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Truth or myth: Monovision is best for presbyopic CL correction?

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This month, in our series looking at common myths concerning contact lenses, Stephanie Wong and John Meyler look at whether monovision is a good place to start

Many spectacle wearers would prefer to experience the numerous benefits of contact lens wear assuming excellent vision and comfort could be achieved. Eye care professionals (ECPs) have multiple options when fitting a presbyopic patient with contact lenses.  

After considering their occupation and lifestyle, practitioners can choose between fitting single-vision distance contact lenses with additional reading glasses, monovision, or multifocal lenses.  

Although single-vision distance lenses are easy to fit, potentially less expensive, and provide good vision at both distance and near – albeit with the addition of reading spectacles – wearers can find it bothersome to require a separate pair of reading glasses and existing contact lens wearers would likely prefer to only reach for glasses as a back-up option.   

An international survey conducted from 2005 to 2009 examined the types of lenses prescribed in 38 countries.1  

Most patients over the age of 45 were not given lenses that correct for presbyopia (63%), with only 8% prescribed monovision and 29% multifocal lenses.  

Significant differences between countries were observed, with 79% of wearers in Portugal fit with monovision/multifocal lenses and none being offered this option in Singapore.  

Reasons for this lack of prescribing include insufficient fitting skills, the preconceived notion that the patient will not be successful, and the misconception that an ideal lens providing good vision and comfort at all distances does not exist.1  

Prescribing of multifocal contact lenses has risen over the years due to increased availability of lens designs, materials and replacement modalities.2 A 2022 survey of 22 countries reported 53% of soft lens wearers over the age of 45 were prescribed multifocal lenses, 7% monovision and the remaining 40% single vision distance lenses.3   

  

Professional Belief Survey Results 

A recent Johnson & Johnson survey involving over 1,000 practitioners conducted in Russia in 2021 and in 2022 for the other markets, examined prescribing beliefs of ECPs in all six countries.4  

On average, nearly one third (30%) of the practitioners surveyed across all markets agreed that ‘monovision was their preferred starting point for correcting presbyopia.’  

Once again, differences were observed between countries, with only 14% of practitioners in the United States choosing monovision as their first choice, while the remaining countries reported greater levels of agreement, ranging from 21% in the United Kingdom to 74% in Russia (figure 1). 

 

Figure 1: Results showing extent of agreement (shown in blue) or disagreement (shown in red) or disagreement with the statement ‘Monovision is my preferred starting point for presbyopia correction with contact lenses’. Data is from 2022 for all markets except Russia, which is from 2021

  

What the evidence shows 

Monovision can have a high success rate5 but is most successful for early presbyopia,5 with a +1.50 D or lower addition.6 Some researchers have shown that a disparity of greater than +0.75D resulted in a shift from binocular summation to binocular inhibition.7  

Fitting the dominant eye for distance and the non-dominant eye for near vision is relatively easy for practitioners, but requires one eye to be suppressed, which can change depending on whether patients are viewing distant or near targets.5  

Monovision can potentially cause less ghosting and variable vision due to fluctuations in pupil size compared to multifocal lenses.5, 6 However, suppression may be more difficult under dim illumination, which can lead to problems driving at night.6  

Monovision can also cause reduced stereopsis and contrast sensitivity,5, 6 and higher reading additions can affect intermediate working distances.6   

Monovision and multifocal lenses can both achieve at least 20/20 binocular vision when viewing high contrast letters at distance and near.8 Multifocal lenses have the same level of binocular high contrast visual acuity at distance and near as both single-vision contact lenses with reading glasses9 and monovision.8  

Different multifocal lenses produce variable levels of visual acuity,10 therefore it helps if practitioners have multiple lens options available. Multifocal lenses have the same level of stereoacuity as single-vision distance lenses9 and better stereoacuity than monovision.8, 10  

Objective tests may not detect differences between multifocal and monovision lenses, therefore subjective preference can help assess patient acceptance when performing real-world tasks such as while driving, watching television, using the computer or reading.11, 12  

Early presbyopes report higher levels of satisfaction with multifocals for distance vision, driving during the day, and driving at night.12 

When participants who had never worn presbyopic contact lenses were asked to choose between monovision and multifocal lenses, 76% of participants preferred multifocal lenses.8  

When habitual wearers were asked to select which lens they preferred, 51% opted for multifocal lenses and only 37% chose monovision.11 The remaining 12% reported both types were unacceptable due to overall poor vision, poor near vision, ghosting and making the wearer feel off-balance.  

This preference data was from a study conducted in 2014 and with newer multifocals designs now available in daily disposable modalities, the preference for multifocal designs might well be higher. 

  

Conclusion 

While there will always be a place for both monovision and multifocal contact lens correction, a review of peer reviewed evidence shows that in general, wearers prefer the overall performance achieved with multifocal correction and, thus, this is the best starting point when correcting presbyopes with contact lenses.  

  • Dr Stephanie Wong is a clinical scientist at the Centre for Ocular Research & Education, School of Optometry & Vision Science, University of Waterloo. John Meyler is head of global professional education at Johnson & Johnson Medical Ltd.  

  

References 

  1. Morgan PB, Efron N, Woods CA, et al. An international survey of contact lens prescribing for presbyopia. Clin Exp Optom. 2011;94(1):87-92. 
  2. Rueff EM, Bailey MD. Presbyopic and non-presbyopic contact lens opinions and vision correction preferences. Cont Lens Anterior Eye. 2017;40(5):323-328. 
  3. Morgan PB, Woods CA, Tranoudis IG, et al. International contact lens prescribing in 2022. Contact Lens Spectrum. 2023; 38: 28-35. 
  4. Johnson & Johnson Vision Care. Online survey of 1028 Eye Care Professionals across United States, United Kingdom, Russia, China, Japan, and South Korea. JJV data on file.2021 (Russia) and 2022 (other markets). 
  5. Bennett ES. Contac (other marketst lens correction of presbyopia. Clin Exp Optom. 2008;91(3):265-78. 
  6. Evans BJ. Monovision: a review. Ophthalmic Physiol Opt. 2007;27(5):417-39. 
  7. Pardhan S, Gilchrist J. The effect of monocular defocus on binocular contrast sensitivity. Ophthalmic Physiol Opt. 1990; 10: 33-36 
  8. Richdale K, Mitchell GL, Zadnik K. Comparison of multifocal and monovision soft contact lens corrections in patients with low-astigmatic presbyopia. Optom Vis Sci. 2006;83(5):266-73. 
  9. Ferrer-Blasco T, Madrid-Costa D. Stereoacuity with balanced presbyopic contact lenses. Clin Exp Optom. 2011;94(1):76-81. 
  10. Sivardeen A, Laughton D, Wolffsohn JS. Randomized crossover trial of silicone hydrogel presbyopic contact lenses. Optom Vis Sci. 2016;93(2):141-9. 
  11. Woods J, Woods C, Fonn D. Visual performance of a multifocal contact lens versus monovision in established presbyopes. Optom Vis Sci. 2015;92(2):175-82. 
  12. Woods J, Woods CA, Fonn D. Early symptomatic presbyopes ¬ what correction modality works best? Eye Contact Lens. 2009;35(5):221-6. 

  

  • Important safety information: Acuvue Contact Lenses are indicated for vision correction. As with any contact lens, eye problems, including corneal ulcers, can develop. Some wearers may experience mild irritation, itching or discomfort. Contact lenses should not be used in case of eye infections or any other eye conditions, or in case of a systemic disease that may affect the eye. For complete information, including contraindications, precautions and adverse reactions, please consult the instructions for use or visit our website here.