Review Article
Potential Concerns and Contraindications for IOL Monovision
Fuxiang Zhang*
Department of Ophthalmology, Henry Ford Health System, USA
*Corresponding author: Fuxiang Zhang, Department of Ophthalmology, Henry Ford Health System, ichigan, 22395 Eureka Road, Taylor, Michigan 48180, USA
Published: 26 Aug, 2016
Cite this article as: Zhang F. Potential Concerns and Contraindications for IOL Monovision. Clin Surg. 2016; 1: 1084.
Abstract
Pseudophakic or intraocular implant (IOL) monovision has been widely used in surgical cataract practice for more than 3 decades. More and more premium IOLs compete presbyopia management, but IOL monovision still remains the most commonly used modality with good spectacle independence and high patient satisfaction. Little attention, however, has been paid to its contraindications and concerns in the ophthalmology literature considering the widely used scope of this modality. Due to the length limitation, those well-known contraindications for IOL monovision will be just briefly mentioned, but those not easily recognizable ones are fully discussed. To author's knowledge, this is the first attempted review to address this important issue.
Introduction
Monovision as a method of prescribing optical aids was proposed in 1958 by West smith for
presbyopic contact lens wearers [1-3]. In his paper [1], he revealed the fact that he had a contact lens of +1. 50 D for his own left eye for reading while he did not need any correction for his distance
vision with a vision of 20/20 in each eye. The first clinical report was from Fonda with 13 cases of
monovision corrected by spectacles and contact lenses in 1966 [4]. Dr. Fonda also used different
power for his readings add in his glasses as monoviison [4]. Pseudophakic, or intraocular lens (IOL),
monovision was first published by Boerner and Thrasher [5] in 1984 and is now the most common
surgical management of presbyopia for cataract patientsA,B. For the past decade, refractive cataract
surgery has become a very widely used modality among more and more cataract surgeons in USA
as well as in the world. IOL monovision belongs to refractive cataract surgery, but there have not
been many studies on this topic in literature, considering how widely it is used in our profession.
The high success rate in terms of patient satisfaction and spectacle independence for pseudophakic
monovision is well documented in the literature. It has been shown to work with or without a
contact lens simulation trial prior to cataract surgery, step by step monovision mimic tolerance test
[6], a single +1. 0 lens test [7] or no plus lens test [3,8]. It worked whether the anisometropia level
at <1. 0 D [9], or just a little above 1. 0 D [7,10] or around 2. 0 D [6,11] or even at 2. 75 D level [3].
It worked whether conventional IOL monovision was used or crossed IOL monovision was used
[8,10].
IOL Monovision is probably not assimple as it seems. Not much attention has been paid to its
contraindications and concerns in the ophthalmology literature considering the widely used scope
of this modality. It is probably beneficial to raise these issues for discussion to stimulate future case
reports as well as formal studies.
The major problem associated with monovision relates to the potential compromise inbinocular
visual function. IOL and laser induced monovision are surgically induced, and therefore these issues
are of more concern compared to spectacle and contact lens monovision. Monovision aims to set
one eye for distance and one eye for near. The fundamental purpose is to increase the depth of focus
whilst maintaining acceptable stereovision. Binocular depth of focus refers to the summation of the
monocular range of clear vision for each eye, spanning from the near focal point of the near vision
eye to the far focal point of the far vision eye. The main trade off is the compromise in stereopsis.
If severe enough, it can lead to problems with fusion and even diplopia. The literature contains
varying reports regarding the impact of monovision on stereopsis. Most studies demonstrate only
a mild compromise in stereo acuity in the majority of IOL monovision patients. Overwhelmingly
most IOL monovision patients do not experience depth perception problems in their daily activities.
Compromised fusion and induced diplopia, however, remain the main problems for cataract
surgeons to avoid when they offer pseudophakic monovision.
Even within the 120-degree binocular field of view shared with
both eyes [12] the difference in image size of the same object with the
left and right eyes are potential sourcefor confusion with monovision
if the disparity in image size is too large. One of three outcomes
will happen: Fusion with increased depth focus without any major
issue beside a minor compromise in fine stereopsis as occurs in
the majority of patients with IOL monovision; one image can be
suppressed, so that only the other is seen, as in amblyopia; If fusion
and/or suppression do not occur, two images of a single object are
seen with symptomatic diplopia. Theoretically, any external ocular
muscle abnormality can compromise binocular function in Panum’s
fusional area. Anisometropia and aniseikonia are an additional
demand on the fusional capacity for patients with monovision.
