Full range of vision and visual quality after mini-monovision FS-LASIK in high myopic patients with age-related accommodative deficiency

Full range of vision and visual quality after mini-monovision FS-LASIK in high myopic patients with age-related accommodative deficiency | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Full range of vision and visual quality after mini-monovision FS-LASIK in high myopic patients with age-related accommodative deficiency Ruiyu Zhang, Yifei Yuan, Yu Zhang, Yueguo Chen This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4269833/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 30 Sep, 2024 Read the published version in BMC Ophthalmology → Version 1 posted 4 You are reading this latest preprint version Abstract Background To evaluate clinical outcomes and visual quality 3 months after mini-monovision femtosecond laser-assisted in situ keratomileusis (FS-LASIK) for correction of high myopia in patients with age-related accommodation deficiency. Methods Patients who had mini-monovision FS-LASIK for high myopia (spherical equivalent [SE] < -6.0 D) and aged between 40 and 50 years were included. At the 3-month postoperative visit, we evaluated full range of visual acuity; defocus curve; optical quality; accommodation function, contrast sensitivity and stereopsis. Binocular tests were done twice, once in mini-monovision condition and once with the residual myopia in the non-dominant eye corrected. Subjective visual quality was evaluated with questionnaire. Results Clinical data of 31 cases were analyzed. The average patient age was 42.58 ± 3.06 years. At the 3-month follow-up, the mean uncorrected binocular visual acuity at distance, intermediate, and near was − 0.11 ± 0.07, -0.06 ± 0.10, and 0.04 ± 0.11 logMAR separately. In comparison, full distance correction group achieved better UDVA (P = 0.02), and the monovision group achieved superior UNVA (P = 0.04). FS-LASIK induced significant increases in higher-order aberrations (HOAs) (P < 0.001). For accommodative function, only the negative relative accommodation (NRA) improved significantly after surgery (P < 0.001). A slight decrease in contrast sensitivity was observed at low spatial frequency with monovision (P < 0.05). Questionnaire demonstrated high satisfaction with near vision and visual quality. Conclusion FS-LASIK with mini-monovision appeared to be safe and effective in treating high myopia combined with age-related accommodation deficiency to get satisfying visual quality at distant and at near. visual quality mini-monovision FS-LASIK high myopia age-related accommodative deficiency Figures Figure 1 Figure 2 Introduction Age-related accommodative deficiency, also known as presbyopia, manifests as a gradual deterioration in the clarity of near vision with age, usually occurs in people aged 40 or older[ 1 ]. To properly manage the age-related accommodation deficiency while correcting the existing refractive error, femtosecond laser-assisted in situ keratomileusis (FS-LASIK) with monovision/ optimized monocular vision protocol, an unbalanced correction between the two eyes in which the dominant eye is corrected to emmetropia mainly used for distance vision, whereas the non-dominant eye retains a certain degree of spherical diopter for intermediate or near vision, continues to be the regular and effective choice[ 2 ]. Studies have demonstrated good clinical outcomes of this scheme in myopes with presbyopia, and most have focused only on the correction of low to moderate myopia[ 3 , 4 ], or analyze all included eyes without further grouping by degree of myopia[ 5 , 6 ]. With the increasing prevalence of high myopia worldwide nowadays, more and more patients during the incipient phase of presbyopia with relatively clear lenses are prone to seek corneal refractive surgeries to correct high myopia as well as presbyopia[ 7 ]. Notably, higher degrees of myopic correction changes corneal morphology to a greater extent, introducing more HOAs and might thus take a toll on visual performance[ 8 – 10 ]. Besides, refractive surgery breaks the balanced state of binocular visual function suddenly while changing refractive status[ 11 ], for presbyopes with high myopia, the size and nature of ciliary body have changed to some extent, concerns have thus been raised whether this asymmetry correction would have an adverse effect on reorientation of visual system[ 12 ]. Hence, conclusions of the studies in low-to-moderate myopia cannot be directly generalized. The aim of this study is to evaluate the efficacy and safety of mini-monovision FS-LASIK in high myopia combined with age-related accommodation insufficiency, and focusing on the postoperative visual quality and patient satisfaction comprehensively. Patients and Methods This retrospective study included 31 consecutive patients undergoing Q-value-guided FS-LASIK with monovision at the Peking University Third Hospital (Beijing, China) between Jan. 2023 and Sep. 2023. The study was approved by the ethics committee of the Peking University Third Hospital and adhered to the tenets of the Declaration of Helsinki. All participants were