Monofocal set for near, are my expectations too high?

Eye care
1

Hi all, I have some questions regarding monofocal lenses set for near. I am a fairly young patient for cataracts (32 years old), and am having some trouble imagining what my vision will be list after surgery. My eyesight pre-cataracts wasn’t great to begin with. I have a prescription of -9 and -10. Currently, with correction, I can no longer achieve 20/20 vision. So I have decided it’s time to fix these cataracts.

From what I have gathered, looking through personal experiences online, is that there are a lot of patients who just do what their surgeon recommends when it comes to lens options. The surgeons I met with did not seem too surprised at my request to remain nearsighted. What we didn’t do, however, was talk about the lens brand they may be using or any numbers as far as how nearsighted I’d remain after surgery. I am regretting not asking those questions now.

I have read a lot of positive experiences from people who have chosen to remain nearsighted (including Bookwoman and Mike2.5 on these forums), so I am feeling confident in my choice to remain nearsighted. I am, however, still another confused cataract patient. So here are my questions:

1.) I am imaging that after surgery my eyes won’t be that much different, but it will be as if I have a decreased prescription to get to 20/20 vision. I know I will lose accommodation, but I don’t know how to account for it in my post-surgery imagination.

2.) Those of you who have chosen near, what is your eye glasses prescription like? If I get set for -2 does that mean that my new eyeglass prescription for distance will be -2? I keep reading about progressives, and I am not sure if cataract surgery means I will automatically need progressives. This part is confusing me.

3.) If I tell my surgeon I would prefer to have good, clear vision at a range of say 8 inches to 20 inches, is this a reasonable goal?

4.) When you have to wear your glasses because things are blurry, what does “blurry” mean? I know there probably won’t be a sudden and dramatic drop in my visual acuity, but right now I am picturing “blurry” as what my -9/-10 eyes see without any correction.

2

I cannot relate to your plan to set near vision to be 20/20 at 8". I hope you really give this some thought before proceeding. IMHO life occurs at distance and remember distance will give you decent vision down to 2 to 3 feet.

But to answer your questions I would suggest you get familiar with the defocus curve for the IOL you will have implanted. The curve shows the average result and some show 1 Standard Deviation. Even though everyone’s results will vary it will give you some ideas of your vision quality at different distance.

3

Hi Christa,
To begin with your last question, ‘blurry’ is much, much less blurry than when I had pre-cataract -8 vision in both eyes. You will (I hope) be astonished at how much better you see at almost all distances than you did before. The difference between, say, -2 and -9/10 will be quite remarkable.

My prescription for progressive glasses is -2 and -2.5 (since you’ve read my other posts you know that one eye wound up half a diopter more nearsighted, which has worked out very well for me), with a +2.5 add for the lowest part in both.

As for specific distances, the defocus curves are apparently useful. The only drawback to IOLs is that we high myopes can no longer hold something right up close to our eyes and see it perfectly. But that’s a very small price to pay. Hope this has been of some help.

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Interesting. I will look into the defocus curve. I have always been nearsighted, so anything different just sort of feels wrong to me. I do a lot of up-close activities, like reading and bead work. I’m also on computer and phone screens a lot throughout the day. There seems to be so many options and configurations. I know I will end up with better vision than I have now, but there’s still this nagging pressure to “get it right”.

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Hi Bookwoman! Thanks for replying to my post. Your posts actually really helped me feel assured that I was making the right choice aiming for near. I guess we never know the impact we have on strangers.

Most people I have talked to aimed for distance and are happy, but their starting points were all much different than mine. I have been having a hard time imaging life after cataract surgery. I can barely even remember what it was like when my prescription was lower. Right now, even without cataracts, I’d have to bring things so close to my face to see that it’s not really functional. If after surgery my distance is still blurry but I can go into the closet and tell that I’m grabbing a shirt and know what color it is without bringing it only 3 inches from my face I’d call that quite functional. I am fine with wearing glasses to read signs and see details, but if I can make out what I’m looking at without glasses around the house that’d be pretty cool (and something I don’t think I’ve ever done!)

I think I am feeling the pressure of making the correct decision. I really want to be excited for surgery, but I’m just nervous. I think it’s easy for someone who’s going in for LASIK to image what they’ll see after, but a little harder for cataract patients.