We probably do not need to spend much time with detailed
discussion about some well accepted facts: IOL monovision should
not be offered to those patients who have history of External Ocular
Muscle (EOM) surgery, diplopia, prism usage; those who have signs
of tropia, significant phoria of >8 prism diopters, or EOM restriction.
(Some studies have shown a unique function for extreme monovision
to correct symptomatic diplopia, [2,13-15] that will not be discussed
in this article). It is important to know that those patients are not
good candidates for IOL monovision in most clinical situations.
Some ocular conditions, however, are not that easy to recognize
as potential contraindications for IOL monovision. This will be the
main topic to discuss for this paper. To author's knowledge, this is the
first attempted review to address this important issue.
Long-standing unilateral traumatic cataract
Patients with long-standing unilateral dense cataract, especially
traumatic cataract, may already have compromised fusion function.
If preoperative strabismus is noted at examination, even if the trauma
happened during adulthood, there is a good chance that that patient
will have diplopia after cataract surgery [16-18] due to disruption
of fusion. Pratt-Johnson [16] reported 24 cases of unilateral longstanding
traumatic cataract from 1984 to 1988. All 24 cases had
unilateral traumatic cataract and developed intractable diplopia
after their vision was restored with IOL or contact lenses to 20/40
or better. None of the 24 cases had a known history of interrupted
binocular function prior to their trauma and the average age when
trauma occurred was 18 years. There was no central nervous system
trauma associated with the ocular trauma and the study noted that
risk of diplopia increased if the interval of cataract formation prior to
vision restoration reached 2.5 years or longer. The authors also noted
that these patients typically had secondary strabismus in the injured
eye one year or longer after the injury. It can be difficult or sometimes
impossible to accurately evaluate ocular alignment if the vision is very
poor and if the strabismus is very small or if it is in the transitional
process of becoming deviated. For those patients, warning of the
possibility of postoperative diplopia is warranted even if the eyes
appear straight. It may worsen the risk if crossed monovision is
planned. In this circumstance, therefore, it is reasonable to correct the
affected eye aiming for slightly more myopia than the fellow normal
eye. After the first eye surgery is done, if postoperative Worth-4-Dot
test at that time shows intact fusion with 4 dots at 6 meters, or if
4-diopter base out test does not suggest small central scotoma, or if
the patient has good stereo acuity, then it is probably safe to consider
IOL monovision option with the fellow eye aiming at plano, if the
patient requests spectacle independence. The Worth-4-Dot test, 4DBO
prism testand Titmus stereopsis test prior to the first eye surgery
in the presence of long-standing dense cataractis typically not possible
in the presence of poor vision.
Fixation switch diplopia
Fixation switch diplopia has been described as an acquired
diplopia in adults who have a history of strabismus or amblyopia
since childhood [19,20]. With a history of childhood strabismus or
amblyopia, the patient may not have diplopia if the affected eye is not
the fixation eye. Diplopia can happen if the amblyopic eye starts to
be the fixation eye when refractive status changes, such changes can
happen as the original fixation eye becomes more myopic (as happens
as cataract forms), intentional or unintentional monovision modality
introduced, or if an inaccurate refraction prescription is provided.
Kushner [19] reported 16 adult patients with fixation switch
diplopia. All 16 had a history of strabismus since childhood. Six of the
16 developed diplopia owing to their monovision correction. In all 16
patients, symptoms were completely eliminated when proper optical
correction was instituted to encourage fixation with the dominant eye
at all viewing distance.
Boyd et al. [20] reported a group of 24 patients as “Fixation
Switch Diplopia” who had spontaneous intermittent unilateral
diplopia. All 24 patients had the following features: When they
were asked to demonstrate the production of diplopia, each patient
fixed with the non-preferred eye and no suppression was present in
the preferred eye; when fixing with the preferred eye, suppression
could be demonstrated in the non-preferred eye and the diplopia
disappeared. They were all able to alternate fixation, but not able to
alternate suppress. There is no alternate suppression present in this
entity of patients. Each of the 24 patients also had strabismus onset
before age 7 years old and the preferred eye had better vision than
the non-preferred eye. The vision of the preferred eye in all cases
was 20/20 or better. The severity in the non-preferred eye can be
quite variable. In some of the mild cases, the symptom was trivial
and 5/24 was even not able to tell the duration of their intermittent
diplopia. Vision was only mildly affected at 20/40 to 20/20 level in
17 out of 24 cases. 5 out of 24 had good stereovision with 80 to 40
arcs of seconds. The EOM deviation could be minimal to less than 10
prism diopters. This finding had some similarity with what Parks had
noted in his 100 cases of monofixation syndrome21Parks. This study also
noted that intermittent fixation switch diplopia happened more if the
non-preferred eye vision had good visual acuity. For that reason, the
authors intentionally treated some cases by decreasing the vision with
glasses in the non-preferred eye.
