Hello All, I have cataract surgery for my right eye scheduled in a couple of weeks. It will be laser assisted. My astigmatism is slightly more pronounced in that eye, so I will be getting a monofocal toric lens to clean up whatever astigmatism the laser can't. The lens will be set for distance. After a LOT of reading and research, I've decided against multifocals. I'm risk adverse and don't like the wide range of possible outcomes. However, I am seriously considering mini-monovision. The cataract in my right eye is so bad that if wasn't for my left eye, I'd probably be on short term disability right now. I'm in front of a computer all day, and if I cover up my left eye, I can't barely read the word "Test" with a 36 font. My left eye is currently dominant, but I am right handed. Questions: 1) Has my left eye likely become dominant as a result of the cataract progressing so much more quickly in the right? Unfortunately, I have no idea which eye was dominant prior to the cataracts. 2) Considering that my left eye is currently dominant, if the monofocal in my right eye is set for distance (since I'm getting that one done first), and then the monofocal in my left eye is set at, say, -1.5, is that going to be a problem, or will my right eye just naturally become the dominant one? Personally, I don't care which eye is dominant as long as I get good results. 3) My surgeon told me (and I read in a few different articles) that the ideal patient for monovision is easy and outgoing. Apparently, Introspective, detail oriented introverts like me don't adapt as well. I'm not sure if that applies to mini-monovison. Can anyone here with personal experience confirm or refute that? Thanks in advance. I spent most of the day reading through posts here, and everyone that has contributed has helped to create a treasure trove of information.
Your situation is somewhat similar to mine prior to my cataract surgeries. I am left eye dominant and know that I have been that way for a long time before cataracts. I do most things right handed, and shoot right handed. I think that shooting right and being left eye dominant has probably saved the lives of a lot of ducks and pheasants! . One difference is that my left eye still had excellent corrected vision when my right eye was diagnosed with a cataract. The right eye was off 20/20 but not that bad. I was seeing double vision and that is what got me in to get diagnosed. So I had a bit of time prior to surgery to try monovision using contacts. When it came time to get the right eye done, I had learned a bit more about the options. A friend had gotten PanOptix during this waiting time and was very negative about the outcome. She still needs +1.75 readers to read, and feels her distance vision is not as crisp as it should be. My surgeon (at that time) was not high on PanOptix either so it was an easy choice for me to get a monofocal in the first eye. I had a discussion with the surgeon about monovision and he was favourable to that choice. We talked about dominant eyes and he said that it was not necessary for the dominant eye to be the distance eye. I did a bit of research on in it and found there were studies showing that to be the case. My astigmatism was predicted to be 0.00 to -0.40 D and he said that did not warrant a toric lens. So I went with an AcrySof IQ monofocal for distance. It worked well and I got 20/20+ vision in that eye. . I had a long wait for my second eye as I am in a public healthcare situation where I had to wait until I had a cataract bad enough to operate on. I spend this time doing trials of contact lenses that would leave me -1.25 to -1.50 D myopic in my non operated left eye. I was quite happy with the results, other than wearing contacts is a bit of a hassle. Still I was getting 15 hours or more a day with them, and I was eyeglasses free. . When it came time for the second eye which was about a year and a half later I was convinced monovsion was the right way to do. I briefly considered at Vivity set for monovision, but the surgeon talked me out of it. I am a perfectionist and I think he recognized it. He said he had another patient like me that was well informed of the options and had high expectations. This patient was not happy with the Vivity outcome so he discouraged me from getting it. Is still think it is an option for some and has its pros and cons. In any case I went for a Clareon monofocal in the second eye. I should have gotten a toric but I didn't and the target was adjusted lower to take into account the predicted residual astigmatism. I wanted -1.5 D based on my trials with contacts, but the surgeon talked me into -1.25 D with remaining astigmatism bringing it back up to the -1.50 on a spherical equivalent(SE) basis. So that is what I got. On a SE basis I am about -1.40 D. . Have I seen any issues with the crossed monovision? Well not much if any. Sometimes when I am in a store and looking at signs say 25 feet away I think my eyes have a little battle about who is boss. Not a big deal. I go about 95% of the time eyeglass free. I use +1.25 readers occasionally, and I wear my prescription progressives very occasionally. I am essentially eyeglass free and happy with my vision. . Hope that helps some,
EDIT:
I should add that there are other options for going with monofocals. You can get them both set for close vision, intermediate, and distance. It kind of depends on what you want to see with no glasses on. For me, I wanted to see pretty much everything without glasses, so that is the reason I went with mini-monovision.