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1 meter divided by diopter value equals the focal point distance. Use 39.37 instead of 1 meter to get the result in inches instead of meters.

Examples:
39.37/5 diopter = 7.9 inches
39.37/4 diopter = 9.8 inches
39.37/3 diopter = 13 inches
39.37/2 diopter = 19.7 inches

That’s for the optimal clarity at those distances. The range of usable/acceptable/practical vision from any given diopter value would be a bit of a guess. Forum members here that opted for myopia will be able to give you some idea of what to expect.

You mention that you know that you will lose accommodation. That means that you’ll become instantly presbyopic when your natural lenses are removed and replaced with IOL’s. Currently, you probably use single vision glasses with the correction from your glasses needed for distance because your eyes have the ability to adjust focus for intermediate and near. If choosing to remain myopic using monofocal IOL’s, then progressive (multifocal) glasses will be needed to restore that simultaneous/seamless range of near, intermediate and far vision.

To give you an idea of my experience, I was myopic & presbyopic prior to surgery and opted for distance vision using Eyhance monofocals. I wanted to be able to drive, watch TV and do water related activities without needing glasses. My previous progressive glasses didn’t easily permit lying on a couch or bed or fully reclining a recliner to watch TV for example as those positions had me seeing through the reading/intermediate sections of the progressive glasses.

7

Hi Christa,I understand being nervous.

We have slightly different starting points. I’m 49yo, so I had already experienced significant presbyopia, so my natural lenses were already starting to act like monofocal IOLS; therefore, I had already started using progressives. Also I wasn’t as near sighted as you (I was -4.0 equal bilateral).My cataracts were posterior capsule so they made light sources particularly bothersome. They were quite advanced (diagnosed 10 years prior to surgery) and I stopped driving at night and had to hold my phone 6 inches from my face to read a text. I’ll try to answer your questions in order:

  1. As far as what to expect, per my experience.If you set your target to near sight, for me it felt just like my eyes were when I was in my 20’s, with zero cataracts. Everything is non-hazy, there are no light induced problems like halos, starbursts, and cloudiness from bright sources.And for me, colors became ultra brilliant. As far as what is “blurry,” what is in "focus."With glasses off, such as when i wake up in morning; everything closer than an arms length (2 feet-ish), feels clear and focused. But in reality 12- 17 inches is perfectly crisp, and 8-20 inches is clear enough to read normal font. Everything farther than arms reach feels like I’m 25 years old, and near sighted, and that I just need to put my glasses on.I put my glasses on after I shave and they stay on most of the day. I do understand though how Bookworm ends up not putting her glasses on at home, in relation to how bad vision was with cataracts, everything better now with or without glasses.

  2. I set both eyes for -2.5 (ended up both 2.75). Its perfect for my work and hobbies. . Now for the part that doesn’t feel like my eyes are 25 years old. And to address your question regarding the need of progressive lenses. I wear distance glasses all day, just like I did when I was 25yo, BUT unlike when I was 25, with my glasses ON, I cannot focus clearly on anything closer than 20 inches. I can see the dashboard/speedometer/GPS quite clearly , but my phone isn’t crisp (I can read a quick text in normal font size, but I wouldn’t read an entire email this way). So the option is to take my distance glasses off for close vision, or use progressive lenses and leave the glasses on.Since you are 32yo, this concept might be new to you.

People who target distance, generally don’t wear glasses throughout the day, and put on reading glasses to see their phone. People who target near, wear glasses throughout the day, and take them off to read close up (OR use progressive glasses).

Then there are mono vision options (both near are far) and other lenses such as multifocals and extended range of focus lenses. These options were not for me, but they are the right choice for many people.

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Target -2D means that you’ll need correction -2D to see 20/20 at distance. In my case, the target was -1.25D and I need -1.5D glasses. I think that’s the feature of glasses: usually you need stronger glasses than, say, contacts. Also possible, the surgeon missed the target.
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I have Eyhance, which is a “premium” monofocal. The distance at which I see the best is around 19”. The vision starts getting obviously not great near 11” if I get closer, and near 31” if I move further away - in the day time. It doesn’t mean that in this range I have clear vision. The vision is the best at a very specific distance. If I move my head an inch closer or further away, the quality becomes less desirable.
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In my other eye, I need -7.5D contacts or -8.5D glasses. In the operated eye the image is much, much(!) less blurry than in the other eye without correction. In fact, it feels almost like a perfect vision compared to the other eye. It’s a very light near-sightedness. I didn’t even know that I was nearsighted when I had -1.5D in both eyes in childhood. It started to be a problem only at -3D. Yet, I can’t read traffic signs with the operated eye when driving without glasses.

