I’ve been researching (and re-researching) different lens combinations for my upcoming cataract surgery 5 weeks from now.
I’m a young and active age 63 and have worn contacts since age 14. When I started to have reading issues at age 44, I began monovision with my contact lenses, and it’s worked great for me these past 19 years, with just one slight reading prescription change 2 years ago.
My current contact lens prescription is -4.50 in my left (dominant/distance) eye and -2.25 in my right (non-dominant/reading) eye. I can read the tiniest of print in good light, a bit less in low light. Distance is not quite as precise, but still very good. Mid-range reading is a bit fuzzy but workable. I have never had to add eyeglasses day or night. The cataracts have started to add some glare at night though.
On a daily/nightly basis I am constantly on the go and switching between reading, driving, and computer use. Not needing any glasses is most important to me.
My ophthalmologist said I should choose either monovision with standard lenses or bilateral PanOptix. At first I decided bilateral PanOptix because the idea of a full range of vision in each eye after all these years sounded amazing. But now hesitation has set in due to the likelihood of significant nighttime glare and distorted bright lights, along with a few lesser side effects.
So I’ve been looking at premium ‘blended vision’ options, especially with EDOFs. Again, I don’t want to wear eyeglasses at all, so I’m thinking of it in terms of full monovision options, not mini/micro monovision. These are the possibilities I’ve indecisively come up with for no added glasses and less glare/halos at night:
- Vivity geared toward distance in dominant eye + Vivity geared toward reading in non-dominant eye.
- Vivity in dom. eye + PanOptix in non-dom. eye.
- Standard monofocal for distance in my dom. eye + Vivity geared toward reading in my non-dom. eye.
- Standard monofocal for distance in my dom. eye and standard monofocal for reading in my non-dom. eye.
The forum here is so well informed and I would love to hear your feedback, suggestions, and experiences. Thank you so much!
If monovision worked so well for you for years, I'm surprised you're tempted by anything else. I'm in kind of/sort of the same situation in that monovision contacts worked great for me (gas permeable) for years, but a step away in that it stopped working some years ago. My optometrist warned me that I was getting to where the difference that would be required between the two eyes to have good distance and near was getting to maximum range -- I don't want usable or whatever they label it near vision, but comfortable reading vision. Sure enough, I had to give up on the monovision contacts. So with cataract surgery, my first choice is to go right back to it.
Maybe both Vivity and Panoptix do wonderful things for the majority of people who get them, but the reports of how very disappointing they are when they fall short of expectations put me right off. Maybe I avoid driving at night when I can, but I still need to do it, and I'm very risk averse.
I hope whatever you decide gives you a great outcome.
Darn it - forgot to manipulate to get paragraph spacing to show. Sorry.
Your situation sounds almost identical to mine with the exception that your dominant left eye is a little more myopic than mine was as I got older (it improved from the -4.0 range). I also had used contact monovision prior to cataracts, but gave it up due to getting frustrated trying to handle the contacts.
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I think you have identified the possible options very well. I started out thinking PanOptix was the answer, but after a friend got them and was unhappy with them, I reconsidered. At my first surgeon consult for cataracts he said that he would not put them in his own eyes, kind of confirmed it. After a discussion we agreed on doing my worst eye (right non dominant) with a monofocal set for distance. This is the reverse of normal, but he said it was not critical and crossed monovision can work just as well. The surgery went well for me, and I came out at 0.0 D Sphere, and -0.5 D cylinder, when using a non toric monofocal AcrySof IQ. Lens I had the choice of that one or a Tecnis 1, and decided on the AcrySof. This gave me 20/20+ vision for distance, and very good vision of my car dash and I could read a computer monitor starting at about 18". Not good enough for reading and most text at normal monitor distance.
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My left dominant eye was not nearly as bad, and I went about 18 months before going ahead with it. I used this time to find better contacts and I simulated mini-monovision at -1.25 D and -1.50 D. I liked -1.25 but I was still getting some accommodation in this eye. By using some +1.25 D and +1.5 D readers on my new distance set IOL eye, I confirmed that I preferred the vision with the +1.5 D. I could read the J1 Jaeger vision chart at 14" in bright light. So I went into my second eye with a target of -1.5 D, but it got a little complicated due to astigmatism. I went non toric, but if I had it to do all over again I would get a toric. My outcome was -1.0 D Sphere, and -0.75 D cylinder. This combines to give a spherical equivalent of -1.4 D. I have very good close vision and can still read J1 in good light. But I have a drop shadow due to the astigmatism. In any case I am convinced that -1.5 D is the ideal for the close eye especially if one can do it without any or minimal astigmatism.
