I have been nearsighted my whole adult life and have never worn bifocals or contacts. I have distance glasses which I take off for reading and computer work and have always been very comfortable with that habit.
Now I need cataract surgery and the idea of being glasses-free for distance for the first time in my adult life intrigued me until I thought of what it would be like to always need reading glasses for up-close work. I don’t like the idea of that. I do feel very comfortable on my computer, phone and around the house without glasses and I’m not sure how I will like needing glasses for those activities.
Also, if I choose near/intermediate lens distance, which distance? That’s not such an easy choice. Whereas, if I choose the normal correct-distance-and-be-farsighted option, there is only one choice “see in the distance without glasses”. I don’t have to decide which distance.
Anyway, I would very much appreciate other people’s experiences and thoughts on the subject of whether to go near/intermediate or far in the choice of new cataract lens.
Thanks in advance.
I was nearsighted when I was young. Got LASIK and have been able to see near, middle and far ever since. It was great not having to wear glasses at all.
Now that I’m getting cataracts, I still want to be able to see at all distances reasonably well without glasses, so I’m considering monovision and multi-focal lenses to achieve that.
If I were in your shoes and picking one focal distance for cataract lenses, I would pick something between near and intermediate, in an effort to get decent vision for both reading and computer work. I’d still need glasses for distance, but you are used to that already. Might need reading glasses for fine print occasionally, but hopefully not too often. It seems better to stick with what you’re already comfortable with, as much as possible. And if you’re willing to go with a different focal distance for each eye, you might get an even better result for near and middle, and need glasses only for distance, same as now.
Good luck with your decision.
Thank you for your reply. Thoughtful and thought-provoking.
It’s only on this forum that I became aware of the possibility of having a different focal distance for each eye, which my doctor didn’t mention to me as a possibility. I do have a phone meeting with on of the doctors in his office next Monday and I’m going to be asking questions about different focal distance.
Is “mini-mono” the term that describes “different focal distance for each eye”?
Anyway, thanks again for your thoughts and though I am going to take some more time thinking about this (I do not have my surgery scheduled yet, lenses not ordered yet) I probably will end up taking your suggestion. I think they key word in my case is comfort. I love going outside but I spend a lot more time inside, on computer, on phone, around the house. Also, something I haven’t seen mentioned: what about faces? What about looking into someones eyes, up close? If you have distance lenses, do you have to put on your reading glasses to do that? 
It seems better to stick with what you’re already comfortable with, as much as possible.
This. David, I’m sure you’ve read my posts on other threads, so don’t want to repeat myself too much. I’ll just say that with an outcome of -2 and -2.5, I can easily read, use the computer, and do just about anything indoors without glasses, except for watching TV (and I can even do that if it’s something like the news, where I don’t have to see fine details.) Lens choice should be based on the life you actually lead.
Monovision is the general term for eyes having different focal distances; mini-monovision refers to the extent of the difference, measured in diopters, between the two eyes. Typically, a difference of 1.5 D or less is considered mini-monovision (and usually but not always can be accommodated without difficulty). Sometimes the term micro-monovision is used to denote an even smaller maximum difference, again measured in diopters, between the eyes.
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Like you, I was nearsighted my entire life, wearing glasses from third grade. At the time of my cataract surgeries earlier this year, my prescription was RE: -6.00 / -0.50 / 10 ; LE: -7.75 / -1.25 / 160. The Add, for the progressive lenses I used, was +2.50 in both eyes.
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After discussion with my first surgeon and extensive reading, I decided that I did not want to run the risks involved with defractive (multi-focal) lenses and that I should trial monovision using monofocal contact lenses. Trialing monovision is important because it can give you and your surgeon a good idea of the amount of monovision you’ll be able to tolerate with IOLs. Because coming within 0.50 D of the surgical target is regarded as a normal, good result, it makes sense to trial a greater degree of monovision than you and your surgeon are thinking of targeting with IOLs. The difference between what you can accommodate with contact lenses and the targeted surgical difference provides a margin for what the surgeons sometimes call refractive surprise.
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Along the way I switched surgeons. Self-reflection and discussion with my second surgeon led me to prioritize near over distance vision. (With mini-monovision, good intermediate vision should be possible with either priority.) My surgeon recommended this approach, and I agreed, because potentially being somewhat myopic and needing glasses for distance vision was a less disagreeable prospect than frequently having to put on and take off readers as I switch between working with my desktop computer and reading printed materials, or needing to put on readers to read material on my smartphone. YMMV.
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Having decided to prioritize near vision, we also decided to begin with my “near” eye. If the result did not provide satisfactory near vision, then I could decide whether to try again or, changing my original approach, go for distance vision in my dominant eye. On the same basis, someone prioritizing distance vision would start with the “distance” eye.
