Crossed versus conventional pseudophakic monovision: Patient satisfaction, visual function, and spectacle independence

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1 ARTICLE Crossed versus conventional pseudophakic monovision: Patient satisfaction, visual function, and spectacle independence Fuxiang Zhang, MD, Alan Sugar, MD, Lisa Arbisser, MD, Gordon Jacobsen, MS, Jessica Artico, OA PURPOSE: To compare patient satisfaction, visual function, and spectacle independence in patients with crossed or conventional pseudophakic monovision. SETTING: Department of Ophthalmology, Henry Ford Health System, Taylor, Michigan, USA. DESIGN: Retrospective comparative cohort study. METHODS: Cataract surgery patient records from June 1999 to December 2013 were reviewed. Crossed monovision patients were identified. Control conventional monovision cases were matched for age, sex, general health, personal lifestyle/main hobbies, preoperative refractive status, postoperative refractive status, uncorrected distance visual acuity, uncorrected near visual acuity, astigmatism level, and anisometropia level. A survey was mailed to participants, and results were independently analyzed. RESULTS: The review comprised 7311 patient records. Forty-four crossed monovision patients were identified, and 30 of them were enrolled. Thirty matched pairs were surveyed. The mean anisometropia was 1.19 diopters (D) in the conventional and 1.12 D in the crossed monovision groups. No significant difference was identified for eye hand coordination, eye foot coordination, or sport-related depth perception, but satisfaction was slightly better in the crossed monovision group (P Z.028). No significant difference was identified for 6 of 8 spectacle independence measures, but nighttime driving was a little easier for the crossed monovision group (P Z.025). Seventy-seven percent of crossed and 50% of conventional monovision patients did not use glasses for intermediate distance activities (P Z.037). CONCLUSION: Crossed pseudophakic monovision appears to work as well as conventional pseudophakic monovision in terms of patient satisfaction and spectacle independence in patients with a mild degree of anisometropic pseudophakia. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned. J Cataract Refract Surg 2015; 41: Q 2015 ASCRS and ESCRS Supplemental material available at The desire to improve not only vision but also uncorrected visual acuity through cataract surgery is increasing. Cataract surgery is no longer a simple vision rehabilitation procedure, and more patients require or demand to be free of their glasses after surgery. Monovision, correcting 1 eye for distance and the other for near, competes with multifocal and accommodating intraocular lenses (IOL) to achieve this goal. Monovision as a method of prescribing optical aids was proposed in 1958 by Westsmith 1 for presbyopic contact lens wearers. 2 The first clinical report was from Fonda in with 13 cases of monovision corrected by spectacles and contact lenses. Pseudophakic Q 2015 ASCRS and ESCRS Published by Elsevier Inc

2 1846 CROSSED VS CONVENTIONAL PSEUDOPHAKIC MONOVISION monovision was described by Boerner and Thrasher 4 in 1984 and is now the most common surgical management of presbyopia for cataract patients. A Surprisingly, the literature on pseudophakic monovision is limited. In conventional monovision, the dominant eye is corrected for distance and the nondominant eye for near. Crossed pseudophakic monovision corrects the dominant eye for near and the nondominant eye for distance; it has rarely been studied. We know that conventional pseudophakic monovision works well for the management of presbyopia, with patient satisfaction of 80% or more and high spectacle independence. 