These studies raised an important concern when we do IOL
monovision. If we happen to choose the non-preferred eye as
distant fixating eye, it may cause fixation switch diplopia. From this
perspective, the pretty common practice pattern of routinely choosing
the worse eye or denser cataract eye aiming plano and the follow eye
for near regardless of dominant eye test may be a concern if we also
missed the history. It is important to ask every single prospective
patient of IOL monovision: “Do you have a history of an eye turned
in or out?” “Can you recall any double vision in your whole life?”,
“Do you always have one eye weaker than the other eye?”. For this
entity group, crossed IOL monovision is contraindicated, and
conventional IOL monovision should be avoided too so we do not
add anisometropia as an extra burden to an already compromised
binocular function.
Case 1
A sixty nine year old gentleman was seen in August of 2008 with
a history of traumatic cataract in his left eye at age 10. No history of
EOM surgery or diplopia. General health was unremarkable. Vision
left eye CF at 4 feet without correction, 20/200 with -4D. Right eye
was the dominant eye, also -4D refraction. Pre op examination also
revealed mild cataract in right eye with an epiretinal membrane. The
decision was made to do cataract surgery in the left eye. Surgery was
uneventful on 8/11/2008 with a 15. 50 diopter SN60WF, and post
op vision was 20/20 without correction for the left eye. The patient
also wanted to do the right eye cataract surgery. Given the fact that
the pre op was -4 myopic, decision was made to target monovision
with the right eye aiming at -1. 50 D. Surgery went well on 8/18/2008
with a SN60WF 14. 50 D in the bag. Post operatively the patient was
unhappy despite achieving the desired target of 20/20 plano in the
left eye and 20/25 in the right eye with -1.5 D. He was not willing
to wear glasses or contact lens, so a piggyback IOL was performed
for the right eye. A Starr AQ -2D sulcus piggyback IOL on 6/1/2009
resulted in 20/25 plano, but pigment dispersion plus steroid response
caused ocular hypertension and secondary glaucoma. The Piggyback
IOL was removed and an IOL exchange was performed on 7/29/2009
with a MN60AC 11. 50D in the sulcus with optic capture and a final
result of plano. Unfortunately he developed CME and ERM with
metamorphopsia. Retina PPV and member peeling was performed
on 1/5/2010 with a result of 20/20. After that, it was first noticed to
have 1-2 prism diopter of LHT, but the patient declined wearing a
pair of glasses and is doing pretty well and fairly happy since then.
Why was that patient not happy after successful surgery result of
20/20 plano left eye and 20/25 with -1. 5D right eye? It is likely that
he had a strong dominant right eye considering the fact that he had
traumatic cataract in his left eye at age 10 and the left eye had been
suppressed with poor vision since then. Now, the left eye corrected to
be 20/20 plano functioning as dominant eye and 20/25 with -1. 5D for
the right eye as the near vision eye. Binocular system may not be able
to function harmoniously if a long suppressed eye suddenly becomes
the dominant fixing eye. It is probably advisable to avoid choosing a
long term-suppressed eye or amblyopic eye for the distant vision eye
if mono vision is to be considered. One argument could be his 1-2
prism diopter of LHT, first noticed after all the surgeries were over,
but still that patient seemed to be able to tolerate that misalignment
well without any prism correction. This special case does suggest
the potential risk of fixation switch issue in long-standing unilateral
traumatic cataract with crossed monovision.
