5 Ocular Comorbidities and Pseudophakic Monovision

IOL monovision is predominantly used in elderly patients and age related ocular pathologies are commonly present in this population. Recent data based on more than half a million registered surgical cases from EUREQUO,1 reported that in about 30% of patients having cataract surgery, a coexisting ocular comorbidity was present. Preexisting pathologies can get worse and new pathologies can arise as the patient ages, mainly affecting function of the macula. Unlike multifocal IOLs where optical quality and contrast loss can become more challenging when macular degeneration, epiretinal membrane, diabetic retinopathy and glaucoma field loss progress to a more severe level, IOL monovision seems to be well tolerated in most mild or even moderate situations. The single most important goal of IOL monovision is to decrease spectacle dependence. How do we match these two situations? First, they should be addressed prior to surgery. It is important to bear in mind that for those with ocular comorbidities and with a strong desire to have glasses independence, they need to understand that as they are aging, these pathologies may get worse and that they may have a greater need to wear glasses in the future. They are not ideal IOL monovision candidates to start with, but IOL monovision is likely a better option to choose than other modalities currently available. Most of these situations are contraindications for multifocal IOLs. Here are some clinical examples. (All the patients listed here have given their permission to F. Z. to use their data as was documented in their medical records.)

5.2 Case 1 Report: Status Post Retinal Detachment and Myopic Maculopathy OU

A 63-year-old woman, a practicing psychiatrist, with a history of high myopia and retinal detachment OU at age 23 had a strong desire for spectacle independence. She had a history of wearing monovision contact lenses (15 years prior to presentation) as well as multifocal contact lenses for several years until a few years ago when she developed cataracts. She did not recall any issues with either type of contact lenses. Preoperative refraction was OD –9.50 + 0.75 × 153 with distance vision 20/40 and OS –8.75 + 1.00 × 005 with vision 20/40. 2–3 + nuclear sclerotic cataracts were present in each eye with 2 + PSC OS. OD was the dominant eye. A mild macular epiretinal membrane was present OD with mild pigment changes of myopic maculopathy OU. Considering the macular changes and significant cornea astigmatism, IOL monovision was recommended rather than multifocal IOLs ( Fig. 5.1 and Fig. 5.2). Because of her history of happiness with contact lens monovision as well as multifocal contact lenses, a contact lens trial was ordered. (One of only two contact lens trial cases in F. Z.’s two decades career using IOL monovision.) Given that her OD was always her dominant eye and was the far vision eye when she was using contact lens monovision, the decision was to aim OD for plano and OS for near, even though her OD had a mild epiretinal membrane (ERM) on OCT. Keeping the same pattern is the point. Surgery was performed with toric IOLs in OU, the left eye was treated first, followed one month later by the right. Postoperative data at 2 months: UCDVA 20/20 OD and 20/40 OS; UCNVA 20/40 OD and 20/20 OS. Refractive status: Plano OD with vision 20/20 and -1.50 sphere with vision 20/20 OS. No glasses were needed after the surgery and she was very happy ( Fig. 5.1 and Fig. 5.2).

Fig. 5.1 Case 1 report. Corneal photography showing significant with the rule astigmatism. S/P retinal detachment OU and ERM OD.

A 66-year-old man had a history of cataract surgery OD and 8 cut radial keratotomy OS about 20 years before his presentation. His main complaint was near vision difficulty with his OS. He strongly desired freedom from glasses. There were mild ERMs OU and open angle glaucoma OD with moderate field loss OD ( Fig. 5.3 and Fig. 5.4). Cup-to-disc ratios were 0.8 OD and 0.4 OS. The dominant eye was OD with the hole-in-card test. No other IOL monovision concerns were noted from his history and preoperative tests. Cataract surgery on OS aimed for –1.00 D. At his last office visit over 1 year later: UCDVA 20/20 OD and 20/50 OS. UCNVA J5 OD and J1 OS. Refraction: Plano OD with vision 20/20, –1.25 sphere OS with vision 20/20. He has been very happy without any glasses. More ERM was present OS, although OD had field loss with mild central fixation involvement. OS was kept for near since his OS had been used for near ever since his remote monocular RK surgery.

Fig. 5.2 (a,b) Case 1 report. OCT showing ERM OD. OS is unremarkable. S/P retinal detachment OU and ERM OD.

