One eye set to -2.0D, considering best option for second eye

Yes, @bookwoman does very well with -2.5 in one eye and -2.0 in the other eye. I believe she does not wear glasses when she is in the house and she doesn't have any problems seeing her feet when she goes up and down steps. But she uses progressive lenses when she drives and I am guessing when she watches TV. I am hoping that she will post something to judith93585.

My situation is very similar. I am wondering how mini monovision would be tolerated with -2.5 in one eye & -1.5 in the other eye (1.0D difference). Hopefully there is a contributor that is using this type of Blended vision. The light adjustable lens appears to be a solution because you can change your prescription up to three times. However, it seems you would have to have a lot of confidence in the refractionist as well as the ophthalmologist who is doing the adjusting.

I don't think one would have any trouble adjusting to -2.5 and -1.5 D. That is only a 1.0 D difference. What I would question is the value of doing it. It would give good binocular vision in the -2.0 D distance of 20" or so. But, one does not need 3D for reading. Perhaps useful if doing some fine needlework or knitting, or some crafts that require very good 3D vision. My wife knits with only one eye (no vision in the other) set for distance (about -0.25 D) and refuses to even wear readers, or her progressives to do it! She watches TV while knitting, so that is probably why she is not using readers. But, not an excuse to not use progressives, which she has.... I guess she is just anti-glasses. She uses her tablet without glasses too, and just increases the font size. I can read it from across the room!

I don't need to reply, as you've stated my situation exactly. 😃

As I recall you did not go into this difference between the eyes as a plan. You had a bit of a miss on the first eye and adjusted the second eye some to compensate? That makes a lot of sense.

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The OP is in a different situation and I believe was attempting mini-monovision with a plan of -1.50 D in the near eye, and there was potentially a miss landing at -2.0 D. Her need as I interpret it is to gain some distance vision not near vision.

Nope - my first eye came out at -2.0, as planned. It was the second eye that shifted to -2.5. A happy accident in my case, but yes, Judith might want to go the other way.

However, it seems you would have to have a lot of confidence in the refractionist as well as the ophthalmologist who is doing the adjusting.

Yes, our situations are very similar and I too hesitate with regard to LALs for the same reasons you mention. I also have some concern about this being a new technology and wonder about any possible problems yet to be discovered. Without a strong recommendation to a particular LAL practice, I'm not inclined to go in that direction. If I find out anything interesting or helpful, I'll be sure to let you know!

LAL is not that new a technology. I looked it up, because I am considering the same lens. It has been used commercially since May 2008 in Europe, and late 2017 in the US. So, over 15 years' real experience, and so far no big problems reported with the tech.

I certainly agree that I would want an experienced doctor and technician.

With reading books the priority, that miss was probably a good thing.

Once again, something I did not think about! 3D vision. It never occurred to me that there would be no value in mini monovision for near and intermediate vision. Is there a way for the optometrist to test you to find out if you can tolerate mini monovision? Even with advanced cataracts?

I would say that there is little value in say having -2.0 and -2.5 unless you have a specific activity where you need excellent 3D vision at a quite close distance. On the other hand there would be huge value in having a -2.0 D and -0.75 D split. You would have excellent vision for all distances in the house and perhaps even vision good enough to drive with.

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I am not aware of any test they can do to determine if you are tolerant to a typical 1.5 D split between the eyes. Keep in mind that having a reasonable split in power between the eyes is not the end of the world if you do not like it. You just get progressives. Progressives will be needed if you have both eyes at -2.0 D. Having a split between the eyes of say -2.0 D and -0.75 D is just as easily fixed with progressives as having both eyes at -2.0 D. The difference between the two options is that with both eyes at -2.0 glasses are not going to be optional, even just within the house. However with one eye at -2.0 D and the other at -0.75 D you have an excellent chance of being eyeglasses free most of the time.

Thank you RonAKA. -2.0 & -.75 may be LAL target I should start with. I had a plan for the LAL adjustments and now realize it will not work. I am grateful that I postponed cataract surgery.

For a refresher, if my current refraction is -2.0 & -2.25 and I choose monofocals targeted at -2.0, I should see pretty much as I do now. I understand that I will lose accommodation. Vision should be sharper without cataracts.

With LAL isn't the recommended method to start with less myopia and then increase it to where you want to end up? For example in the near eye, to start with -1.0 and then increase myopia to -1.50 D, and for the distance eye to start at +0.50 and then adjust to 0.0 D?

I just rewatched the Mayo Clinic webinar about the light adjustable lens for ophthalmologists. In this instance, the Mayo Clinic used a Target (near non-dominant eye) for the IOL implant of -1.0. The patient ended up with a manifest refraction of -1.75. For the first adjustment, the target was -1.0 and the patient ended up with -1.50. Please, someone else watched this webinar to be sure I've interpreted it correctly. I don't think the patient received any EDoF.

