FEATURE EWAP MARCH 2023 11 candidate for monovision,” Dr. Donnenfeld said. Dr. Lee said he will consider monovision for a patient who has had vision corrected with this technique before and was happy with it. “If a patient likes monovision, I would continue it and never switch to a trifocal. At the same time, the only way I would do monovision in someone with no prior experience but too much cataract for a monovision contact lens trial would be with the Light Adjustable Lens,” he said. In general, Dr. Lee said that monovision can give better reading vision than a presbyopia-correcting IOL in both eyes. He also said that some patients who are not good candidates for a trifocal IOL, due to ocular comorbidities, can still be a candidate for monovision. “Monovision avoids the halos associated with a diffractive IOL, and you can optimize night vision with a pair of glasses,” he said. Some ocular comorbidities rule out monovision/blended vision as a viable option. These, according to Dr. Donnenfeld, include patients with amblyopia, macular degeneration, or other pathology in one eye to the extent where the vision has deteriorated, and the patient thus would not be happy with vision in that eye for near or far. Dr. Donnenfeld said he’ll also steer away from monovision in patients who are athletes and need depth of focus. Golfers, for example, can’t see the greens well with monovision, he said. Dr. Donnenfeld doesn’t specifically trial monovision with contact lenses in patients who are cataract surgery candidates because they won’t get a true experience due to the cataract. Dr. Kugler also cautioned against monovision/blended vision in eyes that are compromised in any way because “each eye has to be able to carry the weight of a certain distance by itself.” Additional examples include eyes with strabismus or keratoconus. “I think you need to be very careful with blended vision because you’re asking each eye to function independently. If the eye is not capable of doing that, it’s probably not going to be a successful result,” he said. Dr. Kugler also said there are patients who simply cannot adapt to monovision. “There are patients who I think aren’t great candidates for blended vision but they are good candidates for bilateral multifocals. That’s absolutely on the list of options.” EWAP Editors’ note: Dr. Donnenfeld practices with the Ophthalmic Consultants of Long Island, Garden City, New York, and has interests with AcuFocus, Alcon, Johnson & Johnson Vision, and Rayner. Dr. Kugler in in practice at Kugler Vision, Omaha, Nebraska, and declared no relevant financial interests. Dr. Lee practices with Altos Eye Physicians, Los Altos, California, and declared no relevant financial interests. In the past decade, social habits have changed from reading printed materials to increased use of electronic reading devices such as tablets and mobile phones. This shift has coincided with the advent of newer intraocular lenses (IOLs) that provide a wider range of vision, such as the IC-8 Apthera (Acufocus), Eyhance (Johnson & Johnson Vision), RayOne EMV (Rayner), and Vivity (Alcon). There is renewed interest in monovision—not full monovision as in the past, but mini or modest monovision to achieve good distance and functional near vision and yet maintain good stereopsis. These new IOLs complement this strategy very well. I frequently employ monovision or blended vision in my practice. It is a useful strategy for patients who want to reduce spectacle dependence but are not suitable candidates for trifocal IOLs. The key factors for successful outcomes are to be able to attain the intended target refraction and correct any existing astigmatism. This can be achieved with newer biometers and modern toric IOL formulas. As many of my patients need to read Chinese characters and have a closer reading distance, I would generally aim for emmetropia and –1.25 D to –1.5 D with monofocal plus IOLs such as the Eyhance and RayOne EMV. The near target would be lower for the EDOF IOLs such as the IC-8 Apthera and Vivity. Results of my current study with the RayOne EMV shows that it provides excellent summation, giving a binocular range of about 2.5 D within LogMAR 0.2. The IC-8 Apthera is another very interesting IOL. Its pinhole technology not only provides an increased depth of focus but is also useful in eyes with irregular corneas. This will benefit patients who are not suitable for toric IOLs due to irregular astigmatism. Many patients are suitable candidates for monovision. I seldom do a contact lens trial in patients due to cataract affecting the quality of vision. Patients with previous laser refractive surgery are good candidates, as many of them may already have experienced monovision in the past. The broader landing zone of monofocal plus IOLs also provides a safety margin in terms of their refractive targets. On the other hand, patients with poor vision in one eye due to ocular pathologies or amblyopia are not suitable candidates for monovision. It will be exciting to see how the addition of these new IOLs to our armamentarium will aid surgeons in achieving their desired outcomes. Editors’ note: Dr. Yeo is a consultant for Alcon and Rayner. Yeo Tun Kuan, MD Senior Consultant, Department of Ophthalmology, Tan Tock Seng Hospital 11 Jalan Tan Tock Seng, Singapore 308433 tun_kuan_yeo@ttsh.com.sg ASIA-PACIFIC PERSPECTIVES
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