5 9 Typically, conventional monovision is used; however, patient preference, unpredicted surgical outcomes, or individual clinician practice patterns may result in crossed monovision. Preoperative testing for eye dominance may not always be easy or accurate. Due to the nature of biometry and eye anatomy, we often miss our planned refractive target, but patients may still wish to have spectacle independence. Crossed monovision in laser in situ keratomileusis (LASIK) has been reported to work well without significant differences between conventional and crossed monovision, 10,11 although there is no direct comparison study in the literature. It is common for cataract surgeons to operate first on the eye with the denser cataract or worse vision, aiming for a plano refraction, and on the second eye to correct for near as monovision regardless of which eye is dominant. 8,B D Many of those patients would therefore end up with crossed monovision. There is no fixed pattern between vision and sighting dominance. 12,13 We do not know whether crossed pseudophakic monovision functions as well as conventional pseudophakic monovision as a group or what the potential risks are. For example, if the first operated eye was the nondominant eye and ends up at plano or 0.25 diopter (D), but the patient still wishes to have good coverage for intermediate or near vision, can we safely change the target for the second eye to correct the dominant eye for near? If the first operated eye was Submitted: September 26, Final revision submitted: December 31, Accepted: January 7, From the Department of Ophthalmology (Zhang, Artico), Henry Ford Health System, Taylor, the Kellogg Eye Center (Sugar), University of Michigan, Ann Arbor, the Department of Biostatistics and Research Epidemiology (Jacobsen), Henry Ford Health System, Detroit, Michigan; Eye Surgeons Associates PC (Arbisser), Bettendorf, Iowa. Corresponding author: Fuxiang Zhang, MD, Eureka, Taylor, Michigan 48180, USA. fzhang1@hfhs.org. the dominant eye with the goal of plano to 0.25 D but ends up myopic with good vision for intermediate/near, but the patient still wishes to have better distance vision, can we safely aim the second, nondominant eye for distance? PATIENTS AND METHODS Patient Population This study was approved by the Institutional Review Board of the Henry Ford Health System, Detroit, Michigan. The records of consecutive cataract surgical cases performed from June 1999 to December 2013 by the same surgeon (F.Z.) were reviewed. A matched control from the same surgeon's conventional pseudophakic monovision pool was assigned to each crossed pseudophakic patient (Table A1, available at Inclusion and Exclusion Inclusion When patients with visually significant cataract desired postoperative spectacle independence and had good vision potential, IOL monovision was offered. Study subjects had at least 0.75 D or more of postoperative anisometropia between the 2 eyes, postoperative distance vision without correction of 20/50 or better, near vision of 20/50 or better without correction, and postoperative cylinder correction of 0.5 D or less. Exclusion Exclusion criteria included (1) significant ocular comorbidities such as severe background diabetic retinopathy, severe age-related macular degeneration, glaucoma with significant field loss, (2) hemianopia with history of stroke, (3) a multifocal or accommodating IOL, (4) history of non-cataract ocular surgery, (5) history of severe amblyopia or strabismus, (6) any tropia or phoria more than 10 prism diopters with cover and uncover test, and (7) vitrectomy during cataract surgery. Matching Criteria Each crossed monovision study patient was matched to a conventional pseudophakic monovision patient from the same surgeon's (F.Z.) pool. Criteria included (1) age difference of no more than 10 years, (2) same sex, (3) similar general health, (4) similar lifestyle and hobbies (divided as 3 subgroups: far [eg, golf, sport, television watching], near [eg, reading, woodworking, word puzzles], and mixed), (5) similar preoperative refractive status, such as hyperopia, myopia, or within 1.0 D of emmetropia in the dominant eye, (6) postoperative uncorrected vision same or within 1 line for both distance and near, (7) postoperative sphere power within 0.50 D for distance correction, and (8) postoperative astigmatism within 0.50 D (Table A1, available at Questionnaire A questionnaire was mailed to each patient along with a cover letter explaining that answers would be reviewed in a de-identified manner. The full text of the questionnaire is available on request.