9

Thank you for that info. It can be difficult to pick out the important information when I just do a simple search online.
I do currently wear single vision distant glasses, so it’s a bit difficult for me to be excited at the prospect of wearing progressives (especially since I never have). Currently, I can be corrected to 20/40 in one eye and 20/25 in other. Since glasses can get expensive I have been wearing an older pair, so it’s probably safe to say I am not corrected to 20/40 or 20/25 right now.
I am slowly coming around to the idea of wearing progressives if it means I can still have some good near vision without glasses.

10

Thank you for such a well thought out reply. I have posterior subcapsular cataracts that have progressed fairly quickly for me. My prescription has been changing more than once a year and I can’t seem to keep up. Currently, I can be corrected to 20/40 and 20/25, but I since I have surgery scheduled I have been wearing an older pair of glasses that I am sure don’t get me to 20/40 and 20/25. I drive myself to work, but aside from familiar places I have been avoiding driving because it takes me far too long to read road signs than what’s safe.

I wonder if Bookwoman, and others, are able to keep their glasses off around the house because they ended up with a greater range of “good” vision, or maybe because of the different starting points we sort of learned to accommodate for the blur. It might sound funny, but in going back and trying on some of my older glasses my vision is definitely not great, but I can make it work. Hopefully, without glasses around the house from time-to-time I can make it work in the same way. Right now I would be a danger to myself without glasses around the house.

I really appreciate knowing the distances that ended up being clear and crisp, and at what point you begin to rely on your glasses. My surgeon said that if I chose distance, I would need different powered readers for different tasks (stronger readers for up close, and less powerful for computer distances) but only mentioned needing glasses for driving distances if I opted for near. So, my mind automatically went to single-vision distance lenses.

I wish I knew why I was so intimidated by progressives. A few of my co-workers have progressives and they all seem to have different experiences with them. I keep reminding myself that even if I did not need cataract surgery I would probably end up needing progressives or bifocals in the future anyway. At least this way they will be much thinner lenses.

11

Thank you. I wish my surgeon had talked about the brand of IOL so I could search for information specific to what she’d be using.

What I find interesting about the experiences shared with me so far, is how much of a difference 1 dioptre seems to make. With just myopia and nothing else, I can’t say there was much a difference in my vision when my prescription would increase. I don’t even remember when my eyes were -1.5 or -3, but I don’t remember going from -6 to -7 and thinking to myself, wow I really needed an increase in my prescription to see. At most, I went from “good” vision to “HD” vision when my prescription got bumped up.

I am nervous about experiencing a sudden and dramatic decline in my vision at a certain distance. I first thought that after surgery I’d see well at only one specific distance and anything more than an inch off would be instant and terrible blur. Oh how I wish we could take other people’s vision for a test run!

Things are starting to make more sense to me.

12

If you target near you will be wearing glasses most of the day. I would not target both eyes near, with the hope getting through the day without glasses (unless you are working close up all day). Say you target -2 to -2.5, that is moderately near sighted. It means your distance lens prescription is -2.5. You wouldn’t walk around during the day without your glasses on if you had this prescription. I don’t think your goal should be to “get by” after surgery. I think your goal should be to have amazingly crisp vision at all distances, so crisp you won’t believe your own eyes. That will require distance glasses most of the day in this context. And will require you to remove the glasses to read. (progresssives is just an option).

I’ve chosen this option because I cannot tolerate monovision, and I do not want to risk any of the light disturbances or contrast loss with multifocals or extended range IOLs (I’ve spent 10 years suffering from extreme glares and halos) . Also I like being nearsighted and my work and hobbies are close range . But the top reason we chose near target for me is because I put zero value on being spectacle-free.

If you are thinking about getting by without glasses have you considered the other options ? Most people don’t want to wear glasses, which is why most don’t target both eyes near. I love my new eyes, its everything I was hoping for X 10!But if my goal was to walk around most of day at home without glasses , I’m just not sure I would do this option.