Hi Thomas, First, in regards to eye dominance....If you were to look through a keyhole or pick up a camera which eye would you habitually use? That eye is likely your dominant eye.
Now, in regards to the rest of your situation, I can only offer my experience. My doc was unable to determine my dominant eye 4 years ago when my left eye was basically blind similar to yours. I told him I suspected my right eye was dominant but he ignored it as we were not able to determine definitively. I, too, didn't like the risk of going with multi-focal lenses so we opted for a mono-vision strategy. Because my right eye was naturally near-sighted and had only very mild cataracts, we went with a mono-focal lens set for distance in my left eye. After that surgery I was left with basically plano in my left eye but with about a -2.0 D natural offset in my right eye. It took quite some time for me to tolerate this much mono-vision and to be honest it wasn't ideal for me.
Flash forward several years and my right eye cataract progressed (got worse) to the point I was essentially blind in that eye. So in September of this year it was time to get the right eye done. Because my left eye was set satisfactorily for distance and because I wasn't satisfied with a -2.0D offset, I knew I wanted the least difference between the eyes I could achieve whilst gaining reading vision. My surgeon suggested the Rayner EMV lens, an extended depth of focus (EDOF) "mono-focal" lens, for my right eye. He said he would aim for an offset of about -0.75D. This made sense to me because although the offset would be -0.75D, I would in theory gain about another functional diopter "in" through the extended depth of focus that this lens possesses. He explained it's a rather "forgiving" lens in that even if he hit, say -0.50D or -1.0D, I'd still have a successful outcome.
The results have been excellent in my opinion. He achieved an offset of -0.75 D to my distance eye and I can see the tiniest pill bottle print with my right "near" eye from a range of 11 inches to about arms' length and my distance vision isn't all that bad either at about 20/30 with that right eye alone. So my advice to you is, yes, if you're going for mini-monovision don't go more than a 1.5D offset if using a standard mono-focal lens and you can possibly get away with just a 0.75D offset if using an EDOF lens like the one I used (Rayner EMV). Of course, you need to make the decision you and your surgeon are most comfortable with. I'm only conveying my experience for what it's worth. Good luck to you.
Regards, Indy G
Thanks, Ron. That definitely helps.
One on my biggest challenges is that I’m 56 years old, and even with the astigmatism, I have rarely worn glasses. I should be wearing glasses for distance vision, but I can drive and function perfectly fine without them, so I just haven’t bothered. Uncorrected intermediate and near vision are great, at least in my left eye. So I fall into that category where if I get the two monofocals set for distance, I should get the clear distance vision that I haven’t had since my late teens, but I may have to give up my intermediate and near vision.
I started looking at monovision again, and then came across mini-monovision. All things considered, your result of good vision 12” and out is a compromise I can definitely live with. Poor vision anywhere from 6’ to 2’ in? That’s going to be brutal.
I’m very encouraged that you describe yourself as a perfectionist and that you’re satisfied with your vision. That bodes well for me. Right now I think I’m seeing out of both eyes even though I’m really only seeing out of one. I knew something was definitely off, but I wasn’t even aware that my right eye was bad until I had my exam. I’m hoping that also bodes well for mini-monovision as an option.