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My opthamologist targets the light adjustable lens at +.25 in both eyes. Adjustments towards myopia will create EDoF. No understanding how much extended depth of focus there might be. With help from contributors to this forum, I have come to the conclusion that it is better to Target the LAL close to what you want your final Target to be and adjust in little steps.

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I do not believe that I would be able to obtain an outcome like Deanna 81707. I am too concerned that I would not be able to tolerate that much mini monovision.

That video is good, but I really dislike videos as reference material. There is no easy way to skim through it to finds some specific facts. I did take some notes and I believe the question on EDOF addition was addressed around the 18 minute mark. The speaker provided a lot of qualifications on the claims. What I found interesting was that some point and I did not take a note when, there were graphs provided on the starting point and what each step did in the adjustment. It was interesting how there were different starting point but almost everyone ended up in the -1.3 to -1.5 D range in the near eye. I recall there were few that opted for more than -1.5 D.

Julie, with advanced cataracts that prevent temporary mini-monovision contact lens experiments (something an optometrist could help with) from being effective, the only way I know to test for degree of monovision tolerance is post cataract surgery with LAL IOLs, say starting with dominant eye targeted (surgical or after first adjustment) for plano or -0.25D and second/nearer eye targeted for say -1.5D or -1.75D respectively (high end of mini-monovision). If it works well for you, test successful and you can proceed to further adjust prescription strength of near eye to your optimal preference, using reading glass strength experiments in your near eye to estimate what works best for you (adjusting distance eye also to adjust difference between eye prescriptions per your tolerance and preference).

If mini-monovision tolerance is poor, you can reduce or eliminate the difference between eyes by adjustments. At each adjustment appointment, you could decide to adjust 0, 1, or both eyes, depending on how confident you are on the adjustment you want and whether the second eye's adjustment target depends on seeing how the first eye's adjustment does or not. Even if you started LAL with both eyes near plano, you could adjust one eye first to nearer and see how you tolerate mini-monovision at that point and decide how to proceed from there, increasing or decreasing degree of difference between eyes as you moved eyes closer to target (by choosing whether to adjust one or both eyes at each appointment, and by adjustments in the final target direction which increased or decreased the difference per your tolerance).

As that is post surgical, due to advanced cataracts, an optometrist can't help much with that pre-surgically. This is an ideal use case of LALs - where pre-surgical testing of desired vision is not possible, so LAL is used to test prescription options

Good post, but 3 adjustments max. I would want to try to keep the third for fine tuning, but not needed.

That is not my issue . My surgeon is implanting the LAL Plus. This has more edof. Comes with .375 D. any myopic adjustments cause more edof. he is one of four surgeons in the country who has been implanting the LAL Plus. this surgeon is extremely reputable.

Julie, please let us know how the LAL Plus works for you, and especially your experience with the EDoF, since that seems to be the primary difference with the Plus version.

I was answering your earlier question to Ron: "Is there a way for the optometrist to test you to find out if you can tolerate mini monovision? Even with advanced cataracts?"

I do not feel comfortable with that much edof. nor do I feel comfortable with something this new.

Your point is well taken that its best to have a surgical target relatively close to the target you think you want so macromers remain available for fine tuning before lockin. In the case of advanced cataracts preventing sufficient pre-surgical experiments, there is a balance between the need to experiment post-surgically and retaining macromers for fine-tuning. This is especially important as up to 2D of (corneal) astigmatism may need LAL adjustments before you can accurately test how you like any spherical prescription, as the LAL is actually indicated specifically for 0.75D-2D of astigmatism correction (in case of LAL, surgeon would forgo surgical correction of astigmatism within the LAL correction range, and rely on adjustments to treat the astigmatism).

However, there is not a 3 adjustment LAL limit, though that is advertised as the limit, likely due to concern that adjustments beyond 3 risk exhausting the macromers. I personally have the LAL in both eyes and had a 4th adjustment in my near eye used for fine tuning. The graphic from the Mayo clinic video that Ron linked to showed one or two patients with 4 adjustments. The person performing my LAL adjustments said he's personally performed a 4th adjustment 2 times prior (I was only the 3rd time he did a 4th adjustment) - all 3 resulted in improvement over 3rd adjustment, and that he had heard of someone doing a 5th and a 6th adjustment but no information on effectiveness. He said additional adjustments result in diminishing returns as fewer free macromers remain for adjustments. On the other hand, he thought there were significant number of free macromers left at time of lockin on 4th adjustment as both lockins still required approximately 2 minutes (near the max time) adjustments. That last bit is speculation as adjustments could be long just to err on side of caution to make sure all macromers are polymerized to avoid risk of post-lockin drift.