3 CROSSED VS CONVENTIONAL PSEUDOPHAKIC MONOVISION 1847 Table 1. Demographics and other comparisons between conventional group and crossed group. Parameter Conventional (n Z 30) Crossed (n Z 30) P Value Mean age (y) G SD 72 G G * Sex, n (%) Female 20 (66.7) 20 (66.7) Male 10 (33.3) 10 (33.3) Mean follow-up (mo) G SD 20.2 G G z Mean astigmatism preop (D) G SD 0.34 G G z Mean astigmatism postop (D) G SD 0.06 G G z Mean postop anisometropia (D) G SD 1.19 G G * Toric IOL, n (%).492 x No 28 (93.3) 30 (100.0) Yes 2 (6.7) 0 (0.0) Limbal relaxing incisions, n (%).117 No 21 (70.0) 26 (86.7) Yes 9 (30.0) 4 (13.3) Nd:YAG capsulotomy, n (%).197 No 22 (73.3) 26 (86.7) Yes 8 (26.7) 4 (13.3) IOL Z intraocular lens; Nd:YAG Z neodymium:yag capsulotomy *Two-sample t test Chi-square test z Wilcoxon rank-sum test x Fisher exact test Preoperative Evaluation All patients had a complete eye examination and 2 ocular dominance tests (hole-in-card and camera). If the dominance tests did not agree, then the hole-in-card result was accepted. Corneal topography (TMS-4, version 3.5E, Tomey Corp.) was performed. Manual keratometry (Marco Ophthalmic), partial coherence interferometry (PCI) prior to 2011 (IOL- Master, Carl Zeiss Meditec AG) or optical low-coherence reflectometry (OLCR) since 2011 (Lenstar, Haag-Streit), or immersion A-scan for dense nuclear sclerotic or posterior subcapsular cataract cataracts were performed. The dominant eye was corrected for distance and the nondominant eye for near in the conventional group. The dominant eye was corrected for near and the nondominant eye for distance in the crossed group. Advantages and disadvantages of monovision were fully discussed with each patient. A pseudophakic monovision brochure was supplied. If the first operated eye was nondominant and resulted in good distance vision and if the patient wanted to have the second, dominant eye corrected for near, then crossed monovision was established. Detailed patient counseling was repeated due to the unconventional pattern. To test whether the patient was a good candidate for crossed IOL monovision, a C1.5 D lens was placed in front of the unoperated eye to mimic postoperative monovision. The patient was asked to state how he or she felt in terms of vision and balance. If the patient felt favorable to this mimicked monovision, then the second eye would be corrected for intermediate or near vision depending on patient preference. If the patient did not like the plus lens-mimicked test vision, then crossed monovision was not offered. If the first operated eye was dominant and unexpectedly resulted in good near vision and the patient was satisfied with using that eye for uncorrected reading, the crossed monovision was to have the second eye aimed at plano to 0.25 D. For conventional pseudophakic control patients, no specific extra preoperative tests were performed, but detailed counseling was performed to educate patients about Figure 1. Overall satisfaction in the conventional and crossed monovision groups.

4 1848 CROSSED VS CONVENTIONAL PSEUDOPHAKIC MONOVISION Figure 2. Eye hand coordination without glasses. the pros and cons of pseudophakic monovision. Preoperative monovision mimic testing was not a necessary inclusion criterion, although many patients had a similar C1.5 D lens test. Surgical Technique The same surgeon (F.Z.) performed all surgeries using topical anesthesia. A temporal 2.75 mm clear corneal incision was created at about 200 degrees in right eyes and at about 20 degrees in left eyes. This was followed by phacoemulsification using the Infiniti system (Alcon Laboratories, Inc.), after which a monofocal posterior chamber IOL was implanted in the capsular bag: SN60 prior to 2004, SN60WF since 2004 (both Alcon Laboratories, Inc.), Tecnis 1-piece ZCB00 (Abbott Medical Optics, Inc.) since May of 2013, and Envista (Bausch & Lomb) since March of Limbal relaxing incisions (LRIs) were performed in 14 eyes of 9 patients in the conventional group and 4 eyes of 4 patients in the crossed group to correct symmetrical astigmatism if corneal topography, manual keratometry, and PCI/ OLCR gave matching results. The LRI was performed at the beginning of the procedure, with the location based on the LRI calculator (Abbott Medical Optics, Inc.). The length and depth of the LRI were based on the Nichamin nomogram. 