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I considered the Vivity for this second eye, but got cold feet at the last minute. My surgeon did not encourage it, and that was the final straw against it. I think it still is a viable alternative for the close eye, but does have some additional risk associated with it.
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Thoughts on your options:
1. Yes, this would work. I would target -1.0 D for the close eye with the Vivity. The knock on the Vivity however is reduced contrast sensitivity and potential optical side effects, especially at night. It is an expensive option and I am not sure it will produced better results overall than a pure mini-monovision configuration will.
2. This is similar but you are adding on the significant risks of the PanOptix. It would/should have binocular distance vision though.
3. This is the option I considered, and it does have some advantages. You get the high contrast sensitivity and excellent distance vision with the monofocal, and then the closer vision with the Vivity set at -1.0 D. The question is whether or not it gives better overall vision than the pure monofocal mini-monovsion.
4. This is the option I would choose and did choose. I think the ideal is to target -0.25 D in the distance eye, ideally dominant, and to target -1.5 D in the near eye. I went with AcrySof IQ in the first eye, and Clareon in the second eye. It was not available when my first eye was done. Today I would do both with Clareon.
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I would not suggest going higher than -1.5 D in the close eye, or you will start to suffer a binocular vision/depth perception loss, and even a gap with poorer vision in the intermediate range. There is an excellent report on the options for monovision at the link below. It compares -1.0, -1.5, and -2.0. The conclusion was that -1.5 was best. The whole report is no longer on line, but the graphs and tables that have all the detail are still there. If you click on each one, you will get more info and can piece it all together.
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Semantic Scholar Optimal amount of anisometropia for pseudophakic monovision Ken Hayashi, Motoaki Yoshida, +1 author H. Hayashi Published 1 May 2011 Medicine Journal of refractive surgery
I´m sure, you did read up on all those various possible combinations, and know about pros and cons, and the possibility of outcome surprises. Only you can decide which outcome-risks you are willing to take.
I just want to add another way of thinking about it:
As you´re used to monovision already, it seems to be a good way to go, and it definitely is. But i tried to avoid a too big a difference between both eyes, because in 20 years, when you´re reaching very high age, there´s the possibility of one eye becoming weaker or failing for other unforeseen reasons. If that happens, you´re stuck with the, probably not sufficient, range of refraction from the remaining eye. And then, in very high age, you are possibly not suitable for another surgery anymore. It´s a paranoid thought, i know.
Thats why i, for example, chose mini-mono setup with bilateral Vivity, instead of Eyehance or Monofocals, which require a huge difference between both eyes for the monovision setup, to achieve reading range.
With my Vivity, i could imagine to live with the range of each eye on it´s own (plus then occasionally wearing glasses), though it wouldn´t be too much fun, i guess.
But be warned, with EDOFs in mini-mono, the surgeon has to hit outcome targets very well, to be able to read.
Just my two cents, for ways to think about it.
That's true, that as we age, something unforeseen could happen to one eye. An injury? A sudden loss of vision? A progressive loss of vision? That was one reason, albeit a minor reason, I chose binocular vision.
Interesting feedback about negative possible outcome with advanced aging and monovision. Never thought of that.
Since you have AMD, which is progressive, I would think having binocular vision might be a key consideration for you.
Thank you for your suggestions. I do worry about having too large of a numerical difference between each eye, but I really don't want to need reading glasses.
I didn't mention it earlier, but my doctor discovered a very slight astigmatism in my left/dominant eye that had never been diagnosed before. But he said he was going to correct it by laser so I wouldn't need a toric lens. I'm curious why you didn't have that done?
Also, did you ever consider using the Eyhance monofocal at all? I was just reading that "the Eyhance IOL has extended depth of focus (EDoF)-like qualities through the design of the central 1 mm of its optic. However, the Eyhance was not approved as an EDoF lens and surgeons cannot charge a premium fee for it."