13

I had the same exact struggle, although I’ve decided to opt for distance with Eyhance.. I’m -4 in both eyes and got cataracts around the time I got presbyopia. So I had no experience with progressive glasses. I was still doing the “peek under” trick with my single vision lenses. I was terrified of making the “right” IOL choice. It’s impossible to imagine how what life will be like afterwards because no IOL can fully bio-mimic what we were born with (ability to refocus). And again I’d never had progressives so I didn’t know what that would be like either!
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Making matters worse, I’d ordered some progressive online from Zenni to try out and they were HORRIBLE! The whole room would “swim” when I moved my head and the distortion was horrible. They say you get used to them but I tried off and on for weeks and never got used to this Zenni pair that I bought for maybe $80.
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But it’s a big decision so I decided to bit the bullet and buy “real” progressives to try out even though they’d be expensive and useless to me once my prescription changes after surgery. I visited my optometrist and asked for the cheapest possible “good” progressives. They cost me $360 which isn’t nothing but it’s cheap for progressives from an optometrist.
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The difference between those and the cheap Zenni pair was NIGHT AND DAY. There was still some “swim” and distortion but nothing at all like the Zenni pair. It was mild enough that I was more than comfortable wearing them full time which allowed me to adapt properly. Within a week or so I almost never noticed any “swim” or distortion at all and i love them now. I can go for a run and see my Apple Watch perfectly. I’ve been wearing them daily now for a year (still waiting for surgery) and they’re great. And they have really set my mind at ease about the prospect of possibly needing progressives after surgery.
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I would also add that if you are correcting to 20/25 in one eye that’s actually very good. It’s a personal decision of course but I don’t think there is any rush at the moment for you to have the surgery right away. Take you time. I’ve been living with 20/30 and 20/40 distance corrected vision for a few years now and its fine. Driving isn’t ideal but its not illegal and I don’t feel at all unsafe. I can tell it’s getting a bit worse though. Sunglasses help a lot.

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I think one of the confusion is that you are ripping out your natural lens which adopts, changes shape to focus the light where it is needed, and replacing it with a piece of plastic that does not do that.

So lets say you go with a monofocal. And I am doing this quickly so please double check my numbers.

When you go from distance all the way down to 25" or so it is 1.5 Diopter. Forget 8". Lets say you set your vision to be 20/20 at 10". To go from 10" to just 16" is 1.5 Diopter. And you vision will degrade quickly.

Now maybe this is what you want, but my advice is to see a Top Ophthalmologist, now some friend recommended one. I am talk top in the country who has a lot of experience with this and spends time making sure you understand the tradeoffs.

If this was me I would consider the Eyhance and do micro monovision to get you down to maybe cell phone distance with “Good” vision and learn to live with glasses for close up work. This way you would see from your cell phone out to distance pretty clearly.

IMHO if you set for 20/20 at 10" you will not even be able to see your TV at home clearly without glasses. I am not even sure you would be able to see the computer clearly.

15

Hm, that is a bit of a bummer to hear. My doctor recommended against multifocal, and since I really do not want to lose my near vision, getting set for distance didn’t make sense to me.

My goal for getting by around the house without glasses was to be able to put on my makeup (I wear my glasses when I do my hair, so I’d assume I’d need glasses for that after, too), use the restroom in the middle of the night without glasses, and maybe be able to see if my dog was by the front door asking to go outside (I wouldn’t mind putting on glasses to be able to see which direction she’s facing, haha), that would be nice. Otherwise, getting by would mean walking around the house and not bumping into things without glasses. I would just plan on wearing glasses anytime I left the house, to watch TV, cook, when I woke up and wanted to read the time on the clock, etc.

Currently, I wear my glasses to read books and work on the computer, so if I had to wear them after I wouldn’t be too surprised. I do check my phone when I wake up, and can reply to messages and emails without glasses.

I guess I was just hoping without glasses I could make out big objects and then need glasses to see details. Like, without glasses I could see someone standing there and tell what color shirt and pants they are wearing, then put on my glasses and be able to tell what type of shirt and type of pants they were wearing (and, of course, then be able to see their face). It’s a silly example, but the first one that came to mind.

I have lots to think about.