14 Postoperative Follow-up All patients were examined at 1 day and 2 weeks after each eye surgery. At 4 weeks they were examined by an affiliated optometrist. Most data used in this study were from the 2-week examination rather than later follow-up examinations. The 2-week examinations typically included uncorrected distance visual acuity, uncorrected near visual acuity, corrected distance visual acuity, and corrected near visual acuity. Statistical Analysis A research assistant sent out surveys and collected all the study data independently, and another team member (G.J.) performed an independent statistical analysis of the data. A Cochran-Armitage trend test was used for survey questions regarding satisfaction, eye hand coordination, eye foot coordination, spectacle independence, difficulty in sports, distance vision, intermediate vision, near vision, and nighttime driving. A 2-sample t test, Wilcoxon ranksum test, chi-square test, and Fisher exact test were used for other comparison items. A P value less than 0.05 was considered statistically significant. RESULTS The records of 7311 consecutive cataract surgical cases were reviewed. Forty-four cases of crossed IOL monovision met the inclusion criteria; 30 of them were enrolled, and 14 were excluded. Of the 14, 4 declined, 4 could not be contacted, and 6 could not be matched to appropriate controls. Demographic data are listed in Table 1. For overall satisfaction, 10 (33.3%) of 30 patients and 18 (60.0%) of 30 patients were very happy in the Figure 3. Eye foot coordination without glasses.

5 CROSSED VS CONVENTIONAL PSEUDOPHAKIC MONOVISION 1849 Figure 4. Sports-related depthperception problems without glasses. conventional and crossed groups, respectively, and 19 (63.3%) of 30 patients and 12 (40.0%) of 30 patients were happy, respectively. Only 1 (3.3%) of 30 patients was neutral in the conventional group and none in the crossed group. None of the patients in either group was unhappy. The P value was with the Cochran-Armitage trend test (Figure 1). Regarding eye hand coordination problems when not using glasses, 27 (90.0% of 30 patients in the conventional group had no depth-perception problems at all (13 [43.3%]) or almost no depth-perception problems (14 [46.7%]). In the crossed group, 28 (93.3%) of 30 patients had no depth-perception problems at all (20 [66.7%]) or almost no depth-perception problems (8 [26.7%]) (P Z.109, Cochran-Armitage trend test) (Figure 2). Regarding eye foot coordination problems when not using glasses, all 30 patients in the conventional group had no depth-perception problems at all (23 [76.7%]) or almost no depth-perception problems (7 [23.3%]). In the crossed group, all 30 patients had no depth-perception problems at all (27 [90.0%]) or almost no depth-perception problems (3 [10.0%]) (P Z.166, Cochran-Armitage trend test) (Figure 3). For the sports players, 100% in each group (no problem at all 10 [66.7%] and almost no problem 5 [33.3%] in conventional group; no problem at all 11 [91.7%] and almost no problem 1 [8.3%] in crossed group) did not report having depth-perception problems when they did not wear glasses (P Z.121, Cochran- Armitage trend test) (Figure 4). Twenty-seven of 30 patients (90%) in each group had almost no difficulty in reading a newspaper when they did not wear glasses (P Z.177) (Figure 5). Nineteen of 30 patients (63.3%) in the conventional group and 23 of 30 patients (76.7%) in the crossed group almost never needed glasses for reading a newspaper (P Z.793) (Figure 6). Nineteen (63.3%) of 30 patients in the conventional group and 25 (83.3%) of 30 patients in the crossed group did not have any problem at all with distancerelated activities such as driving and watching television when they did not wear glasses; 11 (36.7%) of 30 patients in the conventional group and 5 (16.7%) of 30 patients in the crossed group had only a little difficulty driving and watching television when they did not wear glasses (P Z.080) (Figure 7). Twenty-six (86.6%) of 30 patients in the conventional group and 27 (90%) of 30 patients in the crossed group never needed or only occasionally needed glasses for distance-related activities (P Z.891) (Figure 8). Twenty-five (89.3%) of 28 patients in the conventional group and 28 (100%) of 28 patients in the crossed group did not have any difficulty or only had a little difficulty in nighttime driving when they Figure 5. Difficulties in newspaper reading.

