Mini-monovision with Eyahnce and RayOne EMV

[nh_user_1447867]

Hi Oscar,

If you’re worried, then take it easy and don’t rush into the second operation.
What is your current vision in sphere in the operated eye? it could be that your doctor targeted or the operation resulted into a +ve sphere.

I would propose that you try -.25, -0.5, -0.75, and-1.0 contact lenses on your operated eye. it would make you understand the gains you get in the near vision and the extent of lost distance vision. If you ‘well’ intermediate vision and your distance vision is still 20/20 that means your operation resulted in a +ve sphere and your doctor must consider this into the next operation.

Good luck,
Will

[nh_user_1448700]

Ron,
Thanks for detailed post–I really appreciate the details, even though I do struggle to understand the optics involved. I’m trying my best to learn as much as I can so as to make an informed decision when the time comes to make an IOL choice.

So, if I understand you correctly, using both eyes, you basically can see pretty clearly from about 12" out, correct? Or is that just using only the near eye? The brain, I gather, is able to fuse the images from each eye into what feels like natural accomodated vision (at least with a mini-monovision offset)?

It’s interesting to me that your distance eye clarity begins about 20" out, since that eye is -0.25D. I read an ophthalmologist (on either this forum or another) who stated that vision with a monofocal lens set at plano will be blurry at around 10 feet and closer; I didn’t think such a lens so close to plano could give good intermediate vision. Perhaps I misunderstood the ophthalmologist?

Your comment about an EDOF or near EDOF lens not being able to be corrected with an eyeglass lens definitely caught my attention. That’s something I will certainly have to consider and investigate further. One of the appeals of mini-monovision for me was, should the final refractive result not be as ideal as desired, progressive glasses can be used to compensate. If that’s only true for monofocal lenses, that would make me a little reluctant to try a lens like the Eyhance or RayOne EMV.

I also wonder, I am extremely myopic: -8.25 in my left eye, and -9.25 in the right, and wondered if that affects the ability of a cataract surgeon to effectively hit a refractive target. I also think I’ve read that high levels of pre-existing myopia reduce the benefits of a lens like Eyhance. Any insight on that?

Last question–right now my acuity is not too bad (although the prescription of the progressive glasses I’m currently wearing is not quite right); my main issue is with night glare and haziness from headlights and other light sources. Have you any knowledge about a spectacle lens like the Zeiss Drivesafe, which is designed to minimize night glare? Some of the reviews are quite positive, although I don’t know if it would help with cataract-related issues. Although, I wonder, for the middle-age folks who seem to be the target consumer for this lens, isn’t night glare usually related to some early changes in the eye’s lens, even if there is no obvious cataract?

Thanks again for all your insights,
Brad

[nh_user_1448700]

Hi Indy,
Thanks for your really detailed reply. It sounds like you’ve received very satisfying results with your IOLs. That’s nice to hear. As I related to Ron on another post in this thread, my own vision is highly myopic, so I don’t know how that might affect my own eventual cataract surgery results. Right now I’m trying to do as much research as possible, but I hope I can hold off getting the actual surgeries for another year or two, if not longer.

For all of my life–or at least since I was around 10 or 11, everything from about 4-5 inches out is blurry. So I’m hoping that any change from an IOL will be an improvement! But being able to function glasses-free isn’t really an expectation for me, although it would be amazing to be able to go through most of my day being able to see reasonably well.

Right now, the progressive glasses I wear, they, well…sorta suck. Some of this comes from the inherent limitations of progressive lenses, but I think its really compounded by my high prescription and choice of high-index lenses. The intermediate area is very small, so although I wear them through most of the day, I finally did decide to get separate single-vision glasses for extended bouts of both computer work and near/reading work. Also, the ABBE value for these high-index lenses is very low, so that produces some aberrations and loss of clarity. In fact, at my last visit to my optician, she actually said the best thing that could happen for me would be to have cataract surgery!

Regarding your present night vision, using both eyes, the 20/15 left, and the 20/30 right, how clear overall is your naked eye astronomy viewing? Do stars seem pretty sharp and crisp, or would you appreciate maybe some glasses that brought the right eye up closer to the left? How does the moon look, naked eye? Right now, for me, there is a lot of haze around the moon, due to the cloudiness of my natural lens, I guess. It would be nice to see a sharp, crisp moon again. And do you drive without any additional lenses, especially at night?

Sorry to pester you with so many questions, but, well, whatever else can be said about the internet, forums like this really do help connect people with others who have valuable knowledge and insights about specific topics.

