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issues relating to monocular vision after cataract surgery
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issues relating to monocular vision after cataract surgery

I will have cataract surgery in Dec and Jan.  My surgeon wants to give me fixed focus IOLs for distance only in both eyes because I have too much astigmatism for any multifocus lens.  During my cataract surgery, he will also correct my astigmatism with AK.  
My surgeon recommends against monocular vision because of depth perception issues.  However, for many years, I very successfully had a distance contact lens in my dominant (right) eye and a reading contact lens in my left eye.  
I want to request that a
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Avatar_n_tn
1) yes, in theory if the surgical correction is close

2) no, not really

3) yes, easily as long as none of your implants are multifocals
32 Comments
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Avatar_f_tn
In my experience, people either love monovision or they hate it.  If you were successful with monovision contacts, then why are you so hesistant about doing monovision with IOLs?  During my four years of successful monovision contact lens wear, my loss of depth perception was so subtle that I never even noticed it.  (Did you notice it yourself?)  At a later time, however, when I truly did experience impaired depth perception due to binocular vision problems, such activities as walking down stairs became so terrifying that I'd cling to the banister for dear life.  In other words, you don't need a formal assessment to tell whether your depth perception (or lack thereof) is a problem.

I'm guessing that your surgeon's experience with monovision is entirely theoretical/academic, and s/he is scaring you unnecessarily about depth perception issues.  One of the cataract surgeons I consulted has used monovision contacts himself for many years, and he told me confidentially that he believed monovision to be far superior to the multifocal/accomodating IOLs which he implants in his patients.  (This converation naturally took place after we agreed that I was not a candidate for multifocal/accomodating IOLs.)  And from everything I've read in journal articles, successful monovision contact lens wearers are quite happy with IOLs set for monovision.
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Hi I had monofocal iol implanted for distance in April and June.  I love mine.  Have not had any problems with depth perceptions and night vision.  From reading what others here wrote about multifocal and halos with driving at night, I didn't want to chance it.  I read computer, watch tv and drive during the day just fine without glasses.  I find I am more comfortable driving at night with my glasses (everything is sharper).  I do need my reading glasses for small print and sewing, but that all.  

My dr. gave me a prescription to change the lens in the operated eye, so that i could still drive and function after the first surgery.  

Hope this helps

Jan
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Avatar_n_tn
Jodie, you were quite right that my surgeon scared me.  I'm 70 and don't want to fall and break any bones.

Like you, I never noticed any loss of depth perception when wearing monovision contact lenses but didn't realize that one would be aware of the problem. I imagined it to be some sort of unseen force that only a formal assessment could evaluate -- similarly to my surgeon telling me years ago I was developing cataracts, before I was aware of it.  Thanks so much for setting me straight.  Your very vivid description of what the loss was like to you is very helpful to me.

I'm curious about your binocular vision problems.  How did they develop and how did you overcome them?

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Avatar_f_tn
I'm hesitant to answer your question because I don't want to scare you again, although I've posted this info elsewhere.  I developed binocular vision problems from doing monovision!  As I understand it, monovision activated what had previously been a latent defect in my visual processing system, and my eyes began to lose the ability to work together as team.  I started experiencing fleeting episodes of double vision (with an eye turning inward), which became more frequent over time.  And the optometrists and ophthalmologist I consulted didn't know what was causing the problem or what to do about it.  My own research eventually got me to a strabismus surgeon, and a 40-minute outpatient procedure completely eliminated my symptoms.  But I was warned not to do monovision again, and I'm still mourning the loss (after more than a year.)

It's extremely rare for monovision to cause such problems.  And there are some simple tests that an eye doctor can perform to rule out possible defects in your binocular vision system.
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I appreciate the information, although yes, it does worry me.  So I'd like to know what the tests are that an eye doctor can perform to rule out possible defects in my binocular vision system.  I'll be phoning him tomorrow to discuss all these issues.

You mentioned strabismus.  Isn't that the condition where eyeballs wiggle involuntarily?  I'm the only person I've ever known who can voluntarily cause my eyeballs to "jitter".  I discovered this "ability" as a child and used to freak out my friends.  Do you think this should be mentioned to my surgeon?
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Jan,

Sounds like both your eyes are set for distance and you're really happy with the results.  I'm looking to mix and match my eyes and hope I'll be as happy as you are.

