EyeWorld Asia-Pacific March 2015 Issue

43 EWAP CATARACT/IOL March 2015 and to hold one arm extended to make an OK sign with the pointer and thumb fingers, while also spotting a distant object. Then he had the patient close one eye at a time to determine which could still see the object. “We were all lucky that in this case it was the non-dominant eye that was –2.75,” Dr. Greenbaum said. He urged the patient to wait and see how he felt after he had the cataract removed in the other eye before considering lens replacement. “Sure enough, once I gave him good uncorrected vision in his dominant eye, he wasn’t complaining about his non- dominant eye, and he had a bonus in that he didn’t need reading glasses anymore,” Dr. Greenbaum said, adding that this success gave him the confidence to try monovision on other patients. “That was in the early 90s, and to this day I haven’t seen anyone who asked for monovision who wasn’t mostly or completely satisfied with it,” he said. Other advantages The technique has several benefits, he said. “One big advantage is that the vision through monofocal lenses is the best vision,” he said. “Multifocal lenses are by definition a compromise.” There is a reduction of contrast that unfortunately comes with the benefit of having a multifocal correction, Dr. Greenbaum explained. This is something even a colleague of his who frequently recommends multifocal lenses for patients keeps in mind, he said. Before suggesting a multifocal lens, this practitioner asks patients how often they use their windshield wipers on a clear day. Those who do this frequently do not receive the multifocal lenses. “Truly that says it all,” Dr. Greenbaum said. Another advantage is that the usual method of measuring the eye for monovision requires no added expense, he said. “We are doing the same contact biometry that we’re used to doing,” he said. Meanwhile, multifocal lenses have a separate billing code for additional measurements at greater cost to Medicare, and patients must fork out more for the lenses. “For multifocal lenses, the taxpayers are paying a little extra, and patients are laying out $5,000 extra for a technique that may not be as good as one for which they don’t have to pay anything extra,” he said. With monovision lenses, Dr. Greenbaum said, there have been no reports of patients having tolerance issues with glare and halos or loss of contrast sensitivity. He finds that there is also an excitement after the monovision procedure that engenders good will. “Every time I put in a monovision correction, the ‘wow’ effect of the patient being the only one at the senior center seeing so well generates referrals,” he said. “That to me is more important than the $5,000.” Dr. Greenbaum has monovision patients from 20 years earlier whose friends still cannot believe that they do not need reading glasses. “They’re patients for life and referrers for life,” he said. While he certainly tells everyone about all of their choices, Dr. Greenbaum said he has not yet had anyone choose multifocal lenses over monovision. On the flip side, he has had referrals from those who were unhappy with the multifocal approach. “I have seen in consultation a dentist who could not practice, who had multifocal lenses put in and ‘Vaseline vision’ (as a result),” he said. “I have also seen patients who had a multifocal lens put in one eye and then had to have it removed and left [the original] doctor.” However, he has never had that experience with the monovision approach. While nothing is for everyone, Dr. Greenbaum sees monovision as possibly rivaling the numbers attained with multifocal lenses. “I think there will be a portion of patients who will be afraid of multifocals because they hate their progressive glasses,” he said. “Those folks will be more apt to want monovision because they are used to single vision lenses.” It is important to offer full monovision to patients who choose this option. “There are lecturers going from meeting to meeting reporting that –2.75 in the non-dominant eye is too much, and that in the era of aspheric IOLs, –1.25 is sufficient. They should review the December 2013 Moorfields data using aspheric IOLs because –1.25 achieved 25% spectacle independence, and –2.75 achieved 91% spectacle independence,” Dr. Greenbaum said. Eventually, however, these options will fall by the wayside, he thinks, should a liquid accommodating lens to restore the full spectrum of vision become available. Even though 25 years ago it was thought that this lens would be a reality soon, it remains just an enticing idea, Dr. Greenbaum said. In the meantime, he is certain that the cataract population will soon become more educated about the monovision option and all it has to offer, with many adopting this approach. EWAP Editors’ note: Dr. Greenbaum has no financial interests related to his comments Reference Wilkins MR, MD, Allan BD, Rubin GS, et al, for the Moorfields IOL Study Group. Randomized Trial of Multifocal Intraocular Lenses versus Monovision after Bilateral Cataract Surgery. Ophthalmology . 2013;120(12):2449–2455. Contact information Greenbaum: thecannula@aol.com