thoroughly informed before written consent was obtained. The inclusion criteria were as follows: age between 40 and 50 years, stable refractive error (≤ 0.5 D change per year in refractive error in the past 2 years), spherical equivalent (SE) of -6.0 D or higher, and astigmatism of up to -3.0 D. The exclusion criteria were as follows: patients with a history of refractive or corneal surgery, suspicion of keratectasia, visually significant cataracts or other pre-existing ocular diseases, any significant abnormality in binocular visual function. Preoperative assessments All patients underwent comprehensive ocular examinations, including uncorrected and corrected distance visual acuity (UDVA, CDVA) evaluated in the logarithm of the minimum angle of resolution (logMAR), subjective manifest and cycloplegic objective refraction, noncontact intraocular pressure (NIDEK Co., Ltd), standard slit-lamp evaluation (IM 900, Köniz), dilated fundus examination, and corneal tomography (Pentacam, Oculus). Ocular dominance was determined using the pinhole test[ 13 ]. Corneal asphericity (Q factor), higher-order aberrations (HOAs) of anterior corneal surface within the central 6-mm region, and retinal image quality (the Strehl ratio, SR), were determined using the Sirius (Costruzione Strumenti Oftalmici, Florence, Italy) tomography instrument. Root mean square (RMS) values for the total amount of HOAs, astigmatism, spherical aberration, and coma were automatically calculated through Fourier transformation. The necessary addition (NA) for reading Parinaud 2 at 40 cm distance was obtained using the “minimal addition” method[ 14 ]. The "minus lens method" measured accommodative amplitude (AA), and positive and negative relative accommodation (PRA and NRA), were evaluated by phoropter as the patients viewed a high-contrast target at 40 cm with full near correction[ 15 ]. The actual accommodation parameters were calculated by subtracting NA added before testing[ 15 ]. Surgical Technique FS-LASIK procedures were performed by a highly experienced surgeon (YG Chen) using the FS-200 femtosecond laser and WaveLight EX500 excimer laser (Alcon Laboratories, Inc.) under topical anesthesia. In all cases, an 8.5 to 9.0 mm diameter superior 50-degree hinged corneal flap with a 90-degree side-cut and 110 µm thickness was dissected. Following blunt dissection and flap lift, the stromal photoablation was performed with a 6.5-mm optical zone and 1.25-mm transition zone using Q-value-guided (F-CAT) treatment option. Preoperative Q Values were measured using the WaveLight Topolyzer Vario instrument (Alcon Laboratories, Inc), reflecting the distribution of characteristics of corneal curvature within 30° of the central cornea. For the dominant eye, the target refraction was set at emmetropia, and for the non-dominant eye, the refractive target was set to slight myopia between − 0.25 D and − 0.50 D, according to the age and requirements of patients[ 16 ]. No adjustment was made for Q value. Postoperatively, all the eyes received treatment with 0.1% fluorometholone (FML, Allergan, Inc., Irvine, CA, United States) in tapering dose for 4 weeks, 0.5% levofloxacin (Cravit, Santen, Inc., Japan) four times a day for 2 weeks and lubricating drops four times a day for 4 weeks. Postoperative assessments Follow-up visits included postoperative days 1 and 7, months 1 and 3. Results at the 3-month follow-up were included for data analysis in this study. The monocular and binocular UDVA, CDVA, refractive status, corneal asphericity, objective image quality, and accommodation function were measured in the same manner as pre-operatively. The uncorrected intermediate and near visual acuity (UIVA, UNVA) were measured at 80 cm and 40 cm distances. Defocus curves from − 3.0 D to + 1.0 D in increments of 0.5 D were obtained by phoropter binocularly. Visual acuity was converted into logMAR scale from the decimal notation for data analysis. Contrast sensitivity measured with CSV-1000E (Vector Vision) was evaluated binocularly under photopic (85 cd/m 2 ) and mesopic (3 cd/m 2 ) conditions at four spatial frequencies (3.0, 6.0, 12.0, and 18.0 cpd), and outcomes were recorded in log unit[ 17 ]. Stereopsis was measured using the Yan’s stereoscopic test. Distance stereoacuity was determined using the synoptophore, and near stereoacuity was measured at a standard viewing distance of 40 cm[ 18 ]. Results were classified as follows: stereoacuity greater than or equal to 60 s of arc (central stereopsis); stereoacuity ranged between 80 and 200 s of arc (macular stereopsis); stereoacuity ranged between 300 to 800 s of arc (peripheral stereopsis); and stereoacuity above 800 s of arc (stereo blindness)[ 19 ]. For comparison, patients with myopic diopter in the non-dominant eye postoperatively were asked to have all binocular tests performed twice, once in monovision condition without spectacles, and once with the residual myopia in the non-dominant eye corrected with spectacles (reverting monovision to full distance correction), serving as control group. At last, all patients were asked to fill out a questionnaire including their perception of