A 72-year-old woman presented with a moderate epiretinal membrane and macular pucker OD and a mild epiretinal membrane OS ( Fig. 5.5). Preoperatively the dominant eye was OS. Cataract surgery was performed on OS and 1 month later on OD. At her last visit, 4 years later, she had UCDVA 20/100 OD and 20/25 OS. UCNVA J3 OD and J3 OS. Refraction then was –2.00 + 0.50 × 025 with VA 20/20 OD and –0.50 sphere with vision 20/20 OS. She has been glasses free since the surgery.

5.5 Case 4 Report: S/P Macular Hole Repair OD and Mild Epiretinal Membrane OS

A 75-year-old woman had macular hole repair OD in 2013 ( Fig. 5.6, Fig. 5.7, Fig. 5.8). Preoperatively, the dominant eye with the hole-in-card test was OS. Cataract surgery was performed OD in 2014 and 2 months later OS. At her last office visit in 2016, UCDVA was 20/200 OD and 20/30 OS. UCNVA was 20/30 OD and 20/70 OS. Refraction was –1.75 sphere OD with vision 20/25 and OS –0.25 + 0.25 × 104 with vision 20/25. She stated that “I only recently started to use over the counter readers for very small print, otherwise I do not have to use any glasses.”

Fig. 5.3 (a,b) Case 2 report. OCT showing ERM more in OS than in OD. S/P RK OS, ERM OU and moderate field loss OD.

Fig. 5.4 (a,b) Case 2 report. HVF showing moderate field defect in OD and unremarkable in OS. S/P RK. OS and ERM OU, OAG with moderate field loss in OD.

Fig. 5.5 (a,b) Case 3 report. OCT showing ERM OU and macular pucker OD.

Fig. 5.6 Case 4 report. OCT showing partial macular hole OD prior to macular surgery.

Fig. 5.7 Case 4 report. OCT showing closed macular hole with mild ERM. S/P Macular hole repair OD as nondominant eye.

A 75-year-old woman had severe AMD, with 3 + soft drusen OU ( Fig. 5.9) prior to cataract surgery. She was post LASIK OU in 1999 for myopia. She had a strong desire to be glasses free. Preoperatively OD was the dominant eye. Cataract surgery was done in 2015. At her last office visit, 8 months later, UCDVA was 20/25 OD and 20/100 OS; UCNVA was 20/100 OD and 20/20 OS. Refraction then was –0.25 sphere OD with vision 20/20 and –1.25 sphere OS with vision 20/20. She had no need for any glasses since surgery and was very happy.

5.7 Case 6 Report: Moderate Low Tension Glaucoma OU

A 69-year-old woman had low tension glaucoma in both eyes ( Fig. 5.10, Fig. 5.11, Fig. 5.12). Her cup/disc ratio was 0.70 OD and 0.9 OS. She had a history of disc hemorrhage OD. A Humphrey visual field test OD was normal but OS had an inferonasal step. OD was the dominant eye prior to the surgery. She had a strong desire not to wear glasses. Cataract surgery was performed in 2012 on the left and 2 months later on the right. Her last office visit was in 2015 with UCDVA 20/20 OD and 20/70 OS; UCNVA was J16 OD and J2 OS. Refraction was plano + 0.50 × 103 with vision 20/20 OD and –1.25 sphere with vision 20/20 OS. She wore glasses as backup only for nighttime driving and very small print.

5.8 Case 7 Report: New Retinal Detachment 1 Year after IOL Monovision

A 63-year-old woman had cataract surgery OD in early 2015 and OS 2 months later for IOL monovision; OD for near and OS for far. She also had a diagnosis of glaucoma suspect with a cup/disc ratio of 0.75 OD and 0.70 OS, her highest intraocular pressure (IOP) being 23 OD and 24 OS. She was doing well until 1 year later when she had a retinal detachment of her right eye. On that day, her UCDVA was OD 20/100 and OS 20/25 +, UCNVA OD 20/30 and OS 20/100. Manifest refraction was OD –1.50 D sphere 20/20 with a supratemporal retinal detachment but her macula was still attached. Pars plana vitrectomy and endolaser were performed. At her last office visit, 6 months later, her UCDVA was 20/80 OD and 20/20 OS, UCNVA was 20/40 OD and 20/200 OS. Manifest refraction was –1.75 sphere 20/25 OD and –0.25 sphere 20/20 OS. She did have an epiretinal membrane in her right eye after retinal detachment and endo-laser treatment. IOP has been fine since cataract surgery without medications. Her field test remains full in each eye. She still does not need any spectacles even after the onset of retinal detachment in OD.

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