4 EyeWorld Asia Pacific | June 2024 Graham Barrett Chief Medical Editor EyeWorld Asia-Pacific • China • Korea • India EDITORIAL Things to Think About The current issue of EyeWorld Asia-Pacific provides lots to think about, when it comes to covering current and frequently encountered issues that arise during cataract surgery. These encompass every topic, from the relatively mundane issues like post-surgical management of foreign body sensation, to futuristic prospects like how intraocular lenses can be more widely used. One of the most interesting topics is the discussion about what we presently understand of ocular dominance — particularly in relation to utilizing modest monovision in Cataract and Refractive surgery. The decision of whether to perform monovision is more complex, however, when the clarity of vision is impacted by significant cataract. Testing for dominance is less reliable and contact lens trials are of little use when the vision is impaired. Monovision can be considered as Mini Monovision in the range of up to -0.50 diopter, Modest Monovision with a range from -0.75 to -1.50 diopters, and Classical Monovision when the myopic target in one eye is -1.75 diopters and greater. An additional category of Extreme Monovision in the range of -3.00 dioptres and greater can be considered as a method to address diplopia following cataract surgery. We are accustomed to thinking that the dominant eye should always be corrected for distance but in reality clinical experience suggests that this is not always the case. Published studies have documented that there is no difference in patient satisfaction among patients who have undergone cataract surgery, while presenting with a modest level of monovision to correct a distanced eye. Although deciding what level of myopia to target, along with eye dominance may seem daunting to a surgeon unaccustomed to using modest monovision in cataract surgery, the reality is that many of these issues can be avoided by targeting a modest level of myopia of -1.25 dioptres. I consider this to be the “magic” number because any negative impact of monovision on stereo acuity is relatively minor at -1.50 dioptres of anisometropia or less and a reduction in bilateral contrast sensitivity is only encountered at higher levels of anisometropia. Furthermore, the issue of dominance at this level of anisometropia is less relevant. As mentioned, patient satisfaction has not suffered, whether the dominant eye is targeted for distance or near at this level of myopia. Having utilized modest monovision for many years in approximately 75% of all cases undergoing cataract surgery, I can summarize the secret of success through four points: the A, B, C, D of Monovision. Address the alternatives, which include monofocal IOLs, multifocal IOLs and accommodative IOLs. Broach the option of monovision, emphasizing the maintenance of optimum quality of vision and reversibility. Emphasize that modest monovision provides excellent intermediate vision but not total spectacle independence. Choose the eye with the denser cataract and poorest vision as the first eye for surgery targeting emmetropia. Demonstrate the impact of -1.25 diopters by adding a +1.25 D lens in a trial frame on the recently operated eye to demonstrate the impact of the defocus on distance vision and the level of reading expected if this target is achieved. Generally, a minimum level of unaided vision of 6/9 is required in the first eye that has undergone cataract surgery for a patient to be a good candidate for modest
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