Thanks for your post.
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Avatar_f_tn
Actually, strabismus is a disorder of binocular vision.  I looked up the names of the tests of binocularity status suggested for a pre-surgery evaluation of patients seeking monovision through laser vision correction.  They are: (1) a cover/uncover and alternate cover test at distance and near fixation, (2) a test of stereoacuity (Titmus, Random Dot E), (3) a test of fusion (Worth 4 Dot Test at distance and near fixation).  My source is a paper by Wagner in the Ophthalmic Hyperguide.

Actually, these tests are probably only administered to people who have not done monovision before.  It's pretty much assumed that successful monovision users aren't going to suddenly develop problems (like I did).
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Avatar_n_tn
Jan, I am so confused by your post.  I made it clear when I went in for my cataract surgery consultation that I did not mind wearing reading glasses.  But I was told that with monofocal lenses, they could only be set for distant, intermmediate, or near.  I was told that most people have them set for distant and that everything to fingertips would then be out of focus without glasses.  I was told that I would not be able to see to even put on makeup.  But when I read this board, most everyone with monofocal seems to see fine, needing glasses only to read.  Can someone give me an answer. Is vision blurry to arms length with monofocal lenses unless set for monovision, which I did not want? And if not, why the multifocal?
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K-D
Why didn't you want monovision?
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Avatar_n_tn
I mixed up "strabismus" and "nystagmus", the latter being the jittery eyeball.  Sorry about that.
Thanks for the binocularity status test information.  I tried to research the Ophthalmic Hyperguide but only medical professionals are permitted to register.  So it's really very helpful that you provided this information.
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Avatar_n_tn
Mine are set for distance.  However, I have great intermediate vision.  I can see things at close range, and long as it is not fine print.  i.e Computer screen is fine, but i can't read the newspaper's small print.  I can drive just fine, but the street signs are fuzzy.  I like you, told my dr that I had no problems wearing reading glasses, but I find for the most part, until I to read a book or newspaper or sew, I don't need them.

Jan
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Avatar_f_tn
Opinions may differ, but I agree with everything you were told at your cataract consultation.  At age 54, there's not much difference in my near and intermediate vision with an IOL vs. my own lens.  Yes, I can generally read menus without reading glasses (if I strain a little), but this doesn't mean I'd be comfortable reading an entire magazine article.  Yes, I can also read what's on my computer screen, but I'd need glasses for doing computer work for more than a few minutes.  Yes, I can cook without glasses--I can smell when something's burning.  Yes, I can put on makeup (if I use a magnifying mirror).  I would definitely not use the words "satisfactory" or "adequate" to describe my near and intermediate vision; I'd be inclined to use a much more negative expression.

Some cataract surgeons believe that being mildly myopic post-surgery is a good thing, so they set distance vision to about 20/40.  For me, there's an enormous difference between 20/20 and 20/40 vision.  (Yeah, you can drive with 20/40, but you can't read the road signs.)  And you still wouldn't have anything close to what I'd call good near vision.

For someone as young as you are, the recommendation of multifocal IOLs makes a lot of sense to me, even if they're not perfect.  And you really haven't experienced their potential yet, since you only have one.  With ReZooms in both of your eyes (or dare I suggest a ReZoom-ReStor combo), I'm sure that you'll be happier with your vision than you are today.
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Avatar_n_tn
Thanks so much Jodie.  You really comforted me.
K-D
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Avatar_n_tn
Doris, please do not go by what I say. I just did not like monovsion contacts at all.  My debth perception made me feel so clumbsy.  Going down the stairs was so strange to me. And my eyes always seemed to be fighting each other.  But that was just me.  Many people like their monovision contacts, which would be very important to try, before having monovision implants.
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Avatar_f_tn
I work in a health-related field, so I was able to get an access code.  If you give me your email address (yeah, I'd be a little wary about posting mine, too), I'll send you my code.
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Jodie,

Thanks so much for the offer but I worry about getting even more spam than I do now.  My daughter also works in a health related field, so I'll ask her to sign up and let me use her code.