Thanks again,
Brad

[nh_user_1291666]

It is a good point to check the refraction in the operated eye to see what the baseline is. I would use the sphere equivalent if there is any astigmatism involved. Using contacts and compensating for any SE from 0.0 D is a good idea, when you can’t work with the unoperated eye due to the cataract. I did that just as a final check but used dollar store reading glasses instead of contacts for ease in switching the powers. This test convinced me to target -1.5 D in my second eye instead of the -1.25 D I was planning.

[nh_user_1447607]

During my last visit. I was told I have perfect 20/20 vision in my operated eye, I didn’t ask for sphere vision details, I can try asking now. When I tried with 0.5 D it was bit blurry with my operated eye. I don’t have 0.5 D at home to test it again, but I have 1.0 & 1.5 readers, both are blurry with the operated eye. Does this mean the results are not resulted in any +ve sphere?

[nh_user_1291666]

Did you get an eyeglass prescription? That will tell you the residual refraction for the eye.

[nh_user_1148776]

Brad,
It’s my pleasure to answer your questions. Let me first say I think there’s considerable hope for you. Do do your research, seek out great surgeons.

As for my naked eye astronomy vision I’d say it’s quite good but not perfect. Of course if my near eye’s 20/30 distance vision was 20/15 like my other eye things would be better. But I as I wanted unaided reading vision I feel the small compromise was well worth it. I live under fairly dark skies and I can see the Pleiades nicely. The Moon is also quite sharp, mainly due to my 20/15 eye. I can also spot faint satellites. Prior to my surgeries, I could not even see a daytime Moon in the sky. It would just wash out completely. Now I see it without any issue with each eye, independent of the other. I can definitely enjoy watching the stars without feeling I’m missing out on the experience.

In terms of driving, I’ve not needed correction in daytime or nighttime scenarios. Certainly not in daytime. Could my nighttime driving vision be improved a bit? I expect marginally so, but I’ve not felt the need to actively seek it out.

Let me know if I can be of further help.
Cheers,
Indy G

[nh_user_1291666]

Yes, I see very well from about 12" out with both eyes together. Close I am mainly using my left near eye, and at distance the sharpness is coming from my distance eye. They probably contribute equally in the 20" to 60" range. I no longer golf but I expect I would have no excuse missing the ball with a golf swing. For fine work close I do wear some +1.25 D readers.
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To really understand the vision vs distance for the various lenses you need to get your head around the defocus curves. Some examples can be found in this article.
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Review of Ophthalmology PUBLISHED 15 APRIL 2021 IOL Review: 2021 Newcomers
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The curves show visual acuity vs distance. A LogMAR of 0.2 is about 20/30 and considered to be the approximate limit of good vision. The distance is measured in diopters and is more tricky. To convert to distance you divide 1 meter by the diopter value. The more negative the diopter the closer the distance. A -1.0 D distance is 1 meter, -2.0 D is 0.5 meters, and so on. From the curves in this article you can see that a Alcon SN60WF monofocal which is what I have in my distance eye hits the 0.2 LogMAR at about -1.5 D. That is about 2/3 of a meter or 24" or so. I seem to do a bit better than that at 18-20". If you look at the J&J curves they show the range of actual outcomes in a study or a number of people. It is quite wide. From what I have read people that are more myopic and have a smaller pupil size (older people?) have a better near sight outcome. I’m 73 but was not that myopic before surgery (-2 or so). I guess the point here is that vision with a monofocal does not drop off a cliff. It goes down slowly and outcomes vary from individual to individual. So, one has to be careful in using anecdotal results (like mine!). YMMV! The other thing you can see from these defocus curves is that the Alcon SN60WF gets to -1.5 D for near vision, while the Eyhance gets to -1.5 D at LogMAR 0.2. However, this is not an apples to apples comparison as it appears the Alcon curves are with both eyes, while the J&J curves are with only one eye. One has to be careful comparing defocus curves…
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My point on the EDOF type lenses not being as easily correctable with eyeglasses is theoretically valid, but perhaps in real life the differences may be minor. They likely make a bigger difference with the MF lenses like the PanOptix and Synergy. But, it is true that EDOF does introduce optical effects that cannot be corrected by eyeglass lenses. So, if you are looking for ultimate optical quality with eyeglass correction it would be better to stick to a pure monofocal.
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Being highly myopic before cataract surgery is a bit of an issue, but should not be a major concern. It usually means you have a long eye. Some formulas used for IOL power calculation are better suited to long eyes than others. You can find some information on the issue if you google this article.
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Zeiss IOL calculation formulas explained
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I would suggest you want the newer formulas that are more suitable for long eyes used. From what I know about them, the Barrett Universal II, the Hill RBF 3.0 and Kane formulas are good ones. The Hill and Kane ones use artificial intelligence in their derivation. It is a good thing to ask the surgeon what formula will be used and why. Ideally you want to see the predicted recommendation of two or three formulas and discuss which one would be the best. The hope is that the same predicted result is given by all formulas. On the second eye you will know which formula is likely to be best. Here is an article comparing accuracy of the formulas with long eyes.
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Accuracy and Precision of Intraocular Lens Calculations Using the New Hill-RBF Version 2.0 in Eyes With High Axial Myopia
Kelvin H Wan 1, Thomas C H Lam 2, Marco C Y Yu 3, Tommy C Y Chan
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The other issue is that some formulas are more accurate when predicting the outcome when myopia is targeted for mini-monovision. See this article:
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OPTIMIZING OUTCOMES WHEN THE TARGET IS LOW MYOPIA BY ANDREW M.J. TURNBULL, BM, PGDIPCRS, FRCOPHTH; WARREN E. HILL, MD; AND GRAHAM D. BARRETT, MB BCH SAF, FRACO, FRACS
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One thing to keep in mind is that the current version of the Hill RBF is the 3.0 one, and from everything I can see it is improved from the 2.0 and is probably the best all around formula. And if you are really paranoid about this aspect you can ask your surgeon for your eye measurements and use the formulas to do your own calculations. Barrett, Hill 3.0, Kane, and possibly others are on line.
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If you can still see well, I would suggest you try contacts to simulate monovision to see if you like it. Best would be to target plano with your dominant eye and -1.25 to -1.50 with the non dominant.
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I am not sure about the impact of night vision glasses. The Alcon lenses are typically blue light filtering (slightly yellow tinted) to give a young eye colour spectrum outcome. Some believe that improves night vision by filtering out light that may cause flare. Not sure…
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Hope that helps some

