Eyeworld

36 | EYEWORLD | DECEMBER 2019 R EFRACTIVE you wear reading glasses. and when you want monovision, you may wear glasses some of the time. For instance, with monovision, when you want both eyes great at distance or near you wear glasses; the key is with quality monovision you are not dependent on glasses. If they're OK with that, then pseudophakic monovision is a great choice. We do need to remember though that we are removing cataracts at younger ages and there is often loss of accommodation. Pseudophakic monovision is different and more of a dramatic change for a 50 year old to adjust to compared to a 70 year old and they need to understand that in the informed consent. Dr. Vukich: I will follow up with the ques- tion: Is it imminent that adjustable lenses will be available in the U.S. market as a premium procedure? It will be positioned as a refractive fine-tuning of the end result. Do we see that as a solution for monovision patients, knowing that you can achieve a predictable end result for their distance and can fine tune the near? Dr. Waring: There is a lot of excitement around postoperative lens adjustability, not only in the monovision circumstance, which is a massive portion of our population. We've got FDA approval for adjustability and we've got upstream technologies that may allow us to do multiple treatments to truly customize and try, and then fine tune and adapt all the way through. The future is bright, if this ends up working like we hope it does. Dr. Solomon: I do a lot of monovision. I think for those practitioners who are optimizing their outcomes and getting good results with monofocal lenses, I think they can get a very good result with monovision, whether they're treating astigmatism or not. For those folks who are struggling, or don't optimize, or are just interested in some of the new things like Light Adjustable Lenses (RxSight), I think that's great, but I don't think we need to wait for Light Adjustable Lenses to add monovison to our practices. At the 2019 ASCRS ASOA Annual Meeting in San Diego, the Refractive Surgery Clinical Committee hosted a roundtable. The roundtable was chaired by John Vukich, MD, and Vance Thompson, MD. They were joined by Daniel Chang, MD, Eric Donnenfeld, MD, Kerry Solomon, MD, Robert Maloney, MD, George Waring IV, MD, and William Wiley, MD. What follows are highlights from a transcript, edited for length, from the final part of the discussion, with the first two appearing in the September and November issues. Dr. Vukich: In a recent ASCRS survey, we learned up to 40% of cataract surgeries are done with a mini-mono or a monovision strategy using single-vision lenses. How do you handle that within your practice, knowing that it's a form of premium expectation, if not a premium lens? Dr. Donnenfeld: We offer monovision but I don't do a lot of monovision any longer. I feel the quality of vision and the quality of life is tremendously better with a presbyopia-correct- ing IOL. There are significant risks with mono- vision once you get over a half a diopter—pa- tients lose stereopsis. I make it clear to all my patients who want monovision, specifically if they have used it in the past, that I expect them to wear glasses when they drive because it doesn't make sense to me to give patients sub- optimal vision for driving, particularly at night. There is a lot of information about patients with monovision losing stopping speed and distance recognition. Finally, I'll mention that the monovision patients are accustomed to their vision with the crystalline lens. It's augmented by the higher order aberrations and the resid- ual accommodation that's there, so a diopter of monovision with a cataract often needs to be replicated with 2 D of monovision with a pseudophakic IOL. Dr. Thompson: We do monovision. We do EDOF and multifocality more than all of them, but we still offer monovision, especially for peo- ple worried about reduced contrast sensitivity and don't mind wearing a pair of glasses. I tell them when you want best both eyes distance, "Patient Out-of-Pocket Expenses for Today's Best Practices and Lessons Learned" About the doctors Daniel Chang, MD Empire Eye and Laser Center Bakersfield, California Eric Donnenfeld, MD Ophthalmic Consultants of Long Island Garden City, New York Robert Maloney, MD Maloney-Shamie Vision Institute Los Angeles Kerry Solomon, MD Carolina EyeCare Physicians Mount Pleasant, South Carolina Vance Thompson, MD Vance Thompson Vision Sioux Falls, South Dakota John Vukich, MD SSM Dean Clinic Madison, Wisconsin George Waring IV, MD Waring Vision Institute Charleston, South Carolina William Wiley, MD Cleveland Eye Clinic Brecksville, Ohio

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