March 2020


Research Highlight
Outcomes with EDOF mini-monovision

by Maxine Lipner Senior Contributing Writer

Symfony IOL in place showing diffractive rings

Symfony Toric IOL in place with positioning markers at 180 degrees
Source (all): Eric Donnenfeld, MD


One of the downsides of extended depth of focus (EDOF) IOLs is that they don’t give completely spectacle-free near vision, but research has found a way around this. By using a slight monovision (nanovision), the distance and intermediate vision of EDOF lenses is maintained, while near vision is improved.1
“The advantage of these lenses is that they provide, in my estimation, the best quality of vision at distance of any presbyopic IOL that gives mid-range or near vision,” said Eric Donnenfeld, MD.
Dr. Donnenfeld and co-investigators researched the use of EDOF lenses where 0.5 D of monovision was left in the nondominant eye with the Tecnis Symfony Toric IOL (Johnson & Johnson Vision). “You get all the advantage of the Symfony lens at distance in the dominant eye, while you’re still getting 20/25 vision, and you’re getting the extra diopter of reading in the nondominant eye,” Dr. Donnenfeld said of this technique.
Outcomes in this prospective case series indicated that 92% of eyes in the mini-monovision group had a mean refractive residual astigmatism of 0.5 D or lower, as did 95% of those targeted for emmetropia. At 4 m, those in the mini-monovision group had slightly worse uncorrected visual acuity in the one eye than those in the emmetropia group. However, with binocular uncorrected acuity, there was not a statistically significant difference, Dr. Donnenfeld said. Meanwhile, at 40 cm the residual refractive error was 0.25 D for those in the mini-monovision group versus 0.34 D in the emmetropia group. “Patients got very good distance but also got significantly better reading by adding that 0.5 D of monovision in the nondominant eye,” he said.
Dr. Donnenfeld actually changed his approach to presbyopia management with EDOF lenses because quality of vision has improved with this technology. Previously, he used to put the lens in the nondominant eye first to make sure that the patient would tolerate the distance vision, then based on this experience, he would decide what to put in the other eye. Now, most of the time, Dr. Donnenfeld said he puts the EDOF lens in the dominant eye first and is comfortable that the patient is going to be happy with the distance vision. For the nondominant eye, he then decides whether to give the patient the same lens or try something else. “If they’re not happy, I have the opportunity to either do mini-monovision like we did in the study or add a higher multifocal in the nondominant eye,” he said, adding that both techniques work effectively.
Dr. Donnenfeld always talks to presbyopic patients about the quality of vision that they can expect with EDOF lenses, if they are candidates. “I tell them that the quality of vision with an EDOF lens is comparable to a monofocal lens,” he said. Such lenses have negative spherical aberration to correct the natural spherical aberration. Also, this lens is a diffractive one, both at near and at distance, unlike other lenses that are only diffractive at near. “Because it’s a diffractive lens at distance, it corrects chromatic aberrations as well as spherical aberration,” Dr. Donnenfeld said.
For patients who want the best quality of vision possible and who don’t mind wearing reading glasses, Dr. Donnenfeld still thinks that traditional monovision IOL techniques do well. But there is a downside to the –1.50 difference between the eyes when using this approach. “The problem is that their distance vision is so compromised by the monovision that they lose the depth of focus,” Dr. Donnenfeld said. “They lose a lot of quality of vision and have a lot harder time judging distance in front of them.” He views the mini-monovision approach as much safer.
Other combinations with the EDOF lens are being studied. “Kerry Solomon, MD, recently presented a paper looking at the EDOF lens in the dominant eye and a +3.25 multifocal lens in the nondominant eye, and there were good results with that,” Dr. Donnenfeld said.

About the doctor

Eric Donnenfeld, MD

Ophthalmic Consultants of Long Island
Garden City, New York


1. Sandoval HP, et al. Extended depth-of-focus toric intraocular lens targeted for binocular emmetropia or slight myopia in the nondominant eye: Visual and refractive clinical outcomes. J Cataract Refract Surg. 2019;45:1398–1403.

Relevant disclosures

: Johnson & Johnson Vision



Outcomes with EDOF mini-monovision Outcomes with EDOF mini-monovision
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