If you "don't feel comfortable with something this new" why are you doing it?

Unless a miracle happens and more information becomes available on the LAL +, I will opt for the 1st LAL, doing so only because I can't try contact mini monovision with my cataracts, How I wish I could do monofocals and get good results like you have with intermediate targets. Did you do IOL calculations plus ask for the calculations from your surgeon to have such good results?

Thank you Lynda111

No. I think I've said I just told my cataract surgeon I wanted good intermediate vision in both eyes because my work requires me to be on a computer 8 hours a day.

I didn't inquire or even know anything about IOL calculations. But as I said, I guess I just got lucky and got really good all around vision afterwards. Most people who have cataract surgery just tell their surgeon the kind of vision they prefer after surgery: distant, intermediate or near. Sometimes a surgeon will suggest blended vision and sometimes a patient will. I think only a very small percentage of cataract surgery patients actually inquire about IOL calculations because they rely on the surgeon and his staff to do what is necessary. But some patients who are well-informed do ask for them and know what they mean.

what really concerns me with the Mayo Clinic webinar for light adjustable lens and ophthalmologists should know, is the targets were missed on the near eye.

the light adjustable IOL Target was -1.0

after the IOL was implanted, the patient's refraction was -1.75

the first adjustment Target was -1.0

the patient's refraction after the first adjustment was -1.5

that seems like a big miss for the first adjustment

am I being overly critical?

thank you

Around 23:00 into the Mayo video, they describe how the targets are hit with excellent precision, from the first adjustment to the final outcome. Everything I've read suggests that accuracy is a strength of the LAL. This is the main reason I am considering the lens for my surgery.

The error you describe on first adjustment does indeed sound larger than I would expect. Where do you see that case?

I discovered this when I tried to comprehend how the LAL process would work - so I watched the Mayo webinar for help. I had to watch 4 times. If I don't understand, please let me know,

2:38 the light adjustable IOL Target was -1.0D

10:02 after the IOL was implanted, the patient's refraction was -1.75D

10:02 the first adjustment Target was -1.0D

11:45 the patient's refraction after the first adjustment was -1.5D

I see the results presented for this patient the same way you do. I also see the summary results displayed for other patients at about 22:55 and 24:00, showing adjustment results within 0.25 D of target for all or almost all patients.

So, the 0.50 D miss for that one patient does seem to be a modest outlier, perhaps affected by technician error, measurement error, rounding to the nearest quarter of a diopter, or just the unavoidable fallibility of any technology operating on human beings. It doesn't bother me, because of all the other indications that LAL adjustments are generally quite accurate, but it does provide a useful reminder that none of these technologies is perfect.

Perhaps there is an error in the presentation? It does not make sense that the 1st adjustment target should be -1.0D.

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JDvison has LALs in both eyes and has much experience.

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What is your opinion on the added EDof in the LAL +?

Could be an error.

I don't know whether your question on LAL+ is directed to me or to jdvision, but I think my feelings are similar to yours. I have used monovision successfully for many years, and don't see a need for additional EDOF; I would be concerned that it may create undesirable trade-offs in quality of vision. I also am cautious about being an early adopter for new technology - I might be willing to be an early adopter for a new model car or smartphone, but I prefer to be very conservative with my eyes!

I can't evaluate the extra

EDOF in the LAL+ as my experience is with LAL in both eyes. Subjectively, I believe I have a bit of EDoF in my near eye but not my distance eye (which matches what I've seen on when LAL/LDD would produce some EDoF). I do not notice any smear or other visual abberations with the likely small amount of EDoF the near lens likely imparted. Using reading glasses cleans up any clarity issues I have when needed (in less than bright light, smaller or closer than is comfortable with my mini-monovision eyes - which provide excellent distance vision at all light levels, and excellent intermediate and functional reading in good light, without any glasses/contacts).

My suspicion is that the EDoF effect would likely be similar/small even with LAL+ as the lens not (currently) marketed as, nor can I find FDA claims for, EDoF. Without such claims, I would think they would get a lot of complaints if the level of EDoF were high enough to cause noticeable smear or other abberations.

That said, the best person to answer would be the person doing the LAL+ LDD adjustments, based on the experience their patients are reporting at their final adjustment before lockins begin.

I can explain the seeming miss on the Mayo Clinic video light adjustment. The near (left) eye target of -1.0D 0 axis required a sphere change of 0.75D and a cylinder (astigmatism) change of 2.0D. That's somewhere in the range of 1.75D to 2.75D total adjustment (depending on whether to count the full cylinder or only half of it as in spherical equivalence calculations). In any case, that is more than can be completed in a single adjustment. It is quite likely the LDD issued a warning to that effect, but in any case, it prioritized the cylinder adjustment to 0 and applied whatever else it could fit into one adjustment as sphere. So, it managed to eliminate all or most of the 2D of astigmatism while also adjusting sphere by 0.25D towards the target. The patient was happy with the resulting "ideal" moni-monovision of plano and -1.5D, so they didn't need a second adjustment to try to get to the -1.0D sphere target.