near-visual ability (satisfaction with near visual acuity and reading spectacle independence) and visual disturbance. The second part includes 8 common complaints after refractive surgery: glare, halos, starbursts, blurred vision, monocular diplopia, fluctuation in vision, focusing difficulty, and difficulty judging depth perception. The incidence and severity of respective symptoms were recorded. Statistical Analysis All statistical analyses were performed using SPSS Statistics for Windows (version 22.0., IBM Corp.). The normality of data was assessed by histogram frequency analysis and the Shapiro-Wilks test. Data were expressed as mean ± standard deviation (SD). The paired samples t -test and the independent samples t -test were performed on normally distributed data, and the Wilcoxon rank-sum test and the Mann–Whitney U-test were performed on non-normally distributed data. The Fisher exact probability test was used for comparisons of categorical variables. P value less than 0.05 was considered statistically significant. Results The study comprised 31 patients (62 eyes). The mean age of the 19 women (61.29%) and 12 men (38.71%) was 42.58 ± 3.06 (SD) years (range 40 to 50 years), and the mean addition for binocular near vision was 0.34 ± 0.46 D. Supplemental Table 1 shows the preoperative characteristics in dominant eyes and nondominant eyes by group. Efficacy, Accuracy and Safety At the 3-month follow-up, the mean UDVA was − 0.07 ± 0.08 in the dominant eye, with a mean residual spherical equivalent (SE) defect of 0.01 ± 0.33 D (range: -0.75 to 0.63 D). In the nondominant eye, the UDVA was − 0.01 ± 0.09, with a mean residual SE defect of -0.38 ± 0.36 D (range: 0.13 to -1.00 D). Figure 1 shows the standard graphs for reporting outcomes of refractive surgery in dominant eye. The accuracy of the achieved spherical equivalent compared to the intended target was within ± 1.00 D in all (100%) dominant eye treated, whereas 90% of eyes were within ± 0.50 D (Fig. 1 D). All surgeries were uneventful, with no infection, inflammation, or intraoperative complications noted in any of the patients enrolled in the study. No eyes lost lines of CDVA at 3 months post-surgery. Binocular visual acuity and defocus curves For all patients, the mean postoperative uncorrected binocular visual acuity at distance, intermediate, and near was − 0.11 ± 0.07 logMAR, -0.06 ± 0.10 logMAR, and 0.04 ± 0.11 logMAR separately. The binocular defocus curve is shown in Fig. 2 A. Regarding the defocus range from 0 D to – 2.50 D (from far to near distance of 40 cm), the mean uncorrected visual acuity was maintained above 20/25. After surgery, 7 patients showed emmetropia status and 2 showed hyperopia status in the non-dominant eye, and there were 2 patients refused to repeat binocular tests with spectacles. Eventually, only 20 patients had residual myopia in the non-dominant eye corrected with spectacles and serving as control group. Postoperative binocular visual outcome in monovision compared to full distance correction are shown in Table 1 . The two groups had comparable mean binocular UINA. For the distant visual acuity, better outcome was achieved in the full distance correction group (P = 0.02); for the near visual acuity at 40cm, superior result was observed in the monovision group instead (P = 0.04). Similarly, as shown in Fig. 2 B, patients in the monovision group showed significant better results regarding the defocus range from – 2.00 D to – 3.00 D (corresponding to a distance range of 50–33 cm). Table 1 Comparison of binocular visual acuity between monovision and full distance correction Monovision (n = 20) Full Distance Correction (n = 20) P Mean ± SD Range Mean ± SD Range UDVA (LogMAR) -0.07 ± 0.06 0, -0.18 -0.10 ± 0.04 -0.08, -0.20 0.02 * UIVA (LogMAR) -0.03 ± 0.09 -0.20, 0.20 -0.04 ± 0.09 0.10, -0.20 0.68 UNVA (LogMAR) 0.07 ± 0.11 -0.10, 0.40 0.12 ± 0.19 -0.10, 0.70 0.04 * UDVA = uncorrected distance visual acuity; UIVA = uncorrected intermediate visual acuity; UNVA = uncorrected near visual acuity; All values are presented as mean ± standard deviation; The Wilcoxon rank-sum test was used to compare differences between the two groups * statistically significance Corneal Asphericity, Aberrations, and Image Quality Corneal asphericity and objective image quality before and after treatment are summarized in Table 2 . Compared to preoperative measurements, postoperative examinations showed corneal asphericity was more positive in both dominant eyes and non-dominant eyes (P < 0.05). The RMS of total HOAs, coma and SA significantly increased after the surgery (P < 0.05) when measured over a 6mm pupil. However, the SR value did not show statistically significant changes due to the surgery. Table 2 Preoperative and postoperative corneal asphericity, aberrations, and objective image quality (6mm) Parameters Dominant Eye (n = 31) (Mean ± SD) Nondominant Eye (n = 31) (Mean ± SD) Preop Postop P Preop Postop P Q value -0.15 ± 0.12 0.46 ± 0.45 < 0.001 * -0.15 ± 0.11 0.63 ± 0.55 < 0.001 * Total HOAs (µm) 0.47 ± 0.14 0.94 ± 0.34 < 0.001 * 0.46 ± 0.11 0.92 ± 0.34 < 0.001 * SA (µm) 0.25 ± 0.09 0.56 ± 0.22 < 