6 1850 CROSSED VS CONVENTIONAL PSEUDOPHAKIC MONOVISION Figure 6. Use of glasses for near tasks. did not wear glasses. Three (10.7%) of 28 patients in the conventional group had moderate difficulty. The P value was with the Cochran-Armitage trend test (Figure 9). Twenty-six (86.7%) of 30 patients in the conventional group and 27 (90.0%) of 30 patients in the crossed group did not have to wear glasses or only occasionally needed them for nighttime driving (P Z.895) (Figure 10). For those who used a computer or played a musical instrument or other intermediate distance activities, all 26 patients in the conventional group and 21 (95.5%) of 22 patients in the crossed group did not have any difficulty or had only a little difficulty (P Z.537) (Figure 11). Twenty-three (76.7%) of 30 patients in the conventional group and 28 (93.4%) of 30 patients in the crossed group never needed glasses or only occasionally needed them for intermediate distance activities (P Z.037) (Figure 12). DISCUSSION Much of the information on crossed monovision comes from LASIK studies. Clinicians typically prefer conventional monovision, but unplanned crossed monovision can occur. Braun et al. 10 retrospectively studied 172 monovision LASIK patients. One hundred sixty (93%) had conventional monovision, and 12 (7%) had crossed monovision. The distance vision success rate was 68% and the near vision success rate was 70% for conventional monovision patients 1 month after LASIK. The success rate in crossed monovision patients was 50.0% and 55.6%, respectively. Jain et al. 11 studied 144 consecutive myopic LASIK and photorefractive keratectomy patients, 42 with monovision; 24 had conventional and 18 crossed monovision. There was no significant difference in outcomes and satisfaction between these 2 groups. Among those 18 crossed monovision patients, 7 had unplanned crossed monovision and 11 planned crossed monovision. The satisfaction was high and did not differ between the groups. Reilly et al. 15 reviewed the records of 82 patients who had LASIK for monovision. There were 5 patients who elected to have crossed monovision; none had monovision reversal. Two of the conventional monovision patients elected to have monovision reversal by changing the near vision to distance correction. Conventional pseudophakic monovision has demonstrated high spectacle independence with anisometropia from about 1.25 to 2.75 D. 5 9 In our study, high spectacle independence was achieved for most patients in both the conventional and crossed groups. It is a common assumption that low anisometropia between the 2 eyes leads to a higher chance of needing glasses, but the current study suggests that Figure 7. Difficulty in distancerelated activities without glasses.

7 CROSSED VS CONVENTIONAL PSEUDOPHAKIC MONOVISION 1851 Figure 8. Use of glasses for distance. a moderate anisometropia level (average about 1.15 D; range 0.75 to 2.0 D) can still achieve high spectacle independence in both conventional and crossed patterns. Variousadvantageshavebeensuggestedincorrecting the dominant eye for distance vision 11 ;however, no studies have conclusively quantified which eye to correct for distance in a monovision patient. Jain et al.'s review 16 noted that correcting the dominant eye for distance improved activities such as walking or driving and produced lesser esophoric shifts at distance. Historically, the dominant eye has been recommended for distance vision and the nondominant eye for near vision as the conventional monovision approach. 5 7,16,17 Interocular blur suppression has been noted as better in conventional monovision than in crossed monovision. 16 For successful monovision, constant interocular suppression of blur is advantageous. Patients with strong sighting preferences have reduced interocular blur suppression and decreased binocular depth of focus, leading to higher monovision failure rates, whereas those with alternating dominance without sighting preference have constant interocular blur suppression. 7,16,18 More basic science and clinical studies are needed to better understand the cause of these phenomena. More important is for clinicians to learn how to identify which patients are not good candidates for monovision, both conventional and crossed. Stereovision decreases when anisometropia increases. 19 One of the reasons why the satisfaction rate of this study was high was probably because the anisometropia was moderate, averaging about 1.15 D with a range from 0.75 to 2.0 D. It is probably advisable to keep anisometropia to no more than 1.50 for crossed pseudophakic monovision to be successful, although it is common to see high success rates for conventional monovision with anisometropia levels up to 2.0 to 2.5 D. 2,5 7 Despite lengthy preoperative counseling in terms of pros and cons of monovision, most of the patients in this study (60% in the conventional group and 73.3% in the crossed group) were not sure whether their dominant eye was still good for far vision or changed to be better for near vision at a mean follow-up of more than 10 months. Most patients did not seem to pay attention to which eye was used for what function if they were doing well. After first-eye surgery is done, it is not rare to find patients with a desire to make the second eye cover whatever the first eye was not able to see well without glasses. That was the main reason for most of the crossed IOL monovision cases in the current study. To make the decision of creating crossed monovision, Figure 9. Nighttime driving difficulty.