The limited range of a single adjustment was never explained in the video.

I meant "ideal" mini-monovision above. This website doesn't appear to allow editing posts.

This website doesn't appear to allow editing posts.

It does at times. I think that time extends from some number of seconds after the initial posting, for some interval afterwards. You are looking for a pencil icon. That interval afterwards I don't know. Less than a day, but maybe a lot less.

This is my first edit on this thread.

And I'd add that if I were picking the adjustment plan, I would have changed the first adjustment target to -1.5D or -1.75D anyway after seeing the post-surgical pre-adjustment refraction, since -1.5D is the sweet spot for mini-monovision and setting the sphere target closer to current refraction saves macromers to maximize flexibility for subsequent adjustments. The patient wouldn't be able to accurately test the -1.75D monovision with 2D of astigmatism present. After a first adjustment to -1.5D or -1.75D with little or no astigmatism, the patient could decide to keep what they had or reduce the mini-monovison to improve tolerance at the cost of near vision.

Trilemma, thanks. I figured out why I couldn't edit. Yes, editing is only available for an hour or two, but that wasn't my issue. When you first [Post Reply], the displayed page is missing the edit pencil icon. You have to refresh the page to get the edit pencil (within the editing time window). I didn't notice the bug that it required a refresh first. Thanks again.

Good to know!

One additional thought on added EDoF from LAL+: A small amount of EDoF is generally beneficial for near and intermediate distance, but EDoF (I can't characterize how much) can be detrimental to distance vision, especially at night as it could smear point light sources and reduce contrast sensitivity, so may risk affecting night driving. I believe Ron has often recommended avoiding EDoF especially in the distance eye in a mini-monovision scenario. So, if I were presented with option of LAL vs LAL+ and planned to use it for mini-monovision, I would likely request LAL in my distance eye and LAL+ in my nearer eye, unless I had more information and evidence on the EDoF effects to expect from LAL+.

This is the 1st post I read on this Forum. This is what tempted me to want to try mini monovision,

https://patient.info/forums/discuss/rxsight-light-adjustable-lens-my-current-experience-792685

This post talks a lot about EDoF. Before this, I was very content to be nearsighted with as much intermediate as I could get.

Jdvision, did you target the LAL IOL for your distance eye at +1.0D? I have read through many past posts! If so, why would the surgeon do so?

Initial surgical target for distance eye was +1.0D, but with plan to adjust (RxSight LAL IOL) to plano. Reason was sugeon's assertion that EDoF is added via adjustments in the myopic direction. However:

1. Dr. Krad YouTube videos claim EDoF is added when first adjustment target is between -0.5D and -2.5D, rather than based on direction of adjustment. I've never seen his claim elsewhere, though.
2. I see no evidence of having EDoF in my distance eye (I believe I have some in my near eye)
3. EDoF may do more harm than good for distance eye

So, in retrospect. though I don't think surgical target of +1D hurt me any since LAL adjusted to near plano, it may have been pointless vs surgical target of plano.

For near eye, there may be some benefit to surgically targeting so adjustments will be myopic direction, as long as adjustment plan is consistent with FDA adjustment range claim .

Is it your understanding, that EDoF occurs only on the first myopic adjustment? This is what I have been told by my surgeon

Do you think you received EDoF with each myopic adjustment?

I have not found any documentation from RxSight on LAL EDoF, so nothing authoritative.

My surgeon implied that adjustments (plural) in the myopic direction resulted in EDoF, but never explicitly said whether it would only be the first, or multiple. I had assumed each myopic adjustment might add some and that it would be proportionate to the magnitude of the adjustment, but that was purely my own speculation.

The Dr. Krad YouTube video claimed that RxSight told him only the first adjustment, if the target were anywhere between -0.5D and -2.5D would result in a one time EDoF addition.

Since EDoF is not an FDA evaluated and approved claim of the LAL, RxSight is likely unwilling or unable to write anything about EDoF due to FDA regulations.

Thank you. I think your suggestion implant the LAL+ in near eye and LAL in distance eye is an excellent idea.

If each ophthalmologist has their own individual method for adjustments, it makes it difficult.

If I see another ophthalmologist, maybe it will help, maybe not.

It is erratic in how long it allows edits. One trick is if you want to do a near immediate edit and the pencil is not showing is to use the browser back button, and then the forward button to bring the post up again. Usually that brings the edit option up.