The Pros and Cons of Mini Monovision
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In view of the recent posts with misinformation about Mini-Monovision I thought I would post my experience with actually having Mini-Monovision. I first used monovision when I was wearing contacts for distance vision and I got to the age where presbyopia started to become an issue. Taking contacts out to read, and then putting them back in again, is not really a viable option, so with the help of a contact lens fitter I set one eye up for closer vision and the other for full distance. It worked very well for me, but with all of the issues associated with wearing contacts. I did it again for about 18 months after I got my first cataract surgery with a monofocal IOL set for full distance, and used one contact for the near eye. That worked well, so I proceeded to do it with my second eye using an IOL. I ended up at -0.25 D in the distance eye and -1.40 D in my near eye. Astigmatism compromises my vision a bit in the near eye, but all in all I am extremely satisfied with the outcome. I would not hesitate to do it all over again. The only thing I would do differently would be to get a toric in the one eye that turned out needing it. So what are the Pros and Cons of doing it?
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Cons:
- First you have to accept a slight decrease in distance visual acuity as at full distance you will not have much binocular summing effect. My distance eye alone is 20/20+. If both eyes were done for distance, I expect my binocular vision would be 20/15. So, I did give up half a line of visual acuity.
- From my minimum distance of vision at 8" out to 18" I do not have much binocular 3D vision. I have threaded a needle, but I think if one was sewing for hours, some +1.25 or so reading glasses would make it easier. From 18" out to 7 feet or so, I have very good binocular vision. I would expect that monovision would not make for a good excuse for swishing on a tennis or golf swing.
- For reading very fine print in dimmer light you will likely need reading glasses, or a light. I use some +1.25 D readers perhaps once a week or so. I don't bother bringing glasses with me when I go out shopping or pretty much anywhere. I have had no trouble reading menus in dimly lit restaurants. I may put readers on momentarily once a week or so, for a particular task. But, they come off immediately as I dislike looking at anything of any distance with them on.
- I drive at night in the city, but for safety purposes I do wear a pair of prescription progressives when I drive out of the city on dark roads at night. I worry about a deer or moose coming out of the ditch and not having time to see it. I may wear my prescription glasses once a month or so.
- You may have trouble finding an Ophthalmologist that will work with you to get properly fitted with the correct IOL powers to achieve good monovision. Some just do routine distance vision in both eyes without even asking what you want. Some seem unaware of how it works. And I don't like to play the conspiracy theory card, but I suspect some find the "premium" lenses much more profitable than doing monovision. Monovision just needs standard monofocals which are the lowest cost and I'm sure the least profitable for them.
- If you have difficult eyes with prior laser surgery, or are at the extremes for myopia or hyperopia, it can be more difficult to hit specific refraction targets needed for monovision. In this case your will want to have a surgeon that will be very careful selecting IOL Power formulas, and making sure the power is as correct as possible. You may also want to consider surgeons that use the Alcon ORA system to measure the power during surgery to ensure higher accuracy.
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Pros:
- Aspherical monofocal lenses bring all the light to a single point and for that selected point give the highest visual acuity. With a monofocal each eye is set to a different distance. Normally the dominant is set for distance (0.00 to -0.25 D), and the near eye set for -1.5 D, or about 2 feet. This gives the brain two options for vision, and with each eye there is quite a wide range of distance they are still effective at while being off peak. The brain does a good job of blending the images together as one.
- Compared to multifocal (MF) lenses and extended depth of focus (EDOF) lenses an aspheric monofocal has a high contrast sensitivity at the peak focus point. So this gives maximum contrast sensitivity in the distance eye at night for driving, while the other eye can provide maximum contrast sensitivity up close, like when reading a menu in a dimly lit restaurant.
- Monofocal lenses, unlike MF and EDOF lenses have very minimal optical side effects like halos, flare, and spiderwebs around point sources of light at night.
- Monofocal lenses have the lowest price and in many jurisdictions it is at no cost. This compares to MF and EDOF lenses which have a premium price in the range of $5,000 to $6,000 a pair.
- If the focus point differential between the eyes (anisometropia) is maintained in the 1.25 to 1.5 D range there is minimal impact on the ability of the brain to blend the two images. In the past some have used full monovsion with anisometropia in the 2.0+ range. This gives better reading, but at a cost. This practice has been pretty much abandoned in favour of mini monovsion (1.25 to 1.50 differential).