[nh_user_1448700]

Ron,

Thanks again for all the information and expertise. The info regarding the formulas used to calculate IOL powers for high myopia patients is definitely something I will further research and explore, as well as the formulas used to target myopia for mini-monovision.

I plan on giving mini-monovision a try using contact lenses, assuming my vision is still good enough to make that an option. I’m hoping it is, since at present my acuity isn’t too terribly bad. But I’ll have to see what my optometrist recommends. I did wear contacts for years until dry eyes forced me to give them up. But I may be able to manage wearing them long enough each day to give me some kind of idea of how mini-monovision might work for me. At least I hope so.

Two last questions.

You’re a -0.25D in one eye and -1.40D in the other, correct? Are you comfortable driving without any additional lenses, especially at night?

And, second, would you have any suggestions as to how to find a cataract surgeon I trust? Are there any ways you know of to evaluate a surgeon’s experience and expertise that can be used to investigate a particular surgeon? I suppose I at least hope to find someone who will sit with me and answer the many questions I have, and it does seem most surgeons–perhaps understandably–don’t have an enormous amount of time to spend with each individual patient.

Thanks again for all your help,
Brad

[nh_user_1448700]

Indy,

It’s nice to hear your experience–that mini-monovision has given you such satisfying vision. It must have been really gratifying to receive the much clearer vision provided by an IOL, once your cataracts were removed. How long did you wait to have the second eye done?

As someone who’s worn glasses since the age of 8, it’s difficult for me to imagine being able to walk around without them. I also watched the video you suggested to another person posting here, the Antonio the Optometrist video showing examples of different levels of myopia. Since my own myopia is so high (-8.25 left eye and -9.25 right eye), everything’s a complete blur without some kind of correction. Seeing examples of -1.0, -2.0, and -3.0 diopters is very useful.

If my optometrist thinks it would be helpful for me, I plan on trying contact lenses to at least try to sample mini-monovision. I think my acuity is still good enough to make the attempt practical, but I’m not sure. I’ll have to see (pun intended).

Thanks again for all your help and advice,
Brad

[nh_user_1447867]

Hi Oscar,

The +1.0D and +1.5D readers have +ve diapoters but to try the monovision you need to try negative diopteres till -1.5.
Which lens did you have in the operated eye, if I may ask?

Take care,
Will

[nh_user_1148776]

Hi Brad,
Whilst I am indeed grateful for my mini-monovision outcome, please know that statistics show a patient satisfaction rate of about 97% with monovision… and it’s likely higher with mini-monovision. So my outcome is what should be expected in large part. This is why, in my opinion, it’s a very good strategy. It is also the preferred strategy for ophalmologists who get the IOL surgery for themselves from what I have read.

