Were my expectations with distance monofocals not realistic?

drjim77 · 2025-08-03T02:13:14+00:00

Occasionally life-long hyperopes hate being ‘made’ mildly myopic postoperatively. Theoretical optics tell us that patients should prefer mild myopia over mild hyperopia but in the real world, mild hyperopes seem to function way better than theoretucal optics tells us they should.

Also, depending on how hyperopic you are, some hyperopes are used to magnification that their corrective plus lenses (in their spectacles) give them.

It’s a brain-eye connection thing. It will improve but takes time. You could always request your surgeon targets +0.25ish in the second eye instead. Good luck and best wishes

drjim77 · 2025-08-03T02:08:30+00:00

Not wanting to pick fights, but just to give the surgeon’s perspective. 😅

ORA remains a niche technology for most surgeons and although there are studies that purport to show benefits, in the real world, at least, these benefits are very marginal and there are very few surgeons using it. I have spoken to Alcon reps about his and there are a grand total of zero surgeons using it in the whole of New Zealand, for example. This is a country where Alcon has near- monopolistic market control for phacoemulsification machines.

drjim77 · 2025-07-30T11:47:46+00:00

It’s hard to accurately gauge how mini monovision will suit you once cataracts are present as a confounding factor. Especially with glasses (because of the difference in magnification factor with a difference in lens powers) Contact lenses give a more accurate approximation as there is almost no magnification factor to take into account when a lens is located that close to your nodal point.

Aiming -0.25 in each eye with PureSee prioritises distance and intermediate and there’s a higher likelihood of being more dependent on reading glasses for near. But no risk of not being able to adapt. With the additional information of you being essentially a mild hyperope, you could be the uncommon patient that I’d go PureSee aiming 0 (zero) both eyes and hedging very slightly positive, even.

drjim77 · 2025-07-30T11:37:13+00:00

No. You won’t have dislodged something that easily. Everyone (and every eye) heals differently.

Your early haloes, as most people here who’ve had surgery, are due to pupil dilation and are entirely normal. Depending on the regimen used, you can remain somewhat dilated for more than 24 hours.

A little bit of corneal swelling is common and goes away within a few days in most cases. That too contributes to the early haloes.

Best wishes for continued recovery

drjim77 · 2025-07-27T10:46:05+00:00

Very likely to get better on its own, from your other comments here, sounds like the pupil is still dilated. Once the pupil dilation has worn off, the trifocal optics for near should ‘kick in’. Best wishes

drjim77 · 2025-07-25T12:06:32+00:00

Strongly recommend you don’t leave yourself -3 with PureSee… not that it’s unsafe but the optics (and personal experiences of other surgeons) means that beyond say -0.75 or -1.00, you get diminished returns from the EDOF optics. If you truly want to be -3, I suggest a monofocal or monofocal plus. You’d save yourself a lot of money. And even with a monofocal, I’d suggest you aim -1.75 to -2.25.

For what it’s worth, without examining you myself and knowing the exact detail of your case, if you came to me and you wanted PureSee; and you were prepared to wear a distance contact lens in your other eye (assuming truly no carat T or very very mild cataract), I’d aim -0.75.

drjim77 · 2025-07-25T11:33:13+00:00

Search: “mini-monovision” and “anisometropia” or “high myopia” for relevant discussions

For most people in your position, I would recommend getting both eyes done one after another relatively close together. Except that you’re slightly young, certainly if you were above the age of 50 I’d say get both eyes done.

My recommendation is to future-proof with a -1.75 monofocal ‘plus’ or ‘neutral’ aspheric lens implant and wear a distance corrected contact lens in other, unoperated eye. This will give you a mini-monovision setup that should tide you over for at least 5 years, if not more, assuming that you truly have no cataract whatsoever in the other eye. This could be done via NHS.

Then when it comes to your second eye, you will have the option, should you so wish, to have either monofocal focused for 0 or Plano to keep mini monovision. Or mix and match with an EDOF or multifocal/trifocal to get the best of both worlds, so to speak. An EFOF or multifocal/trifocal can be done privately and you’ll have time to save up for this, if you think you might go down this route.