- With MF and EDOF lenses you kind of roll the dice and hope to get what you expect. If you do not and are unhappy with the outcome, it may be more difficult to correct the issues with eyeglasses. You can't get eyeglasses that will undo the multiple focal points built into a MF lens, or unsmear the stretched focal point of an EDOF. However when you use monofocal lenses to do monovision your eyes are easily correctable with eyeglasses. Prescription glasses are always a safe plan B that can be counted on.
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Summary
My experience is that Mini Monovision is one of the "Best Kept Secrets" in the Ophthalmology field. Some can't be bothered to tell you about it. Some don't seem to know much about it. Some don't want to be under pressure to hit a specific target for myopia in the near eye. And, unfortunately some only want to do premium lenses with their associated higher profit margins.
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I would suggest if you are interested in mini-monovision there are a couple of critical questions to ask when looking for a surgeon. One of course is to ask if the surgeon does monovision and is willing to work with you on it. The other is to ask what brand and type of lenses does the surgeon use. Some a locked into one specific manufacturer, and others are locked into premium lenses only.
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And for those that suggest monovision is unnatural consider that man has been around for about 200,000 years, while eyeglass correction has only been available for less than 1,000 years. Our brain has evolved to use the images from two eyes and put them together for the best combined image. And also consider that it is not only used for IOLs, but it is also commonly used with contacts, and also with Lasik surgery to get closer vision. They don't use Lasik to give you a multifocal eye, they use it to give you monovision using two eyes.
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I hope that helps some, for those who are considering this Best Kept Secret option for IOLs.
11 likes, 250 replies
indygeo RonAKA
Edited
That's an excellent summary Ron. I would say it's the best strategy out there. Indeed, it's one many surgeons themselves take when getting their own eyes done.
In my case, I have a monofocal in my distance non-dominant eye and an EDOF (Rayner EMV) in my near, dominant, eye. The offset is less than 1.0 D. I start getting binocular summation at around 16 inches out to quite a far distance, particularly during the day. At this moment I'm reading a license plate clearly during the day with my near eye at 90 feet. This was pleasantly surprising to me as I had expected less.
I, too, highly recommend a mini-monovision strategy, if it's possible, for anyone who wishes high quality vision with spectacle independence.
Indy G
joseph54594 indygeo
Posted
Can you see ok inside of 14"? I use my phone like a laptop and was told all solutions are good, but the very close vision, would not be good.
indygeo joseph54594
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Yes, I think the nearest clear distance in my near eye is about 11 inches. I use my phone all the time without issues. I hope this helps.
IndyG
joseph54594 indygeo
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11" is great! how is your night vision? Why did they do your dominant eye with the edof and non dom eye, distance mono? I might have my dominant eye done first and distance was suggested. My choice for my Dominant eye is a monofocal lens or Vivity EDOF. For my other eye, I want the close, 11" or 13", so I am having a having a hard time with that choice. Vivity would give intermediate and far, but I do not know if the near can be set as close. I could do a monofocal lens or look into what worked for you. I like that Vivity could keep my intermediate, but have concern for night vision. How is your ability to look at documents on a table or watch TV or view a behind the counter menue, without eye glasses?
indygeo joseph54594
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Hi Joseph,
Yes, I consider the 11´´ near vision more than acceptable. Now...You ask an astute question about my dominant eye lens choice. When I went for my first consultation in 2018, my left eye was more affected than my right eye. It was quite bad and I considered myself pretty much blind in that left eye. My right eye was less affected at that time but affected nevertheless. My surgeon said that he could not determine conclusively my eye dominance and that, regardless, he was going to do my most affected eye first and set it for distance. Thus my left eye got the monofocal lens for distance. Bear in mind I can see well with that lens from about 24 inches and beyond.
Flash forward to 2022 and my right eye by then was really bad. Again, pretty much blind. Although I´d moved countries, I decided to go back to my surgeon in the UK. I kept reading about some of the new EDOF lenses out there including the Rayner EMV lens and I wondered if I might be a candidate for a lens like that in a mono-vision scenario. In theory, it made sense to me and I hoped that something like that would work. When I visited my surgeon, he said that indeed such a lens would work for me. In fact, he was the first to implant the Rayner EMV worldwide and it was his ¨go to¨ lens for many situations.
My results are beyond my expectations. I can read the tiniest of print with my right (Rayner EMV) eye. I get blending of the two eyes around 24 inches out to, I dunno, 30 feet or so. What surprises me most is that my ¨near¨ eye has pretty good distance vision particularly in relatively bright light/sunny days. It seems about 95% as good as my distance eye in that case. I do not wear glasses when driving at night, probably due to my monofocal distance lens. I can see a dashboard perfectly. I don´t wear glasses for anything really. I´ve not found a scenario where I find myself compelled to purchase glasses. The offset for the Rayner lens was 0.75D from my distance plano eye. Quite tame.
