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Thread: PAL after Monovision IOL's

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    PAL after Monovision IOL's

    So we are currently in debate at my office at prescribing a PAL for patients that have had monovision cataract surgery. One of our doctors keeps pushing patients to get it, but on our side (the opticians) we keep refitting these patients into single vision distance and/or near. Has anyone had success with a PAL post-mono cat surgery?

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    Quote Originally Posted by mml00713 View Post
    So we are currently in debate at my office at prescribing a PAL for patients that have had monovision cataract surgery. One of our doctors keeps pushing patients to get it, but on our side (the opticians) we keep refitting these patients into single vision distance and/or near. Has anyone had success with a PAL post-mono cat surgery?
    How much mono? One major concern is vertical prism imbalance at near, approaching or exceeding their fusional reserves. SVNO is usually best here, especially if historically they wore their eyeglasses as needed pre-surgery.

    If they were full-time eyeglass wearers, the best approach is almost always monofocal implants, LRIs and torics as needed, with progressive lenses over so you don't have to take your eyeglasses on and off a hundred times a day.

    Hope this helps,

    Robert Martellaro
    Roberts Optical Ltd.
    Wauwatosa Wi.
    www.roberts-optical.com
    ~~~~~~~~~~~~~~~~~~
    Science is a way of trying not to fool yourself. - Richard P. Feynman

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    Quote Originally Posted by Robert Martellaro View Post
    How much mono? One major concern is vertical prism imbalance at near, approaching or exceeding their fusional reserves. SVNO is usually best here, especially if historically they wore their eyeglasses as needed pre-surgery.

    If they were full-time eyeglass wearers, the best approach is almost always monofocal implants, LRIs and torics as needed, with progressive lenses over so you don't have to take your eyeglasses on and off a hundred times a day.

    Hope this helps,

    Robert Martellaro

    My current problem patient's rx OD: +1.25 -2.00 x 080
    OS: 0.00 -2.00 x 090
    ADD: +2.50

    He is in a Varilux X Design PAL. His complaint is lack of central vision when referring to distance. Occluding an eye, he's fine. He is a surgeon and wants to be able to see everything perfectly at every focal point. I'm just not sure how to solve his issues while keeping him in a PAL. Oh and to stack on the fun, he's also a self-treated diabetic with a history of retinal issues.

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    What's up? drk's Avatar
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    He also must be a cheap son-of-a-gun surgeon. Robert is right: why he didn't shell out for astigmatism treatment and/or the Technis Symfony IOL is baffling. He wanted cheap, and he got cheap.

    And your surgeon may have been a little too accommodating: inducing monovision "de novo" at that age is very suspect treatment. (If he's a successfully adapated mono CL wearer, then OK.)

    What's worse, "monovision offsetting spectacle correction" is difficult! Even low amounts of monovision (+1.00 add, e.g.) is difficult to offset comfortably with spectacles; try a plano OD and -1.00 DS OS pair of glasses on, and notice the "weirdness" and vergence strain that occurs with even that little aniso. (I know! I've worn mono CLs and tried over-correction specs myself...they were awful.)

    And finally, I don't think this is the world's biggest issue, but you do INDEED get reduced stereoacuity with monovision (which isn't all that re-attainable easily with overspecs). Dude's a surgeon! He needs him some stereo. Again, I know this from personal experience.

    The best bet is indeed task-specific monovision offsetting specs such as SVDO or SVNO, and even then you may need to undercorrect to minimize side effects.

    In other words the surgeon is screwed. He should consider shelling out for surface treatment to eliminate the cylinder and maybe leave his refractive error at -1.00 DS OU and wear a more symmetric overcorrection at distance and near.

    The problem I have with some ophthalmologists is that they have absolutely no "feel" for managing refractive errors, especially artful things like monovision and astigmatism correction.

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    What's up? drk's Avatar
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    P.S. the "X" is pretty dang soft. That's not the choice for a picky visual person. Although it may have been a decent choice for a screwy Rx.

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    What's up? drk's Avatar
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    PPS: If that's his new refraction over the IOLs, it's "monovision fail" because he doesn't have monovision. He has aniso-astigmatism.

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    I hate dealing with these outcomes. Patients are rarely happy.

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    Quote Originally Posted by drk View Post
    He also must be a cheap son-of-a-gun surgeon. Robert is right: why he didn't shell out for astigmatism treatment and/or the Technis Symfony IOL is baffling. He wanted cheap, and he got cheap.

    And your surgeon may have been a little too accommodating: inducing monovision "de novo" at that age is very suspect treatment. (If he's a successfully adapated mono CL wearer, then OK.)

    What's worse, "monovision offsetting spectacle correction" is difficult! Even low amounts of monovision (+1.00 add, e.g.) is difficult to offset comfortably with spectacles; try a plano OD and -1.00 DS OS pair of glasses on, and notice the "weirdness" and vergence strain that occurs with even that little aniso. (I know! I've worn mono CLs and tried over-correction specs myself...they were awful.)