0.001 * 0.25 ± 0.07 0.59 ± 0.23 < 0.001 * Coma (µm) 0.23 ± 0.14 0.61 ± 0.33 < 0.001 * 0.23 ± 0.12 0.55 ± 0.31 < 0.001 * SR 0.13 ± 0.05 0.15 ± 0.04 0.08 0.15 ± 0.04 0.14 ± 0.04 0.50 HOAs = higher-order aberrations; SA = spherical aberration; SR = strehl ratio; preop = preoperative; postop = postoperative All values are presented as mean ± standard deviation; The Wilcoxon rank-sum test was used to compare differences before and after the operation. * statistically significance Binocular accommodation function Table 3 shows the results of the assessment of binocular accommodation function. The postoperative NRA was on average about 0.71 D higher than the preoperative value (P < 0.001), but binocular minus-lens-stimulated AA and PRA did not show any statistically significant changes before and after surgery. Table 3 Preoperative and postoperative accommodation function Parameters Preop (n = 31) Postop (n = 31) P Mean ± SD Range Mean ± SD Range AA (D) 3.91 ± 1.16 2.50, 6.50 3.58 ± 0.91 2.50, 5.50 0.08 NRA (D) 1.70 ± 0.52 0.50, 2.75 2.41 ± 0.49 1.50, 3.50 <0.001 * PRA (D) -1.41 ± 1.16 0, -4.00 -1.08 ± 0.91 0, -3.00 0.08 AA = accommodative amplitude; NRA = negative relative accommodation; PRA = positive relative accommodation; preop = preoperative; postop = postoperative; All values are presented as mean ± standard deviation; P values for comparations before and after the operation of NRA was calculated by paired samples t-test. The Wilcoxon rank-sum test was used to compare differences of AA and PRA before and after the operation. * statistically significance Binocular Contrast Sensitivity and Stereoacuity There were 17 patients showed myopia status in the non-dominant eye after surgery and were willing to have contrast sensitivity and stereoacuity test performed twice. Postoperative binocular contrast sensitivity measurements in the monovision and full distance correction groups at 3, 6, 12, and 18 cpd under photopic and mesopic conditions with and without glare stimuli are shown in Supplemental Fig. 1. Compared to the logarithmic scale, contrast sensitivity was generally reduced with monovision compared to binocular full distance correction in most test conditions. This reduction was only of statistically significant at low spatial frequency of 6.0 cpd under photopic and mesopic conditions (P < 0.05 for all comparisons). The binocular distance and near stereoacuity are shown in Supplemental Table 2. Stereoacuity decreased slightly with monovision compared to full distance correction, but the noted differences were not statistically significant (P > 0.05). The results of stereoacuity were categorized as follows: stereoacuity better than or equal to 60 s of arc (central stereopsis); stereoacuity in the range of 80 to 200 s of arc (macular stereopsis); stereoacuity in the range of 300 to 800 s of arc (peripheral stereopsis); and either stereoacuity equal or above 800 s of arc (stereo blindness). The Fisher exact probability test was used for comparisons of categorical variables. Subjective Visual Quality and Near Visual Ability For the near visual ability, 6 patients (19.35%) were fully satisfied with their near visual acuity, 23 patients (74.19%) were moderately satisfied, and the remaining 2 patients (6.45%) were not very satisfied; 24 patients (70.97%) reported that they never required to wear reading glasses while reading or doing close work, 6 patients (19.35%) needed reading glasses in few cases, and only 1 patient (3.23%) needed reading glasses in most cases. Supplemental Table 3 shows patients’ perception of visual disturbance. The three most commonly reported visual symptoms after surgery were blurred vision, glare, and halos with the cumulative number of 20 patients (64.52%), 19 patients (61.29%), and 19 patients (61.29%), respectively, reporting these symptoms “occasionally,” “often,” or “usually”. Besides, subjective problems with depth perception had been found in only 4 patients (12.90%), which was considered closely related to reduction in stereoacuity, and no one considered them severely bothering. Discussion Results of the study demonstrated that monovision procedure was safe and effective for the treatment of high myopia combined with age-related accommodative deficiency. Binocular vision, which is considered of great clinical significance and simulates better in daily tasks than monocular vision, as patients always function under binocular conditions[ 20 ], was satisfying at whole course 3 months postoperatively. All patients achieved 20/20 or better UDVA, 20/30 or better UIVA, and 20/50 or better UNVA. There were 27 (87.10%) patients achieving unaided far, intermediate, and near visual acuity of 20/25 or better simultaneously. Results of subjective questionnaire were also well related to the functional visual acuity, that the satisfaction rate of unaided near vision was found to be upwards of 94%, and full-distance spectacle independence has also been largely achieved. In the current study, a significant mild reduction in the binocular near vision was observed with full distance correction (wearing spectacles in the non-dominant eye) compared to