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Importantly, we scheduled my two surgeries six weeks apart. First, this gave me a second trial of mini-monovision, using a contact lens in my unoperated eye that approximated the notional surgical target. Second, because it can take some weeks before the operated eye becomes reasonably stable, putting off the second surgery gives the surgeon more information for choosing the refractive target and IOL power for the second eye.
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Of course, the choice of IOL also can matter. Reading and both my surgeons’ recommendations led me to the Eyhance because it offers a modest increase in depth of focus over conventional IOLs like the Tecnis 1 and Alcon Clareon monofocals.
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Luck also helps. Now 2-1/2 months after surgery on my second eye, I have excellent near and intermediate vision and good enough distance vision to be able to drive comfortably in all conditions, watch movies, etc. More concretely, one month post-op my near vision measured J1 and my distance vision measured 20/25. On a spherical equivalent basis, the measured refractive results were RE: -0.50 D / LE: -1.50 D.
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Just to be on the safe side, for potential use when driving in poor visibility conditions or unfamiliar areas I did buy eyeglasses. To preserve my ability to view the dashboard, I got them in a mini-monovision prescription. Ignoring axis, it’s RE: plano / -1.00 ; LE: -1.25 D / -0.50. In practice, having also chosen Transitions Xtractive Polarized version (because they activate inside the car) and because the lenses themselves are much, much thinner than my progressives and I put them in the ultralight Lindberg frame I used pre-surgery, they’ve become my general sunglasses.
Your dilemma is normal when facing cataract surgery. The upside is that at least you are thinking about the options. Many just get IOLs for distance and don’t even consider something else. This said the first think you need to consider is that if you target distance with a monofocal lens, and a targeted outcome of -0.25 D (very slightly myopic, to avoid going far sighted), you will be able to see from 2-3 feet out to infinity. This is an extremely wide range of vision. Your vision does not drop off a cliff at any distance other than far. But, under that minimum distance vision suffers and reading glasses are essential.
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You can go with multifocal lenses like the PanOptix or Synergy, but they are very likely to have optical side effects, and some never get used to them. There are also some extended depth of focus lenses like the Vivity and Symfony, but they can have some optical issues too.
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The Goldilocks solution in my opinion is to do the dominant eye first for distance, and then target the non dominant eye for mild myopia - typically -1.5 D. Then you can read pretty much anything but the finest of print in poor light without reading glasses. This is called mini-monovision and many surgeons are quite OK with doing it. This solution only requires standard monofocal lenses so the risk of optical side effects is avoided. Doing the dominant eye for distance is not essential, if there are other reasons to pick the distance eye.
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If your vision is still reasonably good, I would suggest doing a trial of mini-monovision by using contact lenses to correct to these standard targets. You could even experiment with which eye you like as the distance eye and near eye.
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I have mini-monovision and I am currently at -0.375 D in my distance eye, and -1.60 D in my near eye on a spherical equivalent basis (adjusted for residual astigmatism). I am virtually free from glasses. I have prescription progressives but essentially never wear them. I have some mild +1.25 D readers which I occasionally use, but never take them with me when I leave home. I can drive, watch TV, use a computer and read paper text all without glasses. I like it a lot.
Just to add to my previous post here is an article on mini-monovision that I would suggest is well worth reading. It is by a Dr. Graham Barrett who is a well known cataract surgeon from Australia. He has developed the Barrett Universal II IOL Power formula which is probably one of the best and most used formulas in the world. Perhaps the more recent Hill RBF 3.0 formula is better, but both of these are extremely good. This article is a bit dated but it still applies today. I agree with it almost 100%. Barrett advocates -1.25 D in the near eye. I think in many cases that will do, but -1.50 D is slightly better. I agree with his approach though. You do the first eye for distance, and then use lenses like OTC readers to test what vision you like for near. For example you would try +1.25 D, +1.50 D, and +1.75 D readers on your IOL distance eye to see what is enough for your reading preferences. I did that and initially thought 1.25 D would be ideal, but settled on -1.50 D. You have to google this article as we are not allowed to post links here, without it going into a 1 day delay for moderation.
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CRST Global CATARACT SURGERY | OCT 2009
My Standpoint on Monovision as a Cataract Surgeon
The success of monovision depends on the level of targeted myopia for near vision.
Graham D. Barrett, MD, FRACO
You are facing the same choice I am, and waffling about it has led to me procrastinating over a year about cataract surgery. Monovision contacts lenses worked wonderfully for me for many years, then my eye doctor warned me changes in my vision would make them problematic, and sure enough soon after that it got to where the near vision with them wasn’t good enough for reading, so I tried progressive glasses and hated them. Between that and risk of halos, starbursts, etc., I’m not willing to consider mutifocal iols and same for EDOF lenses like Vivity.