All in all, I would indeed recommend a mono-focal in the distance eye and an EDOF lens set slightly ¨in¨ from the distance eye by maybe 1.00D. I would also consider two Rayner EMV lenses offset slightly in a mini-monovision scenario because I do love the lens. I personally wouldn´t consider the Vivity lens because I´ve read too many accounts of people having problems with them (lack of contrast, waxy vision, poor nighttime vision, etc.). With that said, some people have had great success with it, so I guess it just depends on the luck of the draw. My personal view was to go with something that made sense to me and that I perceived as the lowest risk. Once my distance eye was successfully nailed down, I figured I was low hanging fruit for a reasonable outcome as long as the EDOF lens could come in anywhere between an offset of 0.50D to 1.25D from the distance eye. Plus, I figured if any target was missed I could improve things with Lasik or, as a last resort, glasses. I did take a bit of a leap of faith with the Rayner lens, though, as it was relatively new on the market at the time and was not all that common in the US, for example. Something about Dr. Graham Barrett being behind its design helped to convince me. Plus, I fully trusted my surgeon. Both seemed to have solid reputations. I hope this helps.
Indy G
SandyRose indygeo
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Hi Indy G,
Thank you for sharing your experience, its really helpful.
I am 50 and recently told, after getting a 3rd opinion (across 2.5 yrs), that I have sugnificsnt enough cataracts to be causing my blurred/distorted vision - the right eye more mature than the left. I am a high myope (L - 10.5; R 12.0) with a mild astigmatism. After the delight of finally having a diagnosis and treatment plan, I have spent many (many) hours researching the best lenses for me. A risk averse perfectionist who does not want glare/halos, wanting as much spec independence as possible but not minding reading glasses if necessary, I've honed in on and spent a lot of time weighing up the pros and cons of the Eyhance Toric v RaynerOne EMV Toric lenses for my upcoming surgery.
I'm really encouraged to read of your experience with the RaynerOne, as my surgeon is happy to use Eyhance or Rayner, but has experience of the Rayner here in the UK. My only concern is the newness to market and therefore the lack of long term studies. I am thinking of getting the dom eye set to plano and non- dom to 0.5D, as suggested by my surgeon, with either Eyhance or RaynerOne. The time between your two surgeries gave you the opportunity to assess your dom eye vision, which is great. I will only have 2 weeks (unless I ask if a 6 weeks gap for healing/then assessing is suitable for me, being so myopic). If I cant do that, I'm not sure about attempting mini-monovision? If only there wasn't so much choice out there, and outcome variability. That said, the wealth of information and experience on this forum has been an enormous help.
Sandy Rose
RebDovid SandyRose
Posted
If you can wear a contact lens in the unoperated eye, then you would be much better off delaying the second surgery by six weeks so the first eye has time to 'settle'. If you want, this also would give you an opportunity to trial monovision.
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Regarding the choice between the RaynerOne EMV and Johnson & Johnson Eyhance, you may want to consult the following:
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According to Rayner itself, the RayOne is marginally superior to the Eyhance from 0.0 D to +3.00 D; worse than the Eyhance from 0.0 D to c. -1.50 D; and significantly better than the Eyhance thereafter. See "RayOne EMV and TECNIS Eyhance: A Comparative Clinical Defocus Curve". Note, however, that in addition to coming directly from the manufacturer, this is not an academic study and has none of the informational apparatus a published academic study would have.
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In contrast, a study published in January 2022 in the Journal of Refractive Surgery, of which Mayanik A. Nanavatny is the lead author, reports superior vision with the Eyhance, both uniocularly and binocularly, at every point to the myopic side of 0.0 D; nearly identical results from 0.0 D to +1.0 D; and slightly better vision with the Eyhance from +1.0 D to +1.50 D. The article is paywalled, but I was able to get online access through my library. "Visual Acuity, Wavefront Aberrations, and Defocus Curves With an Enhanced Monofocal and a Monofocal Intraocular Lens: A Prospective, Randomized Study".
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According to @Lynda111, if you cut and paste the Nanavatny article on Google, you can read it on "Healio."
