The Pros and Cons of Mini Monovision

I wonder if that ophthalmologist considers 15 months to be short term? I have had mini-monovision for that long now, and essentially never wear glasses. Perhaps once a week with some very fine print I may pick up my +1.25 readers to read something. I have some progressive glasses that fully correct both eyes, and I virtually never wear them.

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Traditional full monovision has about 2.5 D of anisometropia, and my surgeon says he has had requests to do up to 3.0 D. I can see that amount causing issues. But, in my case the anisometropia is 1.25 D (1.625-0.375) and it does not cause me any issues.

@RonAKA, I am reviewing your reply here and on another thread about the settings for near and far to give 13" or closer near on my smartphone, but also good night distance. I will have minimono and have the distance eye done Monday. For settings, I think - .25 was the distance setting for close, that you or someone suggesting, but for close, I think you or another suggested a max of - 1.75. But, my optometrist, who is not the surgeon, but has been practicing 30 years and a personal friend for 40 years and has worked with the surgeon, is strongly recommending-2.50 for the close eye. The dominate eye, I think he agrees with the 2.5 or -0.5 for the distance eye. I am not sure I am writing it correctly with decimal placement.

The 2nd eye won't be done for 2 or more weeks, but wanted to be sure I understood things and that a stronger distance vision setting could cause a problem with miniono. So, I think my optometrist is suggesting -.50 for distance and -2.50 for near. That is a 2.0 difference in D, but someone here suggested more than 1D could cause depth perception issues. What are your thoughts?

A distance target of -0.25 D is very standard. You should ask the surgeon what the predicted outcome will be in diopters. Because the lenses come in steps of 0.5 D, the outcome will almost never be exactly -0.25 D. If the predicted outcome is very close to 0.0 D I think I would be tempted to take the next higher available lens power which would bring the target to be a bit more than -0.25 D. The problem is that if you go past 0.0 D into the positive territory, then you become far sighted and that hurts nearer vision. Best to be a little under to avoid that.

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Targeting -2.50 D is old school full monovision. It can be done, but most no longer go that far. It can leave a gap of poorer vision between the near eye and distance eye. It also can reduce depth perception and be disorienting for some people. The recommended maximum differential between eyes is 1.5 D. So, if you target -0.25 D for the distance eye and achieve that, then you could respect that limit on the differential and target -1.75 D on your near eye. I think based on the defocus curves and my personal experience -1.75 D should allow you to read your phone comfortably.

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One thing you can do after your first eye is recovered (which takes 5-6 weeks) is to try some cheap +1.5 D drug store reading glasses with your new IOL eye. If it hits -0.25 D the +1.5 D readers will simulate -1.75 D in your IOL eye. That will give you a pretty good representation of what your vision will be like with a -1.75 D target in your second eye.

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I would not go ahead with the second eye until after the first eye is fully recovered and your optometrist has done a full refraction and determined where you ended up. This information should help the surgeon be more accurate on the second eye. And, if for example you end up at -0.5 D instead of the -0.25 D then you can make your second eye target a little closer at -2.0 D, and still respect the 1.5 D differential limit.

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I hope that helps some,

it does help, thank you! It also is causing me some confusion. My optometrist right away today heard me emphasize 13" close and did calculations while on the phone with me. going .25 to .5, is not horrible, but I may be less eye glass dependant than you while night driving. His 2.5 recommendation for the near vision is based off his calculations, but you have achieved closer than 13" with 175 and .25, My Optamologist is no help in this and defers to my optometrist. So, short of delaying my surgery to get a second opinion with another Dr, I'm heading towards the .5 dominant eye surgery Monday. It is needed quick with my inability to drive at night. I guess the 2nd eye, I will have time to test and see if 1.75 will give the same close vision as 2.5 and am not locked into that now.