mini-monovision, and although there was a decrease in distance vision with mini-monovision condition, the difference may fail to achieve clinical significance. This further indicates that mini-monovision enables better results for near work while maintaining good uncorrected distance visual function for this subset of patients. This study also focuses on binocular visual function. It has been theoretically proven that the abrupt emmetropization with myopic refractive surgery increases the accommodation and convergence demands for near suddenly[ 21 ]. The binocular function would be hence more altered in high myopia, which raises our concerns of binocular vision impairment or apparent asthenopia in this population with standard physiological function of eye tissue already degraded to some extent[ 21 , 22 ]. Regarding accommodation function, the AA and PRA was unaltered, and we even observed a relatively small preoperative NRA that increased after surgery surprisingly. Possible reasons could include the following. Firstly, it has been found that the accommodation demand for myopes is generally lower than in emmetropes owing to the presence of the spectacle vertex distance (the distance between the lens's inner surface and the cornea's vertex) and prism effect of concave lens[ 23 ], which also interacted with convergence demand and leads to reduced accommodative convergence accordingly. Studies have shown that myopes with spectacles tended to have increased exophoria deviation when viewing a near target, especially in those with high myopia[ 23 – 25 ]. As a result, the myopic eye may end up using more of its fusional convergence to maintain binocular single vision. Postoperatively, the accommodation demands increased, inducing more convergence demands and thus less exophoria[ 24 ]. A previous study also reported that significant decline of exophoria was observed after FS-LASIK, when compared to preoperative exophoria with the corrected lens[ 23 ]. When adding positive lenses in front of both eyes to relax accommodation, the accommodative convergence decreased, and fusional convergence, which had been heavily used preoperatively, had to further increased to maintain binocular function, thus the preoperative NRA was significantly lower in comparison. Additionally, the increased needs for physiological binocular function might has a training effect on muscles control capability of the brain, thus making binocular function more efficient and coordinated. Moreover, in a state of myopia, people favored near-work activities and putting muscles under high tension for long periods. After the refractive error was corrected, the eye’s far point was away from the corneal plane, which helps significantly in relaxing tensed muscles. Regarding the optical visual quality, the corneal HOAs at 6 mm pupil increased significantly, which aligned with the principle of myopia correction. Besides, attenuation of contrast sensitivity and reduction of stereopsis were thought to be the major disadvantage associated with monovision[ 2 ]. In this study, we also found a slight reduction in binocular contrast sensitivity and stereopsis, compared to the full distance correction. However, the optical quality measured on retinal plane did not show significantly worse performance, and the subjective visual function in real-life scenarios did not worsen. These good results may be partly due to the mild myopic refraction targeted in our series[ 26 ]. Moreover, it should be noted that postoperative visual quality also was strongly related to laser platform and ablation profiles used in this procedure, which cannot be generalized to others with different ablation protocol. In our study, a Q-value-guided profile with WaveLight EX500 excimer laser system was used for treatment, in which the Q factor was adjusted intending to better preserve the original prolate shape of cornea, resulting in fewer surgically induced HOAs within the suitable range and resulted in no severe adverse effects on visual quality, as well as better conservation of cornea thickness[ 27 ]. There are also other lasers available, such as the SCHWIND Amaris laser, with different ablation model and geometric modelling, thus postoperative visual quality cannot be predicted. In this study, patients at the early stage of presbyopia were included[ 2 ], and the mean age was relatively younger compared with relevant studies. One reason was that, as the median age would reach 40 years by 2050 under the backdrop of an ageing global population[ 28 ], it is expected that the number of patients aged around 40 years seeking for refractive surgery will continue to grow. Besides, most patients at this age made the firm choice to choose monovision protocol after being fully informed, rather than full correction in our clinical experience. In this study, major limitation is the lack of a control group (for example, the binocular full distance correction). Besides, we focused only on accommodation function, and attention should be paid to other aspects of binocular visual function, such as the aggregation function. In conclusion, FS-LASIK with mini-monovision