8 1852 CROSSED VS CONVENTIONAL PSEUDOPHAKIC MONOVISION Figure 10. Use of glasses for nighttime driving. the most important thing appears to be a thorough and easy-to-understand explanation, educating the patient on the pros and the cons of conventional monovision and crossed monovision. A C1.50 D lens in front of the planned near-vision eye to mimic postoperative monovision status is also helpful. All monovision patients should understand the rare need for IOL exchange, piggyback IOL insertion, or corneal refractive surgical monovision reversal if they are not able to tolerate monovision, although surgical reversal is rare because glasses or contact lenses can easily correct the problem. That is one of the major advantages of IOL monovision. There is no good explanation for why the crossed monovision group had better scores on some items than the conventional group in this small study. In our routine practice, we did not have the impression of better results if we used crossed monovision. Possible explanations are that (1) this was a small study, (2) when deciding to elect crossed monovision, the surgeon was extra careful to make sure everything was lined up well to avoid any potential medicolegal issue since that was out of conventional practice, and (3) a few crossed monovision patients declined to participate in this study for unknown reasons. Selection bias may have occurred if unhappy patients declined participation more frequently than happy ones. It is reasonable to view the following as potential contraindications to IOL monovision, especially crossed monovision: a history of external ocular muscle surgery, apparent tropia and significant phoria, a history of chronic imbalance caused by inner ear or central nervous system problems, and possibly a highly demanding personality that would make the patient unwilling to use backup glasses. In addition, amblyopic eyes or those with long-term suppression should not be designated the distant eye. People with certain professions that require a high level of stereopsis, such as aviation pilots, should usually not be offered monovision. Intraocular lens monovision does not seem to work in cases of significant uncorrected astigmatism. E Because such patients were excluded from the study, these recommendations are speculative. A weakness of this study is that most vision examination data were from the 2-week postoperative visit, although the mean follow-up was 20.2 months in the conventional group and 10.5 months in the crossed group; the study sample size was also small. Further study into the relationship between conventional and crossed monovision with regard to issues such as proper candidates versus contraindications and the Figure 11. Difficulty at intermediate distances.