Monofixation syndrome
Monofixation syndrome is the loss of bifixation or foveal fusion
resulting in the manifestation of a facultative absolute scotoma
in the fovea of the non fixating eye [21-23]. To avoid selecting a
patient with monofixation syndrome as a candidate IOL monovision
can be challenging. The absence of foveal fusion that characterizes
monofixation syndrome can occur in strabismic as well as orthotropic
eyes [21-23]. The presence of a unilateral macular lesion can also
cause monofixation syndrome. If eccentric fixation is present in one
eye, the cover and uncover test may not reveal any shift. Due to the
fact that some monofixation patients (~ 30%) appear orthophoric,
especially those primary monofixation syndrome, the commonly
accepted criteria of avoiding any tropia and >8-10 diopter phoria as
the recommendation for IOL monovision may not be enough. What
is more, the largest deviation found in monofixation patients with
cover and uncover testing is 8 prism diopters horizontally and 2 to
3 prism diopter vertically [21]. They retain good peripheral fusion
and they may still have normal retinal non response (NRC) because
the deviation is small. Preoperative examination with 4-diopter
prism base out test (4∆BO) and/or Worth 4-dot fusion at distance
6 meters might be helpful to make the diagnosis, although it may
not be reliable if the cataract is dense and vision is poor. One helpful
question is to ask: “Are you aware if one eye has always been weaker
than the other? If the answer is yes, then we should be careful about
the decision to offer IOL monovision. Being weaker is different
from being non-dominant; the former refers to visual acuity while
the later refers to preference. Two thirds of monofixation syndrome
was noted to have amblyopia whilst one third were not amblyopic
but did have alternate fixation, simultaneously transferring the
macular scotoma from eye to eye [24]. Monofixation syndrome
patients are typically asymptomatic. They have straight or near
straight eyes, with average fusional vergence amplitudes as bifixators
and appreciation of gross stereopsis and do not get worse with aging
[21]. Monofixation syndrome can be primary without any noticeable
etiology, or secondary to small angle strabismus, anisometropia, or
monocular macular lesion. The presence or absence of Monofixation
can be tested either with the 4-diopter prism base out test (4∆BO)
at distance or distance fusion on the Worth 4-dot test [21,23]; it can
also be tested with Bagolinistriated lenses, Polaroid vectographic slide
and Binocular perimeter [21]. Worth 4 dot test was noted to be the
most reliable and 4 prism diopter base-out test to be the least reliable
method to detect monofixation by Parks [21]. Of note, a patient with
normal fusion function with Worth 4 Dot test at 13 inches does not
rule out monofixation since the average monofixation syndrome
patients can fuse at 10 feet [21]. The diagnosis of monofixation
syndrome becomes clinically important when a cataract surgeon
plans to offer a crossed IOL monovision. Conventional monovision
will risk break down in the balance of stable asymptomatic
monofixation syndrome due to monovision-induced anisometropia.
Monofixation syndrome patients can also experience diplopia after
LASIK induced monovision [25]. Since most of the scotoma of mono
fixating patients is approximately about 3 degrees, most, if not all,
monofixation syndrome can fuse at 13 inches with Worth 4 Dot
test but unable to fuse at distance 20 feet [21]. There has not much
attention to the question if monofixation syndrome can be candidate
for conventional monovision. The extra burden of anisometropia of
even conventional IOL monovision will further compromise their
peripheral fusion balance and aggravate the condition. Given the fact
that the affected eye vision/stereo vision can be near normal and the
deviation of the angle can be small or even orthophoric, it is not always
that easy to screen out these patients before we make the decision
for IOL monovision. Modest monovision with anisometropia at 1.0
-1.25 D levels rather than traditional 2D or more level also helps a lot.
With mild anisometropia, dominancy becomes less important. It is a
challenge to screen monofixation syndrome out of IOL monovision
candidates, but a combination of thorough history and careful
examination should work for vast majority situations. Most of them
have some component of amblyopia. With careful cover/uncover test,
if I find any manifest tropia, poor stereo and no fusion then I would
be worried about post op diplopia developing with monovision.
Case 2
Sixty-year-old female executive with preoperative history of
hyperope. Refractive lens exchange OD Restore 3D with LRI, 20/25
distance without correction, J8 at near without correction and
J3 with correction for OD. OS +3. 5D 20/20. There was no high
order aberration in I Trace with perfect optics OU. Two month
postoperative, not happy, came for a second opinion for the operated
OD. With more questions for past history, the patient did recall that
she had patch over her left eye during childhood. 4-diopter prism
base out test (4∆BO) supported the diagnosis of monofixator of OS.