You are a terrific asset to this board.  Your comments are crystal clear and to the point.
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Avatar_n_tn
To all,

My surgeon explained another risk of monovision IOLs (other than the depth perception issue).  

My brain had no difficulty interpreting the two pictures I was seeing when I had monovision contact lenses years ago.  Although astigmatism in one (or both) eyes normally presents one additional (or two additional) pictures, the tear layer between the contact lenses and my eyes corrected my astigmatism, so my astigmatism wasn
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Avatar_f_tn
I think that a 2.50D difference between the eyes is greater than is typically used in monovision.  From what I've read, a difference of between 1.25D and 1.75D is more the norm. (But consider this:  my knowledge about this topic has been acquired largely through online research, whereas your surgeon has years of professional training and experience in this area.)

Aspheric IOLs (as opposed to conventional spheric lenses) involve new technology which aims to improve contrast sensitiviy/night driving ability.  The two major corporate players each make an aspheric lens:  Tecnis (AMO) and Acrysof IQ (Alcon).  They are probably both excellent lenses.  (AMO has a great website--www.tecnisol.com/vision.htm)  I've read that aspheric IOLs can be used for a monovision correction. (I think that SN60WF is the code for the AcrySof IQ.)

Alcon is currently the only manufacturer to incorporate a blue-light filtration property into their IOLs.  Alcon claims that this property may provide protection against age-related macular degeneration.  On the other hand, AMO claims that blue-light filtration results in decreased in vision in dim environments.  I attempted to check it out but couldn't find any hard evidence to back either claim. The SN60AT is the code for the AcyrSof Natural IOL by Alcon, which is a spherical (i.e., conventional) lens with blue-light filtration built in.
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Avatar_f_tn
Another typo!  The correct website address for the Tecnis lens is www.tecnisiol.com/patient.htm. (Incorrectly noted above.)
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Avatar_n_tn
Jodie,

What a resource you are.  You are amazing.  Thank you so much for all your help.

I spoke with a technician at the surgeon's yesterday and learned that my surgeon actually uses the SN60WF.  Sounds good so far.

Will check out the technis website (and then probably will have more questions).

Doris
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Avatar_n_tn
may I jump in here?
Jodie, you are correct in reporting what the manufacturers are free to claim about their products. Some recent developments are that the Tecnis and the AcrySof IQ are recognised by Medicare for providing a greater benefit to patients over standard spherical implants with higher reimbursement to the surgery centers that use them. What is not widely known, yet, is that to establish this category, called NTIOL (New Technology Intraocular Lens), AMO had to do the heavy lifting and produce conclusive data that better vision results from this feature. Other companies were then allowed to submit their data to meet, or beat, the performance of Tecnis. Alcon did, in fact, exceed the performance set by Tecnis' baseline data, including greater contrast sensitivity and better night-time driving results, as well as in fog conditions. This will soon hit the journals and may put an end to the blue-light filter arguments. The AcrySof IQ is available only with the retinal protection of the blue and UV filter. The company also states that all future implant designs will have the filter, and I hear from my contacts at AMO and Bausch and Lomb that they are both pursuing their own answer to this unique feature.
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Hud,

I'm glad you jumped in because you seem to know a lot about Alcon products.

Is Jodie correct that the Alcon AcrySof SN60WF is the code for the Alcon AcrySof IQ?  If so, how does the Alcon AcrySof SN60 differ?
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Hud,

I'm glad you jumped in because you seem to know a lot about Alcon products.

Is Jodie correct that the Alcon AcrySof SN60WF is the code for the Alcon AcrySof IQ?  If so, how does the Alcon AcrySof SN60 differ?
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Avatar_n_tn
not to be nit-picky, but Alcon makes several models of implants that start with SN60. You will need the last 2 letters to determine if it is meant to mean the spheric, aspheric, diffractive, toric, or preloaded versions of this platform. SN60, to my understanding, represents any model that is a single-piece foldable AcrySof design with the "Natural" blue-light filter. WF means it has a "Wave-Front", or aspheric optic. But I know there is SN60AT, and SN60D3, and SN60TT, also, with different features.
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Avatar_n_tn
Hud,

Your response was very helpful and answered my question.  I didn't realize "SN60" referred to a family of IOLs.  So, my surgeon was just using shorthand when he referred to the IOL he uses as the "SN60" (his technician later referred to it as the SN60WF).