Also, thanks for clearing up the dominant eye question. That buys me some more time since I now don’t have to make a decision before my first surgery. I’ll have another talk with my surgeon during the next day follow-up appointment.
Thanks again. I’m feeling a lot better about my options after reading your reply!
The nearer vision outcome that people get from a monofocal set for distance seems to vary. I can start to read a computer screen with my distance set eye at about 18". But, I find it too far for comfortable computer work on my 24" monitor. I have no trouble at all reading my dash instruments in my car, truck, and motorcycle. However, I seem to get closer vision than what others report. . Keep in mind there are options to see a little closer than a pure aspherical monofocal. The B+L enVista is one example. Instead of targeting zero spherical aberration like the Tecnis 1, or -0.07 like the AcrySof IQ or Clareon, the enVista brings spherical aberration down to neutral which leaves one at +0.27. This does not provide quite as much visual acuity but it increases the depth of focus. Another choice would be the J&J Eyhance which provides a minor amount of extended depth of focus. Vivity is a step further, but it also brings with it increase risk of optical side effects. . Others have success with these lenses, but my preference is to stick with the pure monofocal and use mini-monovisioin to get the full range of focus. I think the Clareon monofocal is a good choice for mini-monovision. I have one in my second eye, and the older AcrySof IQ in the first eye. . There are some compromises to mini-monovision. They will only provide good binocular vision in the 18" to 72" range. Two eyes in good focus will improve vision. Outside that overlap range vision will step down a touch in crispness. That said I still have 20/20+ with both eyes open at distance.
My right eye posterior subcapular cataract got bad enough that I was left-eye dominant for a good part of the last few years. Not sure what I was before since I'm right handed, shot a rifle (very poorly) right handed but golfed and hit baseballs left handed. I may not have had a strongly dominant eye but I'd guess I've always been left-eye dominant.
I had my right eye set for -0.9D, intermediate with the expectation that it would be my "near" eye. After the surgery, I could see 20/20- at distance and reasonably well up close in good light. Monitors in poor light were a problem so I decided to set the dominant left eye to -1.3D. In theory, my right eye should be dominant at distance and it is in lower light. However, in bright sunshine, my left eye is dominant despite getting set nearer than my right eye. I don't really notice this unless I'm testing. My brain can evidently take the two images and figure out when to rely on the left eye and when it can't. So, unless you are a shooter or baseball player or engage in activities that you've trained one eye to do, I doubt you'd have problems switching the dominant eye.
Being a bit more introverted and detail-oriented, I was also concerned about the amount of monovision I could stand and thought about getting both eyes set to -1D. After seeing the need to sharpen monitor vision after the first eye, I chose micro-monovision with Eyhance and am happy with my monitor vision and overall range of vision now. I haven't used readers or distance glasses since getting the surgeries 5-10 weeks ago. If I'd used regular monofocals, I may have experimented with a wider range of monovision, perhaps -0.75D and -1.5D or something like that.
I wanted no chances of hyperopic surprise so I wasn't willing to target anything close to plano. While I think I could have tolerated a difference of up to -1.25D between eyes, I wouldn't have targeted that much difference on the 2nd eye. Targeting misses of 0.5D or more are fairly common. I looked at all outcomes within 0.5D of what I was targeting and made sure I would have a plan for the other eye. I had no good plan if my first eye ended up at +0.5D but was willing to use myopic glasses for driving if I fell short of 20/30 at distance. Fortunately, I didn't need them. I almost certainly wouldn't have been happy with a difference of -1.75D between the two eyes.
So "micro-monovision" with intermediate targets was my solution. It could work with regular monofocals but only if you are willing to use slightly myopic targets for the far eye and take some risk of seeing a bit less than 20/20 at distance. For me, it was well worth avoiding the risk of hyperopia.