appeared to be safe and effective in treating high myopia combined with age-related accommodation insufficiency to get satisfying visual quality at distant and at near. Abbreviations AA= accommodative amplitude, CDVA= corrected distance visual acuity, HOAs= higher-order aberrations, NRA= negative relative accommodation, PRA= positive relative accommodation, RMS= root mean square, SE= spherical equivalent, SR= Strehl ratio, UDVA= uncorrected distance visual acuity, UIVA= uncorrected intermediate visual acuity, UNVA= uncorrected near visual acuity, FS-LASIK= femtosecond laser-assisted in situ keratomileusis, Declarations Disclosures: None of the authors has a financial or proprietary interest in any material or method mentioned. Supported by a grant from The Key Clinical Innovation Program of Peking University Third Hospital, Category A (Grant No. Y65495-05). This study adhered to the tenets of the Declaration of Helsinki and received approval from the Ethics Committee of Peking University Third Hospital. Informed consent was obtained from each subject. Consent for publication: Not applicable Availability of data and materials: All data generated or analysed during this study are included in this published article. Competing interests: None of the authors has a financial or proprietary interest in any material or method mentioned. Funding: Supported by a grant from The Key Clinical Innovation Program of Peking University Third Hospital, Category A (Grant No. Y65495-05). Authors' contributions: Ruiyu Zhang, Yifei Yuan and Yu Zhang participated in the design of the study, Ruiyu Zhang performed the statistical analysis and revised the manuscripts. 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Progress In Retinal and Eye Research 2019, 68 :124-143. Additional Declarations No competing interests reported. Supplementary Files SupplementalTables.docx 3.png Supplemental Fig. 1. Comparision of binocular contrast sensitivity measurements at 3, 6, 12, and 18 cpd under photopic and mesopic conditions with and without glare stimuli between the monovision and the full distance correction groups (n=17). Cite Share Download PDF Status: Published Journal Publication published 30 Sep, 2024 Read the published version in BMC Ophthalmology → Version 1 posted Editorial decision: Revision requested 25 Apr, 2024 Submission checks completed at journal 17 Apr, 2024 Editor assigned by journal 17 Apr, 2024 First submitted to journal 15 Apr, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4269833","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":292575685,"identity":"2661da9a-723d-4fe0-8fe5-ac0f9dbc8a3b","order_by":0,"name":"Ruiyu Zhang","email":"","orcid":"","institution":"Peking University Third Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ruiyu","middleName":"","lastName":"Zhang","suffix":""},{"id":292575686,"identity":"5398bf99-4161-40f3-b9b0-aacb7f971841","order_by":1,"name":"Yifei Yuan","email":"","orcid":"","institution":"Peking University Third Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yifei","middleName":"","lastName":"Yuan","suffix":""},{"id":292575687,"identity":"e4782780-4cec-45d2-9df0-2c2efaecaf72","order_by":2,"name":"Yu Zhang","email":"","orcid":"","institution":"Peking University Third Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yu","middleName":"","lastName":"Zhang","suffix":""},{"id":292575688,"identity":"c1800979-2c46-4748-b333-ebde25b45ffb","order_by":3,"name":"Yueguo Chen","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA30lEQVRIiWNgGAWjYDACCTiL+eCDDz9I08KWbDizB0QTr4XHTJqDjQgt/LObjz3mbbOx23C854M0Aw9DHr98AwFL7hxLN+ZtS0vecObsBuMCC4ZiyTYCthhI5JhJ87YdTja4kbsheQYPQ+KGYwS15H8DavkP1JLz4DAPG0PifsJactiAWg7YAbUwNoO0bCDkfYkbaWaSc84lJ0ieOWbMOLNHInHGsQT8WvhnJD+TeFNmZ893vPn5jw8/bBL7mw8QsAYImHgYGBIboLYSVg4CjMBkYk+c0lEwCkbBKBiRAAD8fkOPjl4yPAAAAABJRU5ErkJggg==","orcid":"","institution":"Peking University Third Hospital","correspondingAuthor":true,"prefix":"","firstName":"Yueguo","middleName":"","lastName":"Chen","suffix":""}],"badges":[],"createdAt":"2024-04-15 12:48:02","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4269833/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4269833/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12886-024-03698-x","type":"published","date":"2024-09-30T15:57:16+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":55323891,"identity":"ddc05eeb-4b86-4f47-9851-d1ec854bc621","added_by":"auto","created_at":"2024-04-25 16:46:55","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":216053,"visible":true,"origin":"","legend":"\u003cp\u003eRefractive outcomes at 3 months after monovision FS-LASIK for the dominant eye. (A) Cumulative histogram showing postoperative uncorrected distance visual acuity (UDVA) and preoperative corrected distance visual acuity (CDVA). (B) Histogram showing the change in CDVA values. (C) Attempted versus achieved spherical equivalent refraction scatter plot. (D) Histogram showing the accuracy of the intended spherical equivalent refraction. (E) Histogram showing refractive astigmatism before and after treatment.