainly find the discussion, and contrary opinions, as to what target to aim for, to be useful.

You have to remember that getting a toric lens does not mean astigmatism is reduced to zero. My wife got a toric that theoretically should have reduced her cylinder to zero. She tests now at -0.50 D cylinder. If they really wanted to even things up they would throw out anyone that has more than 0.75 D of cylinder.

.

What the LAL can do probably depends on the skill of the surgeon or whoever runs the machine that adjusts the lens. I suspect they can aim for any number as it is not a step adjustment like a lens with fixed steps. It is a question of how accurately they can adjust to the target they pick, and how many appointment they want to incur to do the adjustment. The LAL involves much more "chair" time. That is a good part of what you are paying for.