Before having your first eye done, you should decide whether you prioritize near and intermediate or distance and intermediate. Even with monovision, a monofocal IOL is unlikely to give you all three without so large a difference between the two eyes that you're likely to suffer adverse consequences. Accordingly, I respectfully suggest postponing surgery until after you've decided on your priorities and, if at all possible, tested mini-monovision. If you can't test, conventional wisdom is that up to a 1.5 D difference is reasonably safe. Being conservative when it comes to my own eyes, however, without testing I'd target only a 0.75 D 1.00 D difference to protect you against refractive surprise taking you beyond a 1.25D or 1.50 D difference.

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Second, if you prioritize near and intermediate, I suggest asking your surgeon to do your "near" eye first. That will give you a better chance of getting the near/intermediate vision you want. Then wait at least six weeks for the second eye. Evaluate the vision in the first eye, both in terms of a vision test and your personal satisfaction. Then decide on a target for the second eye.

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Good luck.

That would not be wise. If the priority is near and intermediate vision then you do the distance eye first to allow the surgeon to calibrate their IOL calculation formula so they will be more accurate on the near eye if it is the priority. And, you can also then set the target for the near eye knowing where this distance eye is, and use the full 1.5 D differential to set the target for it, to get the most close vision as you can without exceeding the differential limit. And you can also confirm that it will be enough by using the +1.5 D reading glasses test.

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This is advice for @joseph54594, not you. I have concluded you don't really want to take any advice.

Thank you, @RonAKA. Luckily, My optometrist and surgeon agree they want to do the dominant eye, first, for distance. My optometrist felt/calculated that I would hit my near vision target, 13" min, with 2.5D and you hit it with 1.75D. Perhaps he decided that at .5 for distance, he thinks that is closer to the 2.5 and at worst, I need glasses to drive vs you, who only needs on dark, unlit roads. I would prefer to have your results and will still discuss with my surgeon, but he won't see me until the day of surgery. I may ask my optometrist if there is time to test a 1.75D, but he seemed confident of his calculations and he is a personal friend and has a fantastic reputation in Claremont, CA. He is happy I went with momofocal IOLS, as he has not had satisfied patients with multifocal and not sure if he has seem many get EROF lenses. He also doesn't do the surgeries, so his opinion is not based on Premium IOLs.

Then, if the priority is distance, or distance and intermediate, do you recommend doing the near eye first to allow calibration and greater accuracy for the far eye?

I believe RonAKA and most Optamologist have recommended, If not doing the same setting for both, doing the dominant eye first, which seems to typically be distance. Even in my case, I am prioritizing close, but without sacrificing a lot of distance. RonAKA and my Optometrist and my Optamologist, have all said do my distance eye first. I am still Lay in all this, so I could not explain why that seems to be unanimous. But, what I am finding out, is that knowing both goals is important. If I do my distance at some superman distance, that affects where my near is set.

Yes, if distance is the priority, then doing the near eye first would be an option to consider.

Personally, I suggest you discuss your thoughts, priorities, and concerns with your surgeon, then follow his or her advice. In my case, my surgeon has recommended doing the far eye first. If nothing else, this approach gives two chances to secure high quality near/intermediate vision, which is my priority to the point of be willing to wear glasses to, for example, drive.

To be realistic one cannot pick an exact target like -0.25 D or -0.50 D. A more achievable expectation is to ask to be between those two target numbers. Your ophthalmologist should be able to tell you what the IOL power choices are and what outcome in that range can be expected. For example your two choices may be -0.10 D or -0.48 D. The -0.48 D probably would be the better choice for you.

The only issue with dealing with your optometrist is that they may not have your detailed eye measurements and the IOL Calculation sheet which shows your options for IOL power and what the outcome is predicted to be. If they have it then they should be able to tell you what power options there are and what the outcome of each is predicted to be. If not, then you need to have that discussion with the surgeon who will have to have the IOL Calculation sheet so they can be prepared to have the right power lens at hand for your surgery.

I have already collected as many as 7 measurements, including 3 IOLMasters and 2 Pentacams, calculated the average, and my surgeon suggested 2 Vivity options for the near eye at -0.8D and -0.45D. For correct monovision, the -0.8D option is probably better. But I'm afraid that Vivity is still not a monofocal lens, and with a large difference from plano, all negative optical effects will be amplified. Usually mini-monovision studies for Vivity were done at 0.5D, more surgeons are afraid. My surgeon is ready to put anything, but now I'm afraid myself. These extra 0.35D will give a few extra inches up close, but the negative effects of Vivity at a distance may appear, and I will lose a few lines of the optometry table.