The long duration weaker OD now is the fixating eye, which was most
likely the reason why the patient was not happy. Author’s speculation:
If the OS is corrected with a mono focal IOL at plano with 20/20 or
better vision without correction, the patient might be doing ok. No
follow up information available due to the nature of consultation.
Natural monovision
History of preexisting anisometropia, especially prior to cataract
formation, can be a concern. We sometimes see patients with natural
monovision as preexisting anisometropia. They might have normal
bilateral visual function and indeed natural monovision. If that
anisometropia was congenital, however, it could be amblyopia and
monofixation syndrome. In young children, >1.5 D of anisometropia
puts the patient at approximately a 50% risk of becoming a
monofixation syndrome; >2. 0 D increases the risk to almost 100%
[24]. The eyes can be present to be straight or near straight. So a
large preexisting anisometropia should be a red flag for the clinician
and it deserves further exploration and tests. These patients may
have such a history of “my left eye is always weaker than my right
eye ever since I can remember”; or they might have patch treatment
for amblyopia during childhood. Cover and uncover test may detect
some deviation, but not always. If IOL monovision given, the outcome
may be unsatisfactory. If conventional monovision is used, the
patient may not have well near vision coverage due to strong ocular
dominance. The original balanced peripheral fusion may deteriorate
and the amblyopic eye may develop a manifest deviation. Crossed
monovision may be more troublesome due to possible fixation switch
diplopia. Detailed history will help but not all the patients will be able
to provide you a valid history. The Worth 4 dot test and 4-diopter
prism base out test (4∆BO) will be helpful if the cataract is not too
dense to detect the small central macular scotoma of the weaker eye.
Worth 4 Dot test at near may be normal but at distance is likely seeing
fewer than 4 dots. Stereopsis will also be compromised.
We do see natural monovision among our cataract population.
Most of time it is hard for us clinicians to tell if it has been present
since childhood; or was due to a gradual refraction change or related
to cataract formation. Stereopsis, Worth 4 Dot test and 4∆BO are all
likely in normal range. Of course, these patients would be the best
candidates for conventional IOL monovision when they are ready
for cataract surgery but it is not advisable to target crossed IOL
monovision, nor should multifocal IOLsbe offered.
Amblyopia
The main purpose of induced monovision, whether from glasses,
contact lenses, refractive surgery or IOL, is to decrease the dependence
on glasses. When the amblyopic eye is elected to be the near eye, we
typically do not expect any specific major problem, but the chance of
glasses freedom is limited. The speculation is that the fellow eye has
a strong ocular dominance but for near work, the healthy dominant
eye lacks blur suppression. In cases of amblyopia, where strong ocular
dominance is known to exist, patients tend to suppress information
originating from the no dominant eye regardless of its clarity. These
patients are not good candidates for contact lens monovision [26].
From a few cases of IOL monovision with a history of amblyopia in
my practice; I did not find the outcome was impressive in terms of
spectacle independence.
When a child has amblyopia and is hyperopic, typically the
amblyopic eye has a greater refractive error. The myopic shift that
occurs during growth may change the fixation pattern. The original
fixing eye may become more myopic and the no dominant eye still
being slightly hyperopic. If the amount of hyperopia is mild and if the
vision is pretty good in the amblyopic eye, the clinician may assume
that the current fixation eye can be the dominant eye for distance
and the myopic eye for near. That can cause unbalanced binocular
function, or even fixation switch diplopia [19].The nature of this
mistake is due to crossed IOL monovision.
Case 3
61-year male with hyperopia OU and history amblyopia OD came
for clear lens extraction with the hope no need for glasses far and near.
No history of external ocular muscle surgery or prism use or double
vision. Preoperative refraction OD +5.75+0.25 x 39 at 20/40 and OS
+6.00 sphere at 20/20. Dominant eye test noted OS as dominant with
hole in card as well as with camera. Ocular exam was normal except
with questionable trace epiretinal membrane in OD but OCT was
unremarkable. W4D at near showed 4 dots: 2 green and 2 yellow.