16

I’m going to disagree with Mike. As I’ve written before, I walk around all day at home without glasses, with one eye at -2 and one at -2.5. I can see people, the objects in my house, etc. just fine. Is it all perfectly crystal clear? - no. But it’s a vast improvement over my previous eyesight (even before I had cataracts), when I couldn’t see what time it was on the clock radio right next to my bed. And my new vision is crystal clear for reading, working on the computer, etc.

I no longer need glasses to blowdry my hair, and I can now see my body in the shower perfectly. When I took a shower after getting my eyes done I realized that the grout needed cleaning - I had never been able to see it clearly before.

Last night we were watching a movie I’ve seen a million times (Beverly Hills Cop). I had my glasses off for much of the time, and I was able to watch and follow the action with no problem (the TV is across the room), although it was of course somewhat blurry. Now if it had been a new film to me, or one with subtitles, I certainly would have needed glasses, but I say this to encourage you that your eyesight can be quite acceptable with near distance lenses, even if you’re not wearing glasses.

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Yes there is a big difference between being myopic and having the ability to re-focus while wearing single vision glasses (accommodation) and being myopic and having NO ability to re-focus without putting glasses on and off and on and off. The loss of accommodation is the issue. With a distance target you will be able to live life most of the time without glasses… for sure everything from infinity to 3 feet. Or a bit better with Eyhance (maybe 2 feet with a bit of micro monovision). That covers off a lot of vision… most things other than sustained reading or recipe reading, labels, etc. And progressives are still an option to make life more convenient if you wish but they would not be REQUIRED just to exist in the world outside. With a near target set to 8" you’ll only see well within a small range of that 8". Accuity will drop off pretty fast on either side of that 8".

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Its definately not going to be a bummer! All those things you say , including doing hair , will be perfect without glasses. You might end up cooking without glasses. But you will be amazed at how crisp everything looks (distance) with your glasses on and you might put them on more than you think.

Have you talked to your doctor about a near setting mini monovision, like one eye at -2.0 one at -2.5. This might be important to at least consider in somebody with your goals .

19
  1. If you get corrected for full distance with a monofocal, you should get 20/20 at distance or a bit better. Most people can see quite clearly down to 2-3 feet. I have one monofocal set for distance and can see down to 18" on a computer monitor. So it varies from person to person. To see clearly closer you need over the counter readers. Most will choose about +2.5 for readers and you should see reasonably well down to 8" or less.
  2. Yes, if you ask the surgeon to leave you at -2.0 you will need to get -2.0 D prescription glasses. With progressives it will transition from -2.0 to +2.5 D. Virtually every prescription I have seen shows a +2.5 D add for the bottom progressive part. You can get the same thing by asking the surgeon to leave you at -2.5 D, and if you are determined to be left near sighted so you can see close without glasses that is the number I would shoot for. And yes unless you go for MF IOLs you will need progressives or over the counter reading glasses. Progressives will correct any residual error and astigmatism as well as provide the +2.5 D add so they will give you give you the best vision.
  3. A -2.5 D myopic vision target should give you vision in that range.
  4. Your best way to answer that is to try some contacts to simulate the outcome. Places like Costco, and I presume Walmart will give you free samples to try. In your -9.0 eye you can simulate a -2.5 D target by using a -6.5 D contact (approximately as there is small conversion from eyeglass to contacts). And in the -10.0 eye you would need a -7.5 D contact. That will show you how blurry things will appear.

There is one other option to consider as well. That is mini-monovision where your dominant eye is corrected fully for distance and your non-dominant eye is corrected to leave you at -1.5 D. This is not going to give you super close vision but good enough for 95% of things. This is what I have and while I keep; some +1.25 D readers around, I may only need them once a week. The rest of the time I do not wear glasses at all for my iPhone, computer monitor, TV screen, or outside driving. It just requires basic monofocal lenses and the only trick is to under correct the non dominant eye by -1.5 D. It does you reading and close vision, while the other eye does from 2 feet out to infinity. The -1.5 D eye gives reasonable vision out to 10-15 feet so you retain binocular vision from 2 feet out to that distance. This can be simulated with contact lenses too, and that is the advisable way to test drive it before having it done with IOLs.

Hope that helps some,

20

I discussed some possible outcomes with my surgeon, and she suggested aiming for -1.75 in my first eye. Because of the possibility of refractive error, she said it may end up a -2 or -2.5. From there, we will decide what to target for the second eye. I am hoping it goes well and I get the outcome I am expecting.