RonAKA SandyRose
Posted
There probably is not as much choice as there appears to be. The EMV and Eyhance are marginally at best better than monofocals with respect to depth of focus. I believe the standard offset for the EMV is -1.25 D for the near eye. I would not suggest targeting plano for the distance eye as you are then at greater risk of going positive (far sighted). The normal distance eye target is -0.25 D.
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You may want to check out the @karbonbee posts as she was about as myopic as you are. Accuracy of the power calculation is always a bit of a concern with an eye that is that long.
SandyRose RebDovid
Posted
Thank you, I'll check whether I have reviewed these studies.
As an update, I spoke with my optometist today, who prescribes my contact lenses, and he told me not to try monovision, as he knows my eyes are very sensitive, reminding me how many different toric soft contacts with diff readings adds we have tried, and I still put on readers. He recommended I target the best distance vision and work
on everything else afterwards. As he knows me so well, I'm tempted to agree. Then its Eyhance v RaynerOne Toric and whether I get any benefit from an 'enhanced' monofocal if I'm not doing monovision!
SandyRose RonAKA
Posted
Thank you, Ron. I was worried about over or undershooting the target, particularly with my level of myopia. It would be great to have some spec independence, but I have no idea what I'll end up with by trying monovision, so should perhaps steer clear. This is the risk averse part of me coming out!
indygeo RonAKA
Edited
I wouldn´t say the the offset of 1.25D is standard with the Rayner EMV lens as I know my surgeon (who has implanted many of these lenses) usually goes no more than 1.00D and often goes about 0.50D. I do think there´s some benefit with the Rayner lens in terms of depth of focus. I´m just relaying what was said by my surgeon.
IndyG
RebDovid SandyRose
Posted
If you're not doing monovision and are deciding between the Eyhance TORIC and RayOne EMV Toric, then even the Rayner "article" shows that with both IOLs presumably at or near a 0.0 D refraction--Rayner doesn't say--the Eyhance provided superior visual acuity from 0.0 D (4m for its curves) to at or near -1.50 D (66.67 cm / 26.25"). The Nanavaty study in the Journal of Refractive Surgery shows the Eyhance providing superior visual acuity at all distances from 0.0 D (also 4m) and closer in.
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Of possible interest, the Rayner "article" claims that at -3.00 D (33.33 cm / 13.12"), the RayOne EMV's mean visual acuity was (what looks to be) c. 0.32 logMAR (c. 20/42) vs. worse than 0.70 logMAR (20/100) for the Eyhance. In contrast, the mean visual acuities at -3.00 as measured in the Nanavaty study were c. 0.48 logMAR (c. 20/60 Snellen) for the Eyhance and c. 0.62 logMAR (c. 20/83 Snellen) for the RayOne EMV. Also, the average of the mean defocus curve visual acuities from the three binocular Eyhance studies I've found--the Rayner "article" gives claims for binocular results--was, at -3.00 D, 0.437 logMAR (20/55 Snellen).
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Of course, there may be other reasons that favor the RayOne EMV or strengthen the case for the Eyhance. I'd be interested in whatever you're able to report.
RonAKA indygeo
Posted
I was going by an article by Graham Barrett who worked with Rayner on the development of the EMV. If I read the article correctly the early development was based on a -1.0 D offset, but he concludes the article by saying he prefers -1.25 D.
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The Ophthalmologist Closing the Distance How does modest monovision work as a strategy for balancing near and far vision? Graham D. Barrett | 02/01/2022 | Opinion
david32346 indygeo
Posted
indygeo, if you already answered this, sorry for the repeat question, but what are the numbers on your two eyes? 0.00 and -1.50 ? Thanks.
indygeo SandyRose
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Hi SandyRose, Apologies for the very late reply. You may have already done the surgery by now, I don´t know. It sounds like you may be seeing the same UK surgeon I had. He extensively uses the Rayner EMV lens. I would not worry too much about the lack of long term studies on the Rayner lens. I can just say that it performs quite comfortably for me and I would not hesitate to use it again if I needed it. I think it´s important to nail down the first eye for plano. Once that´s locked in there´s quite a bit of wiggle room as to how you can achieve a satisfactory outcome with the second lens. You could be in a range of -0.50 D to 1.25 D and be quite happy with that I think. I hope all goes well for you.
IndyG
aspen88 RebDovid
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Hi RebDovid, I realize this post was several months ago but since I'm interested in these 2 lens I'm curious what the studies show. Isnt the article you're referring to comparing the Rayner One vs Eyhance and not Rayner One EMV? I'm thinking Rayner One vs Rayner EMV are different?