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Up Front | Oct 2009

Monovision: A Multitude of Options and Opinions

This month's cover focus is of specific interest to many readers of this publication. Presbyopia correction in cataract surgery has become one of the most discussed topics in our subspecialty. A variety of IOL solutions that aim to reduce spectacle dependence have been introduced to the market. There is a big effort from the ophthalmic industry to market these presbyopia-relieving IOLs. A huge variety of refractive, diffractive, presumed accommodating, and hybrid IOLs are available to offer our patients adequate visual performance and reduced spectacle dependence. However, the pros and cons of each IOL are different. There is no brief overview of the complexity of presbyopia-relieving IOLs—surgeons must understand such complexities as visual acuity data, contrast sensitivity, light distribution, pupil size dependence, centration dependence, sensitivity to tilt, near-focus distance, potential to mix and match different technologies and/or focus lengths, dysphotopsias, availability of simultaneous toric correction, and patient lifestyles and demands. All of these areas play important roles in the quality assessment and usefulness of each IOL.

There are, of course, also financial consequences. In Europe, legislation varies tremendously between countries with respect to reimbursement and opportunities for copayment. In the transition to a more refractive-conscious cataract surgery practice pattern, many surgeons find it difficult to adopt the required logistics, including gathering patient information, performing preoperative examinations, allotting chair time, and explaining additional cost. In our own hospital, we are in the midst of changing our traditional (old-fashioned) practice into a more client-oriented refractive cataract practice. This takes a lot of time and dedication of surgeons and staff.

But where does monovision fit in to this discussion?

In our cover focus articles, monovision is described as a widely practiced strategy in contact lens correction, laser refractive surgery, and cataract surgery. In their introduction, Carlos Vergés, MD, PhD, and Lourdes Ruiz, MD, describe why now is a good time to reopen the debate on monovision. Contributions from Ronald R. Krueger, MD, MSE; Bruce J. W. Evans, BSc (Hons), PhD, FCOptom, DipCLP, DipOrth, FAAO, FBCLA; and Graham D. Barrett, MD, FRACO, follow to describe how monovision is used in their personal specialties. Dr. Barrett, for instance, advocates monovision as his preferred option for patients who look for reduced spectacle dependence, targeting a modest myopia of 1.25 D. He highlights the importance of the amount of ametropia between the two eyes.

The so-called mini-monovision of -0.50 D is widely used in both refractive and cataract surgery, sometimes in conjunction with presbyopia-relieving IOLs, and has proven to be successful for many patients—although often to a limited degree. True monovision aiming for 2.00 D of myopia has its own limitations and involves significant neural adaptation. Nevertheless, many surgeons use some kind of monovision regularly in our cataract practice. Dr. Barrett describes his systematic approach of offering modified modest monovision for the second eye in all cases. It is an interesting strategy that deserves serious attention from all cataract surgeons. How can we incorporate such a strategy in combination with offering multifocal IOLs? It is difficult for patients to fully understand the advantages and disadvantages of any particular solution. It is also time consuming for surgeons to explain the pros and cons of all available options. Patients often rely on the expertise and judgment of their physicians about the best choice for their personal situation. Interfering with this complex discussion is the financial aspect of IOL pricing and chair time, as well as the variable reimbursement systems in different countries.

CRST Europe will continuously provide you with information on IOL technologies, as well as practice development issues; this becomes increasingly important in modern day cataract surgery. If you have an idea or contribution in mind, please send a letter to the editor. We appreciate all feedback.

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