Do you agree with Jodie that the SN60WF is the code for the Acrysof IQ?  

BTW, one of the reasons for my confusion was based on a Sept 12, 2006 report at the XXIV Congress of the European Society of Cataract and Refractive Surgeons that made six references to the Alcon AcrysofIQ, three references to the SN60, and one reference to the SN60WF, as if they were all different.  Following is the link to that report:  http://www.escrs.org/EVENTS/06LONDON/
sessiondetails.asp?id=512&category=Free&sessiondate=12/09/2006
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Avatar_f_tn
Since your surgeon uses Alcon lenses, there is another lens that you might discuss with him/her.  It's the new (this year) AcrySof Toric IOL.  It's reported to be a more predictable, permanent way to correct astigmatism compared to limbal relaxing incisions.  It's considered a "premium" lens, and my surgeon would have charged me $1000 beyond the amount covered by my insurance.  I would have paid it, but it didn't come in the power that I needed.  However, if you're only mildly to moderately myopic, it might be ideal for you.
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Jodie,

My surgeon has said that toric IOLs tend to rotate, creating new vision problems.  He didn't specify brandnames but seemed to imply that all toric IOLs, presumably including the AcrySof Toric IOL, have that tendency.

I'm becoming very comfortable with the plan to get monovision.  In fact, I'm now looking forward to having it done and not having the eye strain that's getting increasingly worse.  

A major part of the reason for my comfort level is your first post, relating what a cataract surgeon told you about monovision, for which I thank you very much.  Another part of the reason is the third answer from Forum-O.D.-RMP, indicating that a later problem should be easily correctable with glasses.

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Avatar_f_tn
Monovision would absolutely be my first choice correction if I could still do it.  I had a very hard time adjusting to it during the first week, and I would have given up if my optometrist hadn't urged me to try a little longer.  But having good vision at all distances (without halos, glare or concerns about lighting) makes it a great option for those who can tolerate it.  (For what it's worth, did you know that former President Reagan was a big monovision fan?)

I hope your outcome is all you hope for.  Best of luck!

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Avatar_m_tn
Nothing has beat or surpassed the Tecnis lens which has the most valid and published studies to date. I will be anxious to see comparisons. In a recent study by Franchini,which compared four models, Tecnis, IQ, B&L and Staar using a ray tracing program and eye model, the Tecnis demonstrated the best results in depth of focus and overall was most balanced. According to Franchini, the Tecnis IOL remains unsurpassed and the gold standard IOL when compared with its aspherical counterparts.
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Avatar_f_tn
So what's the scoop on the new, soon-to-be-available Tecnis CL?
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Avatar_n_tn
Tecnis CL is an enhanced version of the silicone aspheric monofocal Tecnis. The old style haptics were more difficult for doctors to use, so they changed to the shorter, more traditional PMMA haptics that are easier to visualize. They also implemented the AMO Opti-edge feature on this lens that was originally developed by Pharmacia. The purpose is reduce "secondary cataracts" by stopping the migration of residual cells on the capsule, requiring a "yag" laser treatment.
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My wife had cataract surgery with zoom-lens planted on or around 7-20-06. from the time she left she noticed that one of her eyes had blurred vision and a foggy tent. the 9th of this month she had the lens replaced, and although I know it's only been a few days, she is having the same exact problem as before. The halo's are so bad she can't drive at night and here vision is so blurred she can't see anything out of that eye fromm about 1' away. She says she can see perfect for the first foot but it is still real hazy. Before surgery she could see fine just needed reading glasses, the only reason she had surgery was so she would not have to wear glasses. Only found out about cataracts during office visit. Any advise you might have would be a help.
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A related discussion, worse vision after cataract surgery was started.
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A related discussion, Wait or Not was started.
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