Reading people's experiences, I'm definitely more hesitant to take chances, and am now leaning toward monofocals, but I can see myself opting for full monovision rather than mini. Perhaps the Eyhance brand would compensate slightly for the depth perception issue.(?)
Thank you, that sounds like very advice for me!
get panoptix and a monofocal.
Keep in mind that prescription glasses are always a plan B. They tend to be easier to prescribe with monofocals as compared to EDOF lenses. And they are just as easy to prescribe when there is a monovision split between the eyes. When you consider that glasses are a backup issue, it is really a non issue.
I really don´t want to rain on your preference for monofocals.
But tell me how prescription glasses would help on an eye, that is failing in the future due to other reasons than refraction error.
On the astigmatism part of my issue is that it is irregular astigmatism, and the surgeon would not commit to whether or not a toric would help. He also told me I could get Lasik to correct it, if the outcome was not to my satisfaction. That turned out to not be true. I did consults with two Laser clinic after my surgery and they could reduce my astigmatism, but if they did, I would lose most of my reading ability. So, I asked if they could increase my myopia from the -1.0 D to -1.5 D and at the same time get rid of the astigmatism. The answer was that they can reduce myopia easily (flatten the cornea) but it is very difficult to increase it (make the cornea more steep). And, on top of that they discovered that I most likely have keratoconus (thin cornea) and the surgeon said Lasik is unpredictable with that condition. If you don't have this condition and you don't need to increase myopia you may be fine with it. Normal practice is to predict residual astigmatism and correct it with a toric if it is expected to be 0.75 D or more.
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As far as my reading ability goes, I am 95% free of wearing eyeglasses. I keep a pair of +1.25 D OTC readers around, and perhaps use them once a week or so for very fine print. I don't need them for my iPhone or computer work, or paper documents. I also have a pair of prescription progressives that I keep to use when driving at night out in the country where it is dark. That is almost never as I don't often drive out of the city, and for city driving at night I don't use glasses. When I go out shopping or for dinner I don't bring reading or prescription glasses. I do just fine without them, and even in restaurants reading the menu in dim light. My wife has a distance set monofocal and often forgets her readers, so I end up reading the menu for her...
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I did consider the Eyhance, but not for long. They add about 0.35 D to the depth of focus. It is really not that significant. If I was going to use a Eyhance for the near eye, I would have asked to be left at -1.25 D compared to -1.50 D with a monofocal. It is next to a trivial difference. In Canada I am not aware of the Eyhance being available at no cost. I didn't consider it long enough to find out what the cost would be here. The price of an Eyhance is a line or so loss in distance vision, so I would only use it in the near eye, and not the distance eye.
Glasses won't help an eye that has gone blind of course. But, my point is that the world has not come to an end if you can't go eyeglasses free. You just get eyeglasses. It is nice to be eyeglasses free, but far from essential.
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My wife is essentially blind in one eye and when we were selecting an IOL for her only eye with vision we considered a PanOptix and Vivity. Cost was not a consideration. When she looked at the risks with those lenses and considered that it was her only eye, she selected a monofocal set for distance. She now needs reading glasses or progressives which she has but almost never wears. If her only eye was -1.5 D for example that would be quite OK too. She would read and see most intermediate things without glasses but would need glasses for distance.
Yep, you´re right, when you´re willing to use glasses on and off all day, or use progressives.
But for me though, EDOFs are a nice balanced compromise between multifocals and monofocals, presumed there are no drastic surgery outcome surprises.
And later, in very old age, i think i would prefer better functionality over the advantages of a monofocal.
I have no info. on that. Can you elaborate? That could be a key point?
For sure putting glasses on and off all day is an annoyance. I don't like that much, which is why I chose mini-monovision with monofocals. I almost never use glasses. I often use the computer at 14" or so and watch TV at 12 feet away at the same time, and can do it all with no glasses.
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But on the other hand I wore progressives for decades and managed.
I get it. Interesting! I know you chose binocular intermediate which I was supposed to do originally. This is now something new to review.
If you were to choose straight binocular with a basic monofocal what do you feel would be the best choice given that you of course would have to wear glasses. I wonder about -01? Someone in a past discussion actually chose that for binocular.