As for trialing monovision or mini-monovision, bear in mind to get a true sense of the experience, you would need to trial it until your brain neuro-adapts, and sometimes that can take weeks or months. Despite that, you can probably get some sense of it with a short trial knowing that things will likely improve even more from that starting point over time.

As for finding a good or great cataract surgeon, there are rankings of eye hospitals online that you can check out. If you happen to live near one of the top ones, you might consider going there.

Lastly, to answer your question, the time between my surgeries was about 4 years. My first eye was set with a monofocal for distance back in 2018. My Rayner EMV in my “near” eye was done this past September. I hope this helps.

Indy G

[nh_user_1291666]

I tried a lot of different contacts and the one firm conclusion I came to was that the J&J Acuvue Moist were the worst. Extremely hard to handle and despite their name, they seem to dry out during the day. The Acuvue Oasys were much better. But I found the Costco Kirkland Daily to be the best. They are CooperVision MyDay. Next were the Alcon Total1. The newer Alcon Precision1 may be good but I never got a chance to try them. I could go the whole day with the Kirkland lenses. And Costco is good about giving out free samples to try.
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Yes I drive all the time with no prescription glasses, and even at night in the city. Out of the city at night I do try to remember to bring my prescription glasses. We have moose and deer here and being able to see them coming up out of the ditch when you are at highway speed is a good thing.
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Finding a good surgeon is always a challenge. There is the “Newsweek America’s Best Eye Doctors 2022” article that you could try to see if there is a high rated ophthalmologist in your area. And there is the RateMD site that can be used to look up individual doctors to see what comments there are. I think the best instrument used to measure eyes is the Zeiss IOLMaster 700, so a further screening tool is asking what they use. Typically this is used with the topography measuring Pentacam. And if you have a particular lens in mind you will want to ask up front which ones they do. It seems they end up in either the J&J camp or the Alcon one, but often do not give you a choice between the two brands.

[nh_user_1291666]

Here is a real world astronomy example. There is a Mars occultation event tonight where Mars is very bright and will go behind the moon for about an hour where I am. Currently it is about 15 minutes from going behind the moon. I think it is going to look like it is crashing into the moon.
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In any case with no glasses I can just barely see Mars with my distance eye, or with both eyes open. There is no chance of seeing it with my close eye. With glasses I can easily see Mars with either eye, and my close eye which has more astigmatism may even be a touch clearer. With both eyes and glasses it is sharp and easy to see. And of course with my 10 power binoculars and glasses it is really clear and sharp.

[nh_user_1291666]

I would just add on the screening of the surgeons to be careful with the ones that either want to do both eyes at the same time, or want to do the second eye in a short period of time after the first eye. Surgeons should learn something on your first eye, but to do that your eye has to heal for 6 weeks or more to get an accurate refraction measurement. So, I would look for a surgeon that is willing to review your 6 week outcome before making the final decision on the power selection for the second eye.

[nh_user_1447607]

Will, you meant negative diopters with operated eye, which is already set for distance? I am bit confused.

BTW, I am still waiting for my spherical numbers for the operated eye from doctors office. I will share as soon as I have it.

For now, I am leaning towards the offset of 1.0D, unless the spherical vison in the operated says something different.

[nh_user_1448700]

Ron,
Thanks for the advice. I definitely would not allow myself to be rushed into having the second eye done before seeing how the first eye heals and recovers. That being said, because I’m severely nearsighted, the unbalance between one eye corrected with an IOL and the still-nearsighted, untreated eye will, I’m guessing, give me problems, although perhaps wearing a contact lens in the untreated eye might help address that.

[nh_user_1291666]

Yes, using a contact in the non operated eye, is the best solution for the temporary unbalance between the surgeries on each eye.

[nh_user_1448700]

Indy,
Thanks again for all your helpful insights, they’ve been extremely useful. I think my next step will be to look into a min-monovision trial with contacts, and I plan on discussing it with my optometrist when I next see her.

I am, of course, also going to keep lurking here on this forum, and will probably from time to time pester knowledgeable and experienced folks like you and Ron for your expertise in the future.

Cheers and happy holidays,
Brad

[nh_user_1291666]

Doing mini-monovision with contacts before the first surgery is a good idea. I did that. The only caution I would raise is that you likely still have some accommodation and near vision will be slightly better than with the equivalent IOLs. The other thing to be aware of is that contacts worn in the week before eye measurements are taken can interfere with an accurate measurement. Hard contacts are longer, but I suspect you will not be trying them. The upside is that the contacts for your non operated eye can be used to cover the 6 week interval between eyes.