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I think it’s a very individual decision for each of us. For instance, these days I only use my distance contacts maybe 4-8 hours a week as I only put them in for driving. Yet I need to be able to drive, including drive at night. I walk around the house and even walk the dogs, including at night, with what are considered computer glasses and am quite happy with them. Yet if I’m going to read for any length of time I take them off and read with naked eyes. Text isn’t quite as crisp that way, yet for some reason it’s more comfortable for reading, and I hate to lose that.
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So I’m torn between going whole hog for near as Bookwoman did or doing something more moderate like RebDovid did. I have an appointment at the end of the month with a surgeon who I hope will help me make that decision (and I’ll like better than the 1st one I saw ). Right now I lean toward what RebDovid did.
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I hope you report on what you decide, your outcome and satisfaction level.
You are already making a good decision by reading this forum. Don’t just read the replies to this post, go back and read other threads, because many people have asked the same question. And many people have written lengthy descriptions of their experiences. It might be confusing at first, but you will learn a lot. Even the best doctors do not have enough time to give you this amount of detail.
It’s good that you have some time before the surgery. Only you can decide what your priorities are. Take time to think about it.
If you prioritize distance over near vision, then I agree with RonAKA that you should begin with your distance eye. But, as I suggested earlier, that’s to give you two chances to get the distance vision you want, not because there’s a golden rule that says do the distance eye first.
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And if instead you prioritize near vision, then the same idea–wanting two chances to get the vision you prioritize–leads to beginning with your near eye.
Be careful! There are some people that try to make mini-monovision way more complicated than it needs to be, and end up making a mess of things. Keep it simple and use monofocal lenses set to the standard -0.25 D SE target for distance, and -1.50 D SE for near. There is no reason that correctly targeted mini-monovision cannot be just as successful with IOLs as with contacts. There are three independent but somewhat related objectives to keep in mind for successful mini-monovision.
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- You want to be as close to plano as possible without going into the plus far sighted zone for the distance eye. This means setting a target at -0.25 and not plano or -0.50 or less.
- You want to minimize the myopia in the near eye, but still be able to read comfortably. Some will be happy with -1.25 D, but I suspect more will like -1.50 D.
- You want to minimize the differential between the eyes to maintain good intermediate vision and depth perception. If you follow points 1 and 2, that is automatically accomplished with a differential of 1.25 D.
Paraphrasing my jurisprudence professor, Roberto Mangabeira Unger, we should aim to make things as simple as possible, but no simpler.
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Because people have different visual priorities, when talking about monovision it’s important to recognize that a guideline that works most of the time for, say, a priority on distance vision may not work for a priority on near vision. That said, one guideline that I think generally applies in both cases is that, if at all possible, one should trial monovision–ideally both before surgery on the first eye and again during the interval between the two surgeries–rather than rely on the likelihood that most people accommodate to a 1-25 D difference between the two eyes. Why? For the simple reason that you may not be most people, and you’ll be very unhappy if you end up with more monovision than you can tolerate comfortably. (But maybe you’re a gambler. In that case, why aren’t you considering a multi-focal IOL?)
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For those who prioritize distance vision, and assuming successful trials of, say, 1.50 D of monovision, then it makes sense to begin by targeting the distance eye at the first minus at or below -0.25 D SE and to target the second eye at -1.25 or -1.00 D SE less myopia than the refractive result in the first eye. Granted, this is a more complicated way of stating the guidance than simply saying -0.25 D SE and -1.50 D SE, but, first, the IOL power calculations may not let you choose -0.25 D SE. Second, your surgeon may not hit the target. Not only is this a reason not to target plano, it’s also a reason not to blindly target the second eye without regard to the actual results in the first eye. Third, even though your trials of monovision may show, as mine did, that 1.50 D of monovision is well-tolerated, because absolute accuracy isn’t guaranteed it makes sense to target a smaller amount of monovision in case the result is more myopic than planned: 0.50 D less if you’re more risk averse (that’s me); 0.25 D less if you’re less risk averse.
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Finally, however, it doesn’t always make sense to begin by targeting the first eye for distance. If it’s more important to you to nail near vision, then you’ll want your first surgery to do your “near” eye. If the result is unsatisfactory, you get to decide whether to try again for near vision or settle for what you have and go for less myopia in the second eye.
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Alas, it’s neither simple nor self-evident. You need to think for yourself, assisted by your surgeon and your own research.
A neighbor who used the surgeon I have the end-of-month appointment with told me that her optometrist, who recommended this surgeon to her, had his own eyes done by this surgeon. And the optometrist chose along the lines of what Bookwoman has because his work all day every day is close intermediate and near.