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4269833/v1/4c10ec120a474c0a4ea666b6.png"},{"id":55324903,"identity":"c2a2cfb2-a072-442e-ad9a-506f5e4b4c1f","added_by":"auto","created_at":"2024-04-25 16:54:55","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":98550,"visible":true,"origin":"","legend":"\u003cp\u003eBinocular defocus curves assessed at 3 months follow-up. (A) Binocular defocus curve for all patients (n=31). (B) Comparision of binocular defocus curve between the monovision and the full distance correction groups (n=20).\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-4269833/v1/0bc3e1ce0a4ed3c1d35342bb.png"},{"id":66096788,"identity":"5485aedc-415a-4d92-9fad-8f89ce76d811","added_by":"auto","created_at":"2024-10-07 16:10:07","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1407643,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4269833/v1/a2969d32-9174-420e-8d33-c87a749fe413.pdf"},{"id":55324902,"identity":"28579ac0-552f-4b63-8974-8fd4e5205329","added_by":"auto","created_at":"2024-04-25 16:54:54","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":27621,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementalTables.docx","url":"https://assets-eu.researchsquare.com/files/rs-4269833/v1/b390d62f91dede775dc93ba6.docx"},{"id":55323895,"identity":"3ab51a58-7541-4f00-abd8-06a830277192","added_by":"auto","created_at":"2024-04-25 16:46:55","extension":"png","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":244717,"visible":true,"origin":"","legend":"\u003cp\u003eSupplemental Fig. 1. Comparision of binocular contrast sensitivity measurements at 3, 6, 12, and 18 cpd under photopic and mesopic conditions with and without glare stimuli between the monovision and the full distance correction groups (n=17).\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-4269833/v1/55429f8d17fd4bc9932f03dd.png"}],"financialInterests":"No competing interests reported.","formattedTitle":"Full range of vision and visual quality after mini-monovision FS-LASIK in high myopic patients with age-related accommodative deficiency","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAge-related accommodative deficiency, also known as presbyopia, manifests as a gradual deterioration in the clarity of near vision with age, usually occurs in people aged 40 or older[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. To properly manage the age-related accommodation deficiency while correcting the existing refractive error, femtosecond laser-assisted in situ keratomileusis (FS-LASIK) with monovision/ optimized monocular vision protocol, an unbalanced correction between the two eyes in which the dominant eye is corrected to emmetropia mainly used for distance vision, whereas the non-dominant eye retains a certain degree of spherical diopter for intermediate or near vision, continues to be the regular and effective choice[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Studies have demonstrated good clinical outcomes of this scheme in myopes with presbyopia, and most have focused only on the correction of low to moderate myopia[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], or analyze all included eyes without further grouping by degree of myopia[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWith the increasing prevalence of high myopia worldwide nowadays, more and more patients during the incipient phase of presbyopia with relatively clear lenses are prone to seek corneal refractive surgeries to correct high myopia as well as presbyopia[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Notably, higher degrees of myopic correction changes corneal morphology to a greater extent, introducing more HOAs and might thus take a toll on visual performance[\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e–\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Besides, refractive surgery breaks the balanced state of binocular visual function suddenly while changing refractive status[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], for presbyopes with high myopia, the size and nature of ciliary body have changed to some extent, concerns have thus been raised whether this asymmetry correction would have an adverse effect on reorientation of visual system[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHence, conclusions of the studies in low-to-moderate myopia cannot be directly generalized. The aim of this study is to evaluate the efficacy and safety of mini-monovision FS-LASIK in high myopia combined with age-related accommodation insufficiency, and focusing on the postoperative visual quality and patient satisfaction comprehensively.\u003c/p\u003e "},{"header":"Patients and Methods","content":"\u003cp\u003e This retrospective study included 31 consecutive patients undergoing Q-value-guided FS-LASIK with monovision at the Peking University Third Hospital (Beijing, China) between Jan. 2023 and Sep. 2023. The study was approved by the ethics committee of the Peking University Third Hospital and adhered to the tenets of the Declaration of Helsinki. All participants were thoroughly informed before written consent was obtained.