If the calculations gave -0.5D or -0.6 it would be easier to make a choice, but -0.8 seems like a lot of risk to me. After all, if Vivty, due to EDOF technology, by 0.5D gives an increase in near vision from 3 feet to 2, then additional -0.5D should give another half a foot, and the next 0.3D is already quite a few inches.

I am ready to put up with incomplete near vision, it is enough for me to see a large font on a smartphone, and small inscriptions can be read from the camera of the same smartphone. And for long reading if it is needed - let there be readers.

the -0.85 will be totally worth it. you are lucky to have landed on refractive sweet spots of -0.10, -0.45 and -0.80. make use of it. myopia doesn't exaggerate the optical effect as much as the lens design itself. good luck!!

also with my clareon experience i would do what the surgeon is suggesting -0.45 and -0.8. this will prevent any risk of hyperopia and both eyes will give you very good near and far.

i am at -0.4 with panoptix and the distance has no problems.

While choosing a lens only for the non-dominant eye from two options -0.45 or -0.8D, for the dominant one I want to make it as close to plano as possible for the best distant vision.

What did you mean? "myopia doesn't exaggerate the optical effect as much as the lens design itself"

I have read reviews that the bad effects of multifocal lenses are exacerbated by large deviations from plano.

If it were me, I would only do Vivity in the near eye, and stick with a monofocal like the Clareon in the distance eye. That addresses much of the contrast sensitivity loss risk with the Vivity. To be largely eyeglasses free I think I would go with the -0.8 D choice. I am grasping for a name, but I recall there is one contributor here that has a Vivity at -1.0 D. The other obvious option is simply a Clareon monofocal at -1.5 D of course.

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One thing to keep in mind is that with monovision the brain suppresses the poorer image. So in some ways the poorer the image at distance from the near eye, the easier it is for the brain to suppress that image.

-0.45 is tour best plano option. the better than that is -0.10 which has a high risk of you being hyperopic which will make all distances blurry. i just checked again and i am -0.45 in the panoptix and it is 20/15 for distance.

your choice of myopia will be same for monofocal, vivity and panoptix and for your distance eye that is what i would suggest for all 3. the -0.45.

i am sitting 10 feet from my tv and it says 'superb picture quality' on the right too side. i never saw it with symfony -0.19 but i see it clearly with -0.45 panotpix.

the bad effects of multifocal are due to the lens design the myopia choice doesn't worsen them much at all. also i have cone to believe that these bad effects are specific to individuals.

i have the worst of multifocal bad effects and i am soon going to post about it with drawings.

Yes, there is such a member: laurie30147 - David970

Message Edited 10 days ago

"My right eye is -1.0D and my left eye is -0.25D.

My right eye is in best focus from about 8 inches to 5 feet, while in my left eye, good focus starts around 3 feet.”

But I do not need 8 inches without glasses, 15 is enough to see the phone, smaller and closer either with the phone or with glasses.

Thank God we are men and we don't need to dye our eyelashes where glasses can't help.

About Clareon on the second eye - a good option if the surgeon agrees. Our surgeons consider that if a multifocal lens is installed on one eye, then only the same on the second.

"i never saw it with symfony -0.19 but i see it clearly with -0.45 panotpix"

soks Did you replace symfony at the panoptix, or are they in different eyes?

different eyes.

i attached my iol master but replied to ron by mistake and is currently under moderation. it is very similar to yours.

what was your pre cataract refraction?

Here is a graph of defocus curves I made when I was seriously considering the combination of a Vivity in the near eye and monofocal in the distance eye. It strikes me that a combination of a Vivity at -0.75 D and a monofocal at -0.25 D gives pretty good coverage down to -2.75 D (15", LogMar 0.2). The distance vision of the Vivity eye stays quite high at a LogMar of 0.1. Combined with the distance vision of -0.05 LogMar of the distance eye, overall 20/20+ should be achieved.

