Cateract surgery in one eye with future monovision

Eye care
1

Hi,
I need to have cataract surgery on my right eye. I have had vitrectomies on both eyes due to retina detachments and have been advised I can only have monofocal lenses. I’m currently left eye dominant but this may because of the advanced cataract in my right eye. I’ve always been near sighted and worn glasses - my left eye is -4.5. My doctor has suggested we aim for monovision with a near vision lens on my right eye set at -1.5 and a distance lens on the left eye down the track when the cataract on that eye progresses to the point it also needs surgery (a side effect of vitrectomies is that you get cataracts due to gas damaging the lens). That could be a number of years down the track.

My concern is what if I don’t like monovision (which we’ll experiment with using contacts after the surgery) and then I would have to put another near vision lens in my left eye. I think I’d prefer both set to distance rather than both near if monovision isn’t right for me.

Feeling quite uncertain about what to do? Would appreciate any opinions.

2

I actually have crossed monovision where my dominant left eye is now my close eye in a mini-monovision configuration. I kind of backed into it. Like you my right eye had a significant cataract while the left did not, and the right eye needed to be done first. My surgeon recommended doing the right eye first and targeting it for distance. I do some shooting and having the right eye set for distance was a preference despite it not being the dominant eye, as I am right handed. The surgeon said it was not necessary to have the dominant eye as the distance eye and that they can be reversed. So I went ahead with the right eye for distance and then simulated mini-monovision with my left eye as the near one. I found it worked very well and a year and a half after my first eye I got the second eye done for near and it has turned out at -1.60 D. I am quite satisfied with the outcome. I am probably 95+% free of glasses. I occasionally use mild readers for tough reading in dimmer light. And while I have prescription progressives I almost never wear them.
.
So, if you want to keep your options open to do distance in both eyes in case you don’t like monovision, I think it is a reasonable plan to do distance in your right eye first. There are actually some studies which suggest having the near eye as the dominant eye may even be better. I was not aware of them at the time I made the decision but possibly my surgeon was. In any case here are a couple of articles to read.
.

.
Rationale for choosing crossed monovision Myers, William G. MD Journal of Cataract & Refractive Surgery 42(2):stuck_out_tongue: 346, February 2016. | DOI: 10.1016/j.jcrs.2016.02.006

3

Thanks, good to know that crossed monovision is probably fine.

What about my left eye being -4.5. If I put a distance lens in my right eye would that be a problem until I get the left eye done?

4

I have crossed monovision and I have no issue with it. Of course there is no way of knowing how I would like it the other way around, but I am very satisfied. I have Vivity lenses so there is a good deal of overlap blended vision, which might be a slightly different situation compared to standard monofocal lenses.

I had never thought about a dominant eye. Both my eyes were myopic most of my life, at similar prescriptions, and both developed cataracts pretty much identically. But I am right-handed and when I looked through a telescope, I always used my right eye, so I guess that means right eye dominant.

My cataract surgeon chose to do my right eye first, I don’t know why. I wanted Vivity lenses, and we discussed staying myopic in both eyes because I was used to it and I wanted to continue to read without glasses. My second eye surgery was 2 weeks later. I had just started reading this forum, where I learned a lot in a short period of time (thanks, RonAKA!). So I liked the idea of some amount of monovision and I asked the surgeon for a little more distance in the second eye. He agreed, and I really like the result.

If you find that a contact lens trial leads you to decide against monovision, you might end up being happier staying myopic instead of switching to being farsighted. It’s just a preference, of course, but I really dislike the idea of reading glasses.

5

Yes, that is too much for even full monovision and you would not find it tolerable without a correction in your left eye. The best solution is to use a contact that corrects your left eye to leave it at -1.50 D. I also got progressive eyeglasses but the contact lens solution was much better. You can also ask to speed up the surgery on the second eye to minimize the time with the large differential between the eyes.

6

First, regarding crossed-monovision, a 2020 open access article in BMC Ophthalmology, “Crossed versus conventional pseudophakic monovision for high myopic eyes: a prospective, randomized pilot study”, found: “The conventional monovision and the crossed monovision group showed no significant differences of mean BUDVA, BUNVA, BCDVA, BCNVA 2 weeks, 1 month or 3 months postoperatively (P > 0.05). There was no difference in the bilateral contrast sensitivity or stereoscopic function between the convention conventional and crossed monovision groups (P > 0.05). Patient satisfaction with near and distant vision, as well as spectacle dependence did not differ significantly between the two groups (P > 0.05).” While you don’t have high myopia, the authors’ stated reason for studying this population had to do with (what they say are) factors that “may limit the use of multifocal intraocular lenses in cataract patients with high myopia.”
.
Second, because even if you like monovision it may not achieve the visual acuities you want, you’re right to base your decision on the priorities you give to the distance, intermediate, and near visual zones. My priorities are intermediate and near, so with my surgeon’s encouragement we targeted my first, nondominant eye at c. -2.00 D and my second, dominant eye (done two days ago) at c. -1.00, both with Eyhance IOLs. As of now I’ve been very fortunate: my 'distance" eye tested at 20/25 while also improving on my already good intermediate vision from my ‘near’ eye. With my ‘near’ eye, I’m able comfortably to read my Pixel 7 Pro smartphone held at my normal distance of 12.5"-13". Holding a book as I normally would just above my lap, I can easily read 10 point Lyon Text. As for my 27" Asus ProArt PA27QV monitor, 2560 x 1440 at 60 Hz., text is clear and comfortably readable at 32", where I had the monitor before the surgeries. For example, in Microsoft Word all the menu titles are clear and legible; I can make out four point Century Schoolbook text, easily read five point CS text, and read comfortably nine point CS text. Also, all the names in Windows Explorer in “Details” mode are easily and comfortably readable.
.
But if I didn’t get, or as my ‘distance’ eye settles don’t keep, comfortable driving vision, I’ve no problem wearing glasses to drive, and I’d prefer that to the alternative. Of course, if you prioritize distance then you should plan accordingly.
.
Third, if I understand you, your plan is to trial monovision with a contact lens after the surgery on your first eye. (I trialed mini-monovision both before my first surgery and during the weeks between it and my second surgery.) Even if you prioritize distance vision, I suggest asking yourself how good you want your distance vision to be. For target shooting and eye-hand coordination sports you probably want better than 20/20. For most other distance-oriented activities, including driving, 20/25 (or even 20/30) may be good enough. While I think myself fortunate to have at least initially 20/25 vision with a c. -1.00 target, I think that’s a very reasonable expectation with a -0.50 or even -0.75 D target. (At her six-month check-up yesteray, my wife, with Eyhance IOLs both targeted at -0.50 D had 20/20 vision.)
.
If you follow this suggested approach and your first eye at least initially gives you distance vision with which you’re happy, then you could trial mini-monovision with a contact lens in your unoperated eye that’s under-corrected to at least give you very good intermediate vision and possibly also good near. (I think the Eyhance a good candidate for this approach.) If your first eye remains stable during the trial and you like mini-monovision, then you can ask your surgeon to replicate it in targeting your second eye. But if you don’t like it or if vision with your first eye deteriorates during the trial so that your distance vision no longer makes you happy, you can target your second eye for either the same as your first eye or for micro-monovision, that is, a very, very slightly less myopic target then target/result in your first eye.