I had my cataracts replaced in January and February of 2022 with Vivity lenses. I had been nearsighted all my life, though not at severe as some folks (around -3D at worst). My doctor and I originally talked about keeping roughly the same near focus vision, and that's what he put into my right eye. That eye ended up with about -1D prescription, with a Vivity EDOF lens.
We never talked about monovision at first, and we never talked about a dominant eye. I am right-handed, and when I use a spotting scope to look at birds, I always used my right eye. So I presume that I was right eye dominant.
For my second IOL, after I read a bunch of info on this site and thought about it, I asked for a little more distance vision. So my left eye is now my distance eye; this is what some people call crossed monovision.
And I am very happy with the results. I don't see any issue with the crossed monovision, or with monovision in general. I am an introvert, but I am a pretty chill person, not a perfectionist. I would have to say that I am somewhat "detail-oriented" due to my profession as a technical writer and editor, but I was not expecting perfection in my vision, because I never had perfect vision anyway. And it got much worse in recent years due to the cataracts. I feel like my eyes are better than ever now.
I do use glasses occasionally to sharpen up vision as needed. I love having the options, and I feel that glasses are great for fine-tuning vision. I really don't understand how people can expect the IOL replacement process, with all its variables, to result in perfect vision (at multiple distances, no less). I have prescription sunglasses (distance correction only) and clear progressives. But I always go without glasses indoors (reading books, working on the computer, and watching TV are all good), and I am fine for daytime driving without glasses. At night I feel more comfortable with glasses, however, I could manage without if I had to.
I meant to say that for night driving, I feel more comfortable with glasses.
Would you please explain hyperopia? Thank you.
Thank you so much for your replies Ron, Indianageo, Greg, and Laurie. I think I've learned more from the four of you in the last 24 hours than I have scouring the internet on my own for weeks. There's no substitute for first hand experience.
You've definitely put my concerns about eye dominance to rest. What was especially interesting was Indianageo's eye test. When I looked though the peephole in the front door or any other small opening, I always used my right eye. So it's very possible that I am right eye dominant and became left eye dominant when the cataracts set in.
I'm also no longer concerned with factoring my personality into my decision. I'm thinking that applies more to full monovision.
The first common thread I see is that outside of Ron, you've all used EDOF lenses to some extent. My eye clinic uses J&J lenses, so that leaves the Eyehance and I believe the Symphony. I'm far more comfortable with the Eyehance and it's .5 additionak depth of focus. If Vivivity was an option, I'd probably read up on it, but I think the Symphony has gotten a lot of mixed reviews.
The second common thread is that both Greg and Laurie targeted -1.0 in their first eye. My surgery will be laser assisted, but refraction errors are definitely a concern. The other consideration for me is that my distance vision wasn't good even before the cataracts. I should have been wearing glasses for distance vision continuously since my late teens, but I've been able to get by fine without them. That begs the question: Would distance vision at -1.0 actually be an upgrade for me? It's possible. I also like the idea of setting the first eye at -1.0 and then having the flexibly with the second eye to go more near (Greg) or more distance (Laurie).
I need to talk with my surgeon. The place I'm going to has an excellent reputation, and I have two co-workers that had cataract surgery there that highly recommended it. However it's another one of those conglomerates that every medical practice in the States seems to have become. In other words, it's like McDonald's and I'll be the guy holding up the drive thru line because I want extra pickles and no onions on my Big Mac. I get the impression they don't do many "special orders". However, I do have a good rapport with my surgeon, and it's my eyes, so whatever I decide, that's what it's going to be, or I'll start over somewhere else if I have to.
Thanks again for all of your advice and feedback. I'm still not sure what I'm going to do. I may still take the ultra conservative route of monofocals set for distance in both eyes. There's not much doubt about that outcome. However, I'm now leaning towards wanting to do the first eye with an eyehance lens and aiming for -1.0.