9 CROSSED VS CONVENTIONAL PSEUDOPHAKIC MONOVISION 1853 Figure 12. Use of glasses for intermediate distance. preoperative magnitude of dominance are warranted to ensure pseudophakic monovision success. WHAT WAS KNOWN Conventional pseudophakic monovision works well for the management of presbyopia in cataract patients in terms of patient satisfaction and spectacle independence. Pseudophakic crossed monovision has been reported in few studies in the ophthalmology literature, but it has been studied in the corneal refractive surgery population. WHAT THIS PAPER ADDS Crossed pseudophakic monovision appears to work as well as conventional pseudophakic monovision in terms of patient satisfaction, visual function, and spectacle independence in patients with a mild degree of anisometropic pseudophakia. REFERENCES 1. Westsmith RA. Uses of a monocular contact lens. Am J Ophthalmol 1958; 46(part 1): Greenbaum S. Monovision pseudophakia. J Cataract Refract Surg 2002; 28: Fonda G. Presbyopia corrected with single vision spectacles or corneal lenses in preference to bifocal corneal lenses. Trans Ophthalmol Soc Aust 1966; 25: Boerner CF, Thrasher BH. Results of monovision correction in bilateral pseudophakes. Am Intra-Ocular Implant Soc J 1984; 10: Zhang F, Sugar A, Jacobsen G, Collins M. Visual function and patient satisfaction: comparison between bilateral diffractive multifocal intraocular lenses and monovision pseudophakia. J Cataract Refract Surg 2011; 37: Zhang F, Sugar A, Jacobsen G, Collins M. Visual function and spectacle independence after cataract surgery: bilateral diffractive multifocal intraocular lenses versus monovision pseudophakia. J Cataract Refract Surg 2011; 37: Ito M, Shimizu K, Iida Y, Amano R. Five-year clinical study of patients with pseudophakic monovision. J Cataract Refract Surg 2012; 38: Finkelman YM, Ng JQ, Barrett GD. Patient satisfaction and visual function after pseudophakic monovision. J Cataract Refract Surg 2009; 35: Xiao J, Jiang C, Zhang M. Pseudophakic monovision is an important surgical approach to being spectacle-free. Indian J Ophthalmol 2011; 59: Available at: nlm.nih.gov/pmc/articles/pmc /. Accessed July 2, Braun EHP, Lee J, Steinert RF. Monovision in LASIK. Ophthalmology 2008; 115: Jain S, Ou R, Azar DT. Monovision outcomes in presbyopic individuals after refractive surgery. Ophthalmology 2001; 108: Pointer JS. The absence of lateral congruency between sighting dominance and the eye with better visual acuity [letter]. Ophthalmic Physiol Opt 2007; 27: Evans BJW. Monovision: a review. Ophthalmic Physiol Opt 2007; 27: Available at: /j x/pdf. Accessed July 2, Nichamin LD. Modified astigmatism correction nomogram [letter]. J Refract Surg 2008; 24: Reilly CD, Lee WB, Alvarenga L, Caspar J, Garcia-Ferrer F, Mannis MJ. Surgical monovision and monovision reversal in LASIK. Cornea 2006; 25: Jain S, Arora I, Azar DT. Success of monovision in presbyopes: review of the literature and potential applications to refractive surgery. Surv Ophthalmol 1996; 40: McGill EC, Erickson P. Sighting dominance and monovision distance binocular fusional ranges. J Am Optom Assoc 1991; 62: Schor C, Erickson P. Patterns of binocular suppression and accommodation in monovision. Am J Optom Physiol Opt 1988; 65: Lebow KA, Goldberg JB. Characteristic of binocular vision found for presbyopic patients wearing single vision contact lenses. J Am Optom Assoc 1975; 46: OTHER CITED MATERIAL A. ASCRS Clinical Survey Fairfax, VA, Global Trends in Ophthalmology and the American Society of Cataract and Refractive Surgery. In: EyeWorld 2013; November Supplement. Available at: default/files/ascrs%20clinical%20survey%20supplement- Digital%20Kiosk%5B1%5D.pdf. Accessed July 2, 2015 B. O heineachain R. Modest monovision. ESCRS Eurotimes May 2012, page 22. Available at: Accessed July 2, 2015 C. Barrett GD, Is Monovision Still an Option for Presbyopia? Cataract & Refractive Surgery Today June 2013, pages

10 1854 CROSSED VS CONVENTIONAL PSEUDOPHAKIC MONOVISION Available at: Accessed July 2, 2015 D. Lisa B. Arbisser, MD. Eye Surgeons Associations PC, Bettendorf, Iowa. Personal communication, December 13th, E. Zhang F, Astigmatism Correction and Mini Monovision/ ReSTOR Comparison, presented at the 13th Winter meeting of the European Society of Cataract and Refractive Surgeons, Rome, Italy, February 2009 First author: Fuxiang Zhang, MD Department of Ophthalmology, Henry Ford Health Center, Taylor, Michigan, USA