Presbyopia correction through monovision

Every lens extraction patient or presbyopic patient eligible for refractive surgery poses a doctor with the challenge of delivering them a full range of vision with a lack of accommodative apparatus.

Multifocal or the currently available accommodative intraocular lenses are not a perfect solution for everyone because of disturbing visual phenomena¹ or an insufficient range of accommodation. Multifocality obtained at the corneal plane suffers the same drawbacks as multifocality at the lens plane. Monovision is a technique where the dominant eye is surgically targeted for the preferred distance of vision (in general infinity, but it could be a different target, e.g. –0, 50 for TV viewers) and the non-dominant eye is targeted for near. The brain then provides suppression of the blurred image coming from the non-focused eye.

Two important general rules govern monovision:

The distinct advantage of monovision is that the anisometropia is temporarily reversible with a normal pair of spectacles used for particular tasks and postoperatively titrable with a laser retouch or lens exchange.

With careful patient selection, the degree of satisfaction with monovision is very high^3,4 but in order to be at its best, it has to be designed and delivered in a certain way.

My general approach

Firstly, always discuss the various options for presbyopia compensation with your presbyopic or pre-presbyopic patients. It may not be obvious but this really is the first step and it should be taken with every over-forty patient who walks into your office asking for surgery. It's also not always obvious to aim for bilateral emmetropia in cataract surgery. Whilst it may be the best option in a far-oriented, avid golfer, the more frequent scenario is that of a patient who has developed cataract-induced myopia and, while suffering from the loss of sharpness for far, would complain bitterly about any post-operative loss of ability to read without glasses. Moreover, be assured that your 36-year old, minus two diopter patient, has always been used to reading with his or her glasses on before dialing –2 into your excimer laser. Very often these patients have developed the habit of taking off their glasses as soon as they do not have to concentrate for far. They soon develop a habit-induced early presbyopia that is difficult to eradicate post-op. A contact lens trial with full correction of the myopic error is mandatory in this case and will uncover any need for addressing presbyopia even if the patient's age is not in itself a red flag indicator.

Ophthalmologist turned detective

As a doctor it can sometimes pay dividends to investigate a patient's circumstances a little further. For example, a patient of mine, a secondary school teacher, with a refractive multifocal IOL implantation, came into my office saying she was unable to read at all whilst at work. She had to admit that she was able to read fluently J1 at the intermediate level of luminance from the examination chair in my office but insisted she was near blind whilst at school. What we discovered was that the position of her desk, by a very large window, meant that on sunny days, (very common in my country) the very bright light forced her to work in a counter-light environment so that her pupil constricted to shield out the near portion of the lens. Monovision would have been a better option for that patient.