All considered including your limitation to J&J lenses and your objectives, I think the Eyhance is a very good choice for you in the near eye. It does not offer a lot of extension in depth of focus, perhaps about 0.35 D, but it also seems to have minimal side effects of flare and halos. Symfony would provide more but with a significant step up in potential side effects. @Sue.an2 here has Symfony lenses and could comment better. . What would an Eyhance set to -1.0 D be like for distance vision? It would be somewhat equivalent to a monofocal at -1.35 D. My near eye with a Clareon monofocal measured by my optometrist is at -1.0 D Sphere, and -0.75 D Cylinder. Converted to Spherical Equivalent that is -1.375, or essentially the same as what you should get with an Eyhance targeted to -1.0 D and assuming residual astigmatism is negligible. And, unfortunately toric lenses come in quite large power steps and even with them getting cylinder to zero is quite difficult. My wife has a toric that brought cylinder down from about -1.0 to -0.5 D. She gets 20/20 vision with the eye as sphere is 0.00. From what I can see in the literature the LogMAR of an Eyhance at distance and set to -1.0 D would be about 0.35. That corresponds to a Snellen between 20/40 and 20/50. That is very close to what I have in my close eye, and with my perfectionist standards, not very good for distance. I would not at all be happy if I had that outcome in both eyes. I'm 100% sure I would be wearing progressives full time if I had that outcome in both eyes. . My thoughts for an eyeglass free solution would be to target an Eyhance between -1.0 and -1.25 D for the near eye, whichever one you decide you want to be the near eye. And in the distance eye you want to target -0.25 D and for the best vision use a monofocal Tecnis 1 rather than an Eyhance. The combination of these two should give you near full range of quality vision.
Hi Thomas, I'm glad you're getting some good info from the comments. I think you're right in that it's wise to speak in detail with your surgeon about which course to take. I'd like to share my thoughts as to how I would approach your situation if I were you. First I would do as much research as you can on the lens options and strategies we've been discussing. Makes sure that everything "makes sense" to you so that ultimately you have no regrets, that you feel you gave it your best fully informed shot. Second, I would consider my ideal desired outcome whilst leaving options open for outcomes that, whilst not perfectly ideal, are still quite satisfactory. In your specific case (and again if I were you) I would actually try to get your true dominant eye set for distance. To be conservative, you could target the dominant eye for -0.25D to -0. 50D with perhaps a monofocal lens or an Eyhance or something like the Rayner EMV ("EMV" stands for "Enhanced Mono-vision) that I have (but I know you might need to go elsewhere for the Rayner lens). But once you've got the dominant eye nailed down successfully for distance, it's rather low hanging fruit to get success with the non-dominant second eye for near vision in a mini-monovision scenario particularly, in my opinion, with an EDOF lens. You can pretty much target from - 0.50 to -1.00 and wind up quite well off. You may notice I'm going a bit counter to your suggestion of targeting at -1.00D in that first eye. This is because I think it's important to have your best shot of getting at least one eye satisfactorily set for distance, and in my scenario you have two attempts at that. If you target -1.00D and you hit that mark and/or there's a refractive error (however unlikely) putting you at -1.50D then you've mainly just got one more shot at plano with the other non-dominant eye. If I may digress for a moment and tout what I've come to learn are the benefits of the Rayner EMV lens (I do not work for Rayner by the way. I'm just a satisfied customer of that lens), know that the lens was designed specifically for a monovision strategy in mind by one of the top experts in the world (Graham Barrett). Even when both eyes are targeted to plano with that lens, 70% of subjects in a study achieved good functional reading vision in addition to excellent distance and intermediate vision with no dysphotopsias or detectable loss of contrast. I think that's pretty compelling. With an offset of just - 0.50D in a mini-monovision scenario it seems very likely excellent reading would be achieved in virtually all cases. If the Rayner EMV lens had been available when I got my first eye done I would have most certainly chosen it for my distance eye. As it is, I have a monofocal for distance in my non-dominant eye and the Rayner EMV in my dominant eye offset by - 0.75D. But I'm still quite satisfied. Ultimately you need to decide what you and your surgeon are comfortable with for your needs in your specific case. I'm just giving you my opinion and the way I thought about things when I went through the process of lens selection, strategy, etc.