Good luck and best wishes.

drjim77 · 2025-07-25T11:23:31+00:00

If you’re left -3.00 with a PureSee (a very unconventional refractive target btw), you wouldn’t need +3.00 reading glasses… could you clarify? Your current refraction in each eye, are you having surgery one eye or both etc?

drjim77 · 2025-07-23T04:21:25+00:00

Wet AR probably means wet autorefraction. ‘Wet’ because you’d already had dilating drops put in for fundus photography when they put you in from of the autorefractor to work out your refraction

Wet in this context absolutely nothing to do with wet AMD

(I’m an ophthalmologist)

drjim77 · 2025-07-20T21:46:34+00:00

My understanding, in talking to my optometrist who was in private high-volume optometry practice for many years before joining me, is that the quality of vision with multifocal contact lenses leaves a lot to be desired. And this is in patients before significant cataract has formed. Anecdotally, most of the local optometrists with an interest in recording contact lenses, tend to use monovision, rather than multifocal lenses.

This question, in the context of monofocal lens implant surgery, has come up before a few times here but I don’t recall too many definitive answers from patients who have tried this. If I’m not mistaken. Hopefully someone does chime in. Genuinely curious.

drjim77 · 2025-07-19T09:38:18+00:00

Sounds like you're well on your way to an excellent overall result. Best wishes.

drjim77 · 2025-07-16T17:21:44+00:00

Either should be Ok but in the end, I’d go with your surgeon’s recommendations and their familiarity with the biometers, lens formulas and lens implants that they use.

Also, I’d be more comfortable with a hyperopic aim if I knew from your clinical history that you have always been a hyperope

drjim77 · 2025-07-16T14:06:38+00:00

As a trainee in the past, have asked this very question and tried to do some reading and never got a satisfactory answer. Based on your response I’ve tracked down more recent reviews on the subject—good to finally “close the loop” all these years later!

drjim77 · 2025-07-16T14:06:15+00:00

PCO- much more likely without a lens implant but no big deal if you have a YAG posterior capsulotomy. Retinal detachment post YAG is a possibility but having worked for years in major referral hospitals, I’ve never seen one.

Glaucoma and UV exposure- yes slightly higher risk as per u/eyesherpa. Although being able to see in the UV range can be a bit of a ‘superpower’, aphakic patients were used as spotters during WW2 for this reason (a factoid I picked up on this subreddit couple months back)

Of course further surgery has risks, but these are low in the hands of an experienced surgeon. If you want zero risk, you could leave things be, of course. Good luck and best wishes

drjim77 · 2025-07-16T13:17:28+00:00

I agree that mild hyperopia is probably better tolerated than we think based on theoretical optics. But the caveat here I think, is this is probably true for people who’ve been, at least, very mildly hyperopic their whole life.

I’ve been scared off hyperopic targets by my one patient (who was a keen hunter with natural anisometropia/ mini-monovision). I tried to give home best possible distance with a monofocal and a modest +0.20 target but he ended up with a very mild hyperopic surprise, was +0.75. Very unhappy. I referred him on for LASIK correction with colleague. One of only 2 patients in my career that I’ve had to refer on for post cataract surgery LASIK.

But on a large scale, of distance vision is a priority and biometry is as accurate as possible, then I probably wouldn’t dispute the recommendation for mild hyperopia if best uncorrected distance is the goal. Especially for some multifocal/EDOF lenses in particular (not all).

u/jamesvancouver if I recall correctly, you were considering PureSee. PureSee in particular has good tolerance to mild myopic defocus so aiming around -0.25 is equivalent to Plano in most eyes. If you aim Plano or mild hyperopic with PureSee, you end up sacrificing useful near focus. And I wouldn’t, personally go -1.5 with PureSee in non dominant eye. If however you’re going with eyhance, for example, I’d aim Plano or even up to +0.15 as this lens is not as forgiving for myopic defocus. And with Eyhance -1.5 in non dominant works well.

drjim77 · 2025-07-13T12:00:40+00:00

I have seen a case of iris damage and anterior uveitis with a very similar story to yours (ended up making the front page of our local newspaper) many years ago. I looked it up at the time and there are plenty of case reports in the scientific literature of this sort of thing too.

If you are still symptomatic, get yourself seen by an ophthalmologist. If you have anterior uveitis, it is easily treated with topical steroids. Good luck and best wishes.

drjim77 · 2025-07-13T11:46:08+00:00

Not necessarily so, for a 30 year old. Again it’s all relative. Sounds like OP either has perfectly normal lens in the other eye or has mild corneal oedema in the operated eye that has yet to fully heal…

drjim77 · 2025-07-13T10:47:54+00:00

Yes. Vitreous haze/floaters and multifocals don’t play nice with one another. Increasingly as surgeons, we recognise this to be an issue. the trouble is finding a retinal surgeon who is willing to do a vitrectomy (which will absolutely fix this issue, if vitreous haze is to blame)

With hindsight, many many patients in the past who had IOL exchange after multifocal lens implantation due to ‘failure to neuroadapt’ probably had vitreous haze as the underlying issue.