    And finally, I don't think this is the world's biggest issue, but you do INDEED get reduced stereoacuity with monovision (which isn't all that re-attainable easily with overspecs). Dude's a surgeon! He needs him some stereo. Again, I know this from personal experience.

    The best bet is indeed task-specific monovision offsetting specs such as SVDO or SVNO, and even then you may need to undercorrect to minimize side effects.

    In other words the surgeon is screwed. He should consider shelling out for surface treatment to eliminate the cylinder and maybe leave his refractive error at -1.00 DS OU and wear a more symmetric overcorrection at distance and near.

    The problem I have with some ophthalmologists is that they have absolutely no "feel" for managing refractive errors, especially artful things like monovision and astigmatism correction.
    Nice post.

    I wouldn't be too hard on the patient, they just followed their surgeon's recommendation, which was not as risky as MF IOLs, but riskier than non-monovision IOLs. And the risk is all on the patients end. If it was my mom, it would be the lowest risk solution, which would almost always result in the best acuity and quality of vision.

    Quote Originally Posted by mml00713 View Post
    My current problem patient's rx OD: +1.25 -2.00 x 080
    OS: 0.00 -2.00 x 090
    ADD: +2.50

    He is in a Varilux X Design PAL. His complaint is lack of central vision when referring to distance. Occluding an eye, he's fine. He is a surgeon and wants to be able to see everything perfectly at every focal point. I'm just not sure how to solve his issues while keeping him in a PAL. Oh and to stack on the fun, he's also a self-treated diabetic with a history of retinal issues.
    I forgot to welcome you to OB. Welcome. If you have a trial frame, use it to demonstrate what can or can not be done with spectacle lenses, and to assess their comfort level with different solutions. For surgery, consider task lenses, and maybe another PAL design for general purpose. MF CLs should on the table also, but at the bottom of the list of solutions, but above refractive surgery and lens exchange.

    Hope this helps,

    Robert Martellaro
    Roberts Optical Ltd.
    Wauwatosa Wi.
    www.roberts-optical.com
    ~~~~~~~~~~~~~~~~~~
    Science is a way of trying not to fool yourself. - Richard P. Feynman

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    I have worn and still wear mainly mono vision contact lenses and I wear a progressive sunglass over them with no issues at all. I would at least try rather than dealing with the hassle of switching glasses from distance to near.

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    Happy, I'm happy. But patient is not :)

    Robert, I find that "today's" cataract surgeon is also a "refractive/cataract" surgeon and the lines have blurred. The same guy making beaucoup bucks on LASIK has surfed the demographic crest into high-touch cataract extraction/implantation.

    Round these parts, conservative patients get "the covered monofocal IOL" with maybe a charitable incision placement for a 1/2D astigmatism reduction, but they really want to up$ell to the "refractive package" which includes MF IOLs and (as you alluded to) (even femto laser-assisted) astigmatic keratotomy, or toric IOLs, or now the toric MF IOLs, and all-the-surface-treatment-for-our-goofs-that-you-can-eat. It's nothing to get a secondary surface treatment.

    Clearly this guy wanted to fly coach. He got crammed into the tail section with the crying baby, the port-o-jon, and the fat snoring guy.

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    Quote Originally Posted by drk View Post
    Happy, I'm happy. But patient is not :)

    Robert, I find that "today's" cataract surgeon is also a "refractive/cataract" surgeon and the lines have blurred. The same guy making beaucoup bucks on LASIK has surfed the demographic crest into high-touch cataract extraction/implantation.
    Yup, hard times.

    charitable incision
    Ah, a reach-around.

    Clearly this guy wanted to fly coach. He got crammed into the tail section with the crying baby, the port-o-jon, and the fat snoring guy.
    Insufficient data. If true, toss in a complimentary case of Miller High Life and call it a day.
    Roberts Optical Ltd.
    Wauwatosa Wi.
    www.roberts-optical.com
    ~~~~~~~~~~~~~~~~~~
    Science is a way of trying not to fool yourself. - Richard P. Feynman

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    Mono vision+eye glass correction = Train wreck...I’ve got a referring MD that promotes this....Even after multiple epic failures, and multiple councils from me personally..To my pre-op patients I would not recommend mono unless worn in CL form previously and tolerated.

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    Basic implant good for most.

    A very abused area.

    B

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    Quote Originally Posted by Tallboy View Post
    I hate dealing with these outcomes. Patients are rarely happy.
    And it's all the opticians fault since the exam gave him great vision and the MD sure as heck isn't going to go "My Bad";)

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    Ugh. Pt insists on monovision but also "wants to be able to see everything perfectly at every focal point"? There aren't many more direct contradictions in our business.
    I'm Andrew Hamm and I approve this message.

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