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"what was your pre cataract refraction?"

Glasses? -6D with cylinder 1.5.

But IOLMaster measured the lens for me at 11.5 or 12, there is a rather long eye, but it fits into the Vivity size range.

The American Academy of Ophthalmology Refractive Surgery Preferred Practice Pattern (2021-2022) discusses monovision as a viable strategy for treating presbyopia in some cases without mentioning the concerns you found at an ophthalmologist's website. (I searched on an part of the language you quoted without finding that website.)

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Look for the sections "Refractive Surgery for Presbyopia", "Keratorefractive Surgery", and "Intraocular Surgery".

do all edof lens lower contrast? is vivity being the only non diffractive edof, better than the others. if one is considering a mono focal lens in one eye and an edof like vivity in the other, would the edof always be for closer vision?

Yes, I believe all lenses that meet the standard of extending depth of focus by 0.5 D or more will compromise peak visual acuity and contrast sensitivity. There are not many common lenses that meet that requirement for focus extension other than the Vivity and Symfony. The Symfony however is a combination EDOF and MF lens. It can have the side effects of a MF lens as well as an EDOF lens.

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There is no free lunch. When you stretch the point of focus of the lens you distribute the light available over a range of focus points, which in turn has to impact contrast sensitivity and peak vision.

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Yes if doing a combination or hybrid mini-monovison, it would make more sense to use the Vivity in the near eye. That would let you target it at -1.0 D rather than -1.50 D like a monofocal, and your distance vision in that eye would improve. I think however, that the benefits are very limited and are likely outweighed by the negative aspects.

if near is the priority, why would the rule you use for distant/intermediate (do distant first) not be the opposite for near priority (do near first)? if near is off from projected result, would you not also want to then move distant projection to get the gap between the two correct?

does the panoptix multifocal give u any dysphotopsia issues?

do all edofs and enhanced monofocal have contrast issues?

I think doing the distant eye first allows you to get the near eye outcome more accurate. First you do it second, and the surgeon should learn from your first eye, and be more accurate with the second eye by adjusting the formula for calculation. It also lets you test how much myopia you want by using the reading glasses with the distance IOL eye. The distance eye is simpler as there is no question (at least in my mind) what the ideal target is; -0.25 D.

I think it depends on how honest the manufacturer is. It is very simple. The more you stretch (smear?) the focal point the more the focus is not going to be as sharp and distinct. Some admit it, and some try to pretend it the issue does not exist. I think B+L is most honest about it with their enVista lens and show a graph on how visual acuity suffers when you increase the spherical aberration which is a measure of how sharp the focus point is. The make the point that optimizing the loss in visual acuity has a net benefit in depth of focus.

depends on what definition of dysphotopsia you want to use. do i see the concentric rings at night - yes i do. the halo around light is very transparent and light as opposed to Symfony which was thick.

i do think there is a contrast loss but i dont notice it. i do wear glasses at night to corect -0.75 astigmatism which makes very far away stop lights pin point rather than scattered.

With monovision, you should be able to perform many daily short-term activities without depending on glasses. With extended reading or prolonged distance vision activity, your eyes will tire out (asthenopia), and therefore you will wear glasses to see better and to improve your ocular balance."

In my experience with mini-monovision (-1.5D difference with no remaining accommodation due to non-accommodative IOLs), I have no problem with prolonged distance vision activity without glasses (driving for several hours, watching TV/movies), but have experienced the preference for reading glasses for extended reading. However, I don't think it is an ocular balance issue, but rather a visual acuity (clarity) issue for near vision, since I am reading with what is essentially an intermediate distance refraction, which results in some eye strain (likely from habitual/involuntary squinting to attempt to accommodate to improve my vision despite no longer having any accommodation left). I believe I don't experience that in my distance eye because it exhibits excellent vision (20/20+ or 20/15). Maybe over time, my habitual squinting will fade as I get used to having no accommodation.

I'm happy with not going for more than -1.5D difference though, because I avoid light artifacts that may have required distance glasses for night driving, for instance and other issues caused by too much monovision.