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I had monovision for many years. It worked me and I liked it, but thinking back, if I wanted to sit with a book and read for hours, I popped those lenses out. Just like right now, although the computer glasses range from intermediate down to near, I take them off to read. I’ve always preferred to read with naked eyes, and the thought of giving that up is why I’ve procrastinated so long going back and forth about what to do. In the end, the fact is I’d rather use glasses to drive than to read. Heck, most of my driving is with sunglasses anyway. And that’s the only time I need or care about distance vision these days.
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I really have thought long and hard about what RonAka recommends and likes, what Bookwoman did and is happy with, and what RebDovid targeted, ended up with, and is satisfied with. Posts with -1.5 for near in a mono arrangement often mention how that’s good enough usable reading vision but they put on readers to read a book. Most people nowadays probably don’t read for hours every day. I do.
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Before making a final decision I want to talk to this surgeon, who sounds more inclined to listen to what my preferences and needs are than the first one I tried.
There are a load of similar discussions. I suggest reading some past discussions.
But if you want a simple answer, consider your distance eye with plano as a target. Choose 1.5D with no astigmatism as a target.
BUT hitting targets can be a hit or miss. If you are motivated, have the extra money, are close enough to your surgeon to make about 4 EXTRA visits, are willing to wear special UV blocking glasses for 6 weeks, consider RxLAL by RxSight.
Step 1, as a preliminary, post your last two eyeglass prescriptions. For each eye, you need 3 number: sph cyl, astigmatism. You can post the 4th number (axis) but it cannot help somebody with suggestions.
Most ophthalmologists mostly sell certain brands. So if you identify your candidate lens first, use that info to select a doctor. If there is only one doctor in your area, you can get one of the lenses they install.
Try reading with one eye closed. Do you miss 3D vision when reading a 2-D book?
Having one eye focus fairly closely is helpful to those who put on makeup in a mirror.
In situations where reading is marginal due to the font size or light, I just put on some mild OTC readers of +1.25 D. I almost never read books, so I can comment on that, but I may use these readers as well if I were to read a book. Most of my reading is on the computer, and I do find with my -1.6 D monovision for sites like this, vision is just fine. No need to increase font size. It just works. Before I got into this I wondered if I would have to buy two pairs of readers and put different lenses in for each eye. That has not been necessary even though my near eye will be getting more of a boost than my far eye. It will be like a person plano in both eyes without glasses having readers with +2.85 in one eye, and +1.65 in the other. I guess I could find readers that have frames where the lenses could be easily popped out, buy two pairs, and match up the eyes to leave me closer to the typical +2.5 D add that one would get with progressives, but for the amount of time I use readers, it doesn’t seem to be worth it. This was a problem that I kind of overthought and turned out to not be a problem at all.
Maura wrote: Most people nowadays probably don’t read for hours every day. I do.
Ron wrote: I almost never read books
And therein lies the disconnect. For those of us, like Maura, who spend hours a day reading printed material and prefer to read ‘naked’, so to speak, putting on readers is not only inconvenient but also less comfortable visually. For someone else who doesn’t read in that way and might instead spend hours, say, golfing or driving, then of course having to wear readers would be a minor issue. It’s a really individual choice.
Yes, but I spend hours a day reading a computer monitor, and have no trouble with that. A computer monitor is backlit though which makes it easier than text on paper, especially in poor light.
I also spend a lot of time on the computer but (in my case, anyway) the large monitor is about 2 feet away from my eyes and I can see everything just fine. When I read a book, we’re talking about 12-18" away, depending on where I’m reading and the size of the book and the typeface. Those extra 6-12" make a big difference in visual acuity, especially as I want the text to be completely crisp and clear.
My computer does not have a super large monitor, and is only 24", so I sit closer, and about the same as your book reading distance of 12-18". I don’t like glasses because I “multi-task” and often look up at the TV at the same time. It is about 10 feet away. I consider putting on and taking off glasses to be a major inconvenience. For the few times I use readers, I take them off immediately before getting up. Walking around the house with them on, makes me feel nauseous. I do not like the feeling of everything beyond 2-3 feet being a blur. In recent years but before cataracts my vision was in the -2.5 D range on a spherical equivalent basis. I used to be in the -4.0 D range but for reasons I do not understand it slowly improved as presbyopia developed. In any case with this amount of myopia I would put on progressives as soon as I got up in the morning, and not take them off until I went to bed. I could not stand the fuzzy vision.
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I think some people prioritize eyeglass free close vision with their IOLs, and some prioritize distance. My priority is both. Yes, near and far are slightly compromised, but I consider that as a good tradeoff for being eyeglasses free at essentially all distances.
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I think that is why IOL selection is a personal decision and everyone will not go the same way. But, that said, I think everyone should consider all options before jumping in.