Indy G
Yes, I agree. After giving it more thought, I'm going to proceed as planned with the monofocal Tecnis 1 set for distance and see what that looks like before making a decision on the left eye.
My gut feeling is to just do both eyes for distance with the monofocals and wear the glasses. My track record with going outside the box when it comes to any decision like this isn't stellar. Fortunately, the cataract isn't that bad yet in the left eye, so I want to try a -1.0 to -1.5 contact lens for a week or two and see how well I adjust. The more I think about it, the more I think going into even mini-monovision with no trial run whatsoever might not be wise for me personally despite the success that all of you have had.
Yes, I know. I'm a big chicken! LOL
Yes, if your vision is still good in your left eye, there is no point in rushing into doing it. What is your eyeglass prescription in the left eye? If it is quite strong then there may be some issues to work around for the period of time you have the right eye done, and are waiting to do the left eye. . It is a good plan to do a contact lens simulation of monovision. Because you are younger your eye probably still has some accommodation ability. That will give you a bit of an optimistic view of how much myopia you need to read well. When I did that exercise I determined -1.25 D was ideal, but with an IOL in place and all accommodation gone, -1.5 D was better. . You mentioned astigmatism correction. If you eventually plan to get a toric in the left eye, it would be best to simulate that with a toric contact to correct the astigmatism. Astigmatism aside, for example if you are currently at -2.0 D for eyeglass prescription then you would want to try a -0.5 D to simulate -1.5 D. . The contacts I found the best when I tried many were the CooperVision MyDay (sold by Costco as Kirkland), Alcon 1, and J&J Acuvue Oasys. If you belong to Costco it is a good place to get them as I found they were quite liberal in giving out free samples to try. And, I pretty much tried every one they had samples of... I settled on a non toric Kirkland, and used them in my non operated eye for about a year and a half. I found that to be better than progressives that had the post surgery correction in them.
One could do the contact lens test with drops put in the eye to temporarily paralyze the accommodation response. That is what one of my ophthalmologists suggested. It wouldn't be a long-term test, but it would provide useful info on what your reading refraction should be. For that purpose, it could be lenses in a trial frame rather than a contact lens.
feddi it means someone is farsighted
thomas, I used the Tecnis 1 monofocal set for intermediate vision in both eyes and I see 20/25 and 20/30, without glasses, which is good enough for me. I see my computer very clearly, drive great in the dark, all without eyeglasses. I only need readers for close up reading of small print. I did not correct my astigmatism with a toric or with limbal relaxing incisions. I had planned to correct it with glasses, but I didn't need to. That was how it worked out for me. You may want to consider Intermediate vision, but the refractive outcome after cataract surgery can vary from person to person.
I think the main purpose of a contact lens test is to determine how comfortable one is with the difference in correction between the two eyes. Probably the most accurate simulation of the myopia needed without accommodation is to just buy some low power dollar store readers and try them with your IOL eye which has been corrected for distance. Tests I did while still having some accommodation were favouring -1.25 for myopia. But after I had my first eye done for distance, the test with +1.25 and +1.50 readers pointed me toward the -1.50 target.
That is correct. I would just add that there is nothing good about being far sighted or hyperopic. Some use the term to describe vision where one can see well in the distance but not close up, which is actually presbyopia. For the best distance vision far sighted people need to be corrected too. They use glasses which require a + correction instead of a negative correction. If the correction is significant, you can tell whether a person is far sighted or near sighted by just looking at the size of their eyes through the lens of their eyeglasses. Glasses for myopia make the eye look smaller, while glasses for hyperopia make the eye look larger.
Lynda111, what is your refraction? Your results sound like my vision with glasses set to -0.75 under correction.