W4D at distance 2 dots: 1 green and 1 yellow. Cover and uncover
test distance with glasses: 4 Esophoria at primary gaze, left gaze and
right gaze. Monovision was planed with OD aiming at -1.0 and OS
plano. Surgery was uneventful OU. Three months post operative
follow up noted distant vision uncorrected OD 20/50, OS 20/20, near
vision uncorrected OD J5 and OS J3. Corrected distance vision OD
-1. 0+0.50 x 27 20/25 and OS Plano 20/20. Corrected near vision with
+2.50 add OD J1 and OS J1+. He stated that he did no need glasses for
far, but he needed glasses for arm length such as computer as well as
for all near work. The fact that the anisometropia was low might also
play some role for his poor near vision, but uncorrected near vision
was J5 OD, which was worse than J3 OS. Uncorrected near vision was
expected to be better in OD than OS should he not have amblyopia
in OD. At one year postoperative visit, his ocular condition was the
same as 3 month follow up. Monovision just did not work out well
for this gentleman for his intermediate vision and his near vision.
Fortunately, he remains pretty happy and his cover and uncover test
was still about the same with no deterioration.
Systemic situations
Parkinson’s disease: Patients with degenerative central nervous
system diseases, where motor muscular movement is compromised,
should not be considered candidates for IOL monovision. Parkinson’s
disease is a typical sample. The motor symptoms of Parkinson's disease
result in the most obvious shaking, rigidity and slowness. All three
fundamental types of eye movements can be involved in Parkinson’s
disease: saccadic, pursuit and vergence. All of them, especially the
vergence, are important for focusing, fusion and binocular visual
function. In Parkinson's disease, the saccades tend to be slow. Some
people with Parkinson’s disease require a blink to change their
saccadic position (Wilson's sign). When pursuit movements become
decreased, this can produce what is called jerky or cogwheel slow eye
movements. Inadequacy or slowness of accommodation can result
in eyestrain, vision fluctuation, headaches and double vision when
working on near tasks. Convergence insufficiency and ocular motor
function were demonstrated much worse in Parkinson’s disease than
age matched control group [27].
Graves’ Eye Disease (GED): Also known as thyroid eye disease.
In this autoimmune condition, the body’s immune system attacks
external ocular muscle and orbit connective tissues.
GED may occur in patients, who already know they have
thyroid disease, or sometimes it's the first problem that brings the
person to the doctor's office. The major problems of GED from an
IOL monovision perspective are the tight orbit and eyelids, and the
swelling of external ocular muscles, any and all of which can affect
focusing, fusion and double vision.
Meniere’s disease: Vestibular system disease patients probably
should not be offered to have IOL monovision. The vestibular system
includes the parts of the inner ear and brain that process the sensory
information involved with controlling balance and eye movements. If
disease or injury damages these processing areas, vestibular disorders
can result. Meniere’s disease is one of the most commonly diagnosed
vestibular disorders. It is probably advisable to avoid IOL mono
vision to any patient who has had repeated history of vertigo episodes
because those diseases are often chronic in nature. Monovision
itself may not necessarily make Meniere’s disease worse, but extra
anisometropia load may make balance and visual function system
complicated.
Profession selection
There are some concerns about profession selection. Some
professions may need perfect stereovision and we may need to avoid
IOL monovision. Medical-legal case reported [28] for an airplane
accident related to contact lens monovision pilot. The practitioner was
not aware of the occupation of the patient. Truck driver, professional
sport athletics such as basketball, tennis, baseball and golf likely do
well with modest monovision, but may not be the ideal candidates for
full mono vision.
IOL monovision is a very popular modality in the management
of presbyopia in the cataract patient population. The vast majority
of them are doing well, but it is not risk free. Not all patients can
be safe candidates. Due to limitations on the scope and length, this
paper did not discuss those situations which are well known to avoid
for IOL monovision, such as tropia, significant phoria, history of
double vision, prism usage, ocular muscle surgery, significant ocular
comorbidities, extremely demanding personality, etc. , but rather
focused on some less well known limitations but still potentially
problematic with regard to the outcome. After near 2 decades of IOL
monovision practice, I have had only one case, which I took back to
operating room with a piggyback IOL to reverse the monovision,
although that does not mean all the rest of IOL monovision in my
practice have been successful, because some of them might have been
wearing glasses/contact lenses to reverse the IOL monovision. Having
said that, I can still reasonably state that IOL monovision is a very
safe modality in the management of presbyopia as long as we have
a thorough preoperative history and examination to avoid potential
contraindications, accurate biometry measurement and seamless
surgery.
Acknowledgement
The author wants to sincerely thank Graham Barrett, MD for his editing and advices, Lisa Arbisser, MD and David Chang, MD for the contribution of their special case reports.
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