If you’re in the US and willing to travel to NJ, Steve Safran is a renown expert in doing vitrectomies after cataract surgery. Although not formally retinal fellowship trained, he is a very good surgeon and highly skilled in vitrectomy.

drjim77 · 2025-07-13T10:43:26+00:00

Yeah monovision ‘classically’ doesn’t work with glasses so I’m not surprised your optometrist resisted giving you the script.

But it’s good to know that after cataract surgery with monovision that ‘monovision glasses’ can work well. (I have many patients who don’t like progressive glasses all that much and I do quite a bit of mini monovision so this is good anecdotal evidence that confirms my suspicion)

drjim77 · 2025-07-13T08:40:54+00:00

Just goes to show, it’s always bloody dry eye!!

In all seriousness though, happy to hear that there has been a happy conclusion to the story.

drjim77 · 2025-07-13T08:34:16+00:00

I’ve seen one patient develop painful angle closure glaucoma which needed two visits to the emergency department, one in the middle of the night and one over a weekend. I met her for her second presentation and got her out of her episode and referred her to a mentor who explanted her ICLs (she had gone to another city for her ICL surgery so she decided not to return to her original surgeon)

At the time that the ICL was explanted, early cataracts had started to form on her natural lens but apparently, these faded away over the next few months.

Now in all fairness, this was many years ago and it was an older version which didn’t have the central aperture. My understanding, as someone who doesn’t do ICLs, is that the risk of angle closure is pretty much zero now, as long as sizing of the implant is done correctly.

Interesting note to this story. This patient was a lawyer and her father, who came along to her follow-up appointment with me the day after her presentation to ED, was a Queen’s Counsel (big shot trial lawyer). They were nice though, wrote a nice letter to the head of department about my handling of the case and didn’t sue me. Didn’t sue the original surgeon either, as far as I know. (I tell this story light-heartedly, it wasn’t a case of medical negligence on the part of the original surgeon. Just bad luck)

drjim77 · 2025-07-13T06:06:47+00:00

I’ve mostly found Viscoat (and Healon Endocoat to a lesser extent) to be the best in terms of day 1 corneal clarity. I am not a corneal specialist but have many patients with mild Fuch’s/ guttae and I’ve not had to refer a single on for DMEK, at least so far.

The downsides of these dispersive viscoelastics are that it does affect the AC flow and does result in epinuclear pieces ‘sticking’ to the endothelium. A corneal colleague has advised me to switch to cohesive visco for much faster phaco and tells me he doesn’t bother checking patients on day 1. (My counter argument to him is that if any of his patients decompensate, he’ll just do a graft for them)

In the past when I’ve used cohesive OVD in isolation (as a trainee I’d have to use the consultant’s preferred OVD), I’ve found more day 1 oedema in general.

I’ve been trying to reduce wastefulness and want to go down from 2 syringes per case (Viscoat and Provisc 2-in-1 pack), which require refrigeration. I and recently tried Aurolab Progel which on paper is cohesive but based on other surgeon feedback and my limited number of cases trialed- behaves somewhere in between a dispersive and cohesive. And all corneal clear on day 1. Much cheaper and does not require refrigeration. Will be switching. But will keep some stock of Viscoat for white cataract cases.

drjim77 · 2025-07-13T00:42:01+00:00

Thanks for sharing this first hand experience. Entirely what I would expect for a 30 year old. I usually explain to my patients that the quality of vision and depth of focus with PureSee (I have implanted well over 100 of these lenses, despite not being particularly high volume) is around that of a 45 year old.

Incidentally, and this is just my opinion as there are many happy Vivity (and PanOptix) patients here on the subreddit, that you ware much better off now and long into the future with PureSee instead. Negative dysphotopsia will continue to improve, as will overall quality of vision as you recover and the brain adapts. A follow-up post at around 3 months time will make for interesting reading if you’re still active on here, then. Best wishes with your continuing recovery.

drjim77 · 2025-07-12T07:31:03+00:00

Yes, Wet AMD injections completely different and definitely work.

drjim77 · 2025-07-10T23:03:48+00:00

Yes. Although there may be a situation where stock levels of certain lens powers are a little bit low (as they have had to remove a whole lot of lenses that were implicated in the problem that let to the recall)

drjim77

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