\u003c/p\u003e\u003cp\u003eThe inclusion criteria were as follows: age between 40 and 50 years, stable refractive error (≤ 0.5 D change per year in refractive error in the past 2 years), spherical equivalent (SE) of -6.0 D or higher, and astigmatism of up to -3.0 D. The exclusion criteria were as follows: patients with a history of refractive or corneal surgery, suspicion of keratectasia, visually significant cataracts or other pre-existing ocular diseases, any significant abnormality in binocular visual function.\u003c/p\u003e\u003cp\u003ePreoperative assessments\u003c/p\u003e\u003cp\u003eAll patients underwent comprehensive ocular examinations, including uncorrected and corrected distance visual acuity (UDVA, CDVA) evaluated in the logarithm of the minimum angle of resolution (logMAR), subjective manifest and cycloplegic objective refraction, noncontact intraocular pressure (NIDEK Co., Ltd), standard slit-lamp evaluation (IM 900, Köniz), dilated fundus examination, and corneal tomography (Pentacam, Oculus). Ocular dominance was determined using the pinhole test[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Corneal asphericity (Q factor), higher-order aberrations (HOAs) of anterior corneal surface within the central 6-mm region, and retinal image quality (the Strehl ratio, SR), were determined using the Sirius (Costruzione Strumenti Oftalmici, Florence, Italy) tomography instrument. Root mean square (RMS) values for the total amount of HOAs, astigmatism, spherical aberration, and coma were automatically calculated through Fourier transformation.\u003c/p\u003e\u003cp\u003eThe necessary addition (NA) for reading Parinaud 2 at 40 cm distance was obtained using the “minimal addition” method[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. The \"minus lens method\" measured accommodative amplitude (AA), and positive and negative relative accommodation (PRA and NRA), were evaluated by phoropter as the patients viewed a high-contrast target at 40 cm with full near correction[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. The actual accommodation parameters were calculated by subtracting NA added before testing[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eSurgical Technique\u003c/p\u003e\u003cp\u003eFS-LASIK procedures were performed by a highly experienced surgeon (YG Chen) using the FS-200 femtosecond laser and WaveLight EX500 excimer laser (Alcon Laboratories, Inc.) under topical anesthesia. In all cases, an 8.5 to 9.0 mm diameter superior 50-degree hinged corneal flap with a 90-degree side-cut and 110 µm thickness was dissected. Following blunt dissection and flap lift, the stromal photoablation was performed with a 6.5-mm optical zone and 1.25-mm transition zone using Q-value-guided (F-CAT) treatment option. Preoperative Q Values were measured using the WaveLight Topolyzer Vario instrument (Alcon Laboratories, Inc), reflecting the distribution of characteristics of corneal curvature within 30° of the central cornea. For the dominant eye, the target refraction was set at emmetropia, and for the non-dominant eye, the refractive target was set to slight myopia between − 0.25 D and − 0.50 D, according to the age and requirements of patients[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. No adjustment was made for Q value. Postoperatively, all the eyes received treatment with 0.1% fluorometholone (FML, Allergan, Inc., Irvine, CA, United States) in tapering dose for 4 weeks, 0.5% levofloxacin (Cravit, Santen, Inc., Japan) four times a day for 2 weeks and lubricating drops four times a day for 4 weeks.\u003c/p\u003e\u003cp\u003ePostoperative assessments\u003c/p\u003e\u003cp\u003eFollow-up visits included postoperative days 1 and 7, months 1 and 3. Results at the 3-month follow-up were included for data analysis in this study. The monocular and binocular UDVA, CDVA, refractive status, corneal asphericity, objective image quality, and accommodation function were measured in the same manner as pre-operatively. The uncorrected intermediate and near visual acuity (UIVA, UNVA) were measured at 80 cm and 40 cm distances. Defocus curves from − 3.0 D to + 1.0 D in increments of 0.5 D were obtained by phoropter binocularly. Visual acuity was converted into logMAR scale from the decimal notation for data analysis.\u003c/p\u003e\u003cp\u003eContrast sensitivity measured with CSV-1000E (Vector Vision) was evaluated binocularly under photopic (85 cd/m\u003csup\u003e2\u003c/sup\u003e) and mesopic (3 cd/m\u003csup\u003e2\u003c/sup\u003e) conditions at four spatial frequencies (3.0, 6.0, 12.0, and 18.0 cpd), and outcomes were recorded in log unit[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eStereopsis was measured using the Yan’s stereoscopic test. Distance stereoacuity was determined using the synoptophore, and near stereoacuity was measured at a standard viewing distance of 40 cm[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Results were classified as follows: stereoacuity greater than or equal to 60 s of arc (central stereopsis); stereoacuity ranged between 80 and 200 s of arc (macular stereopsis); stereoacuity ranged between 300 to 800 s of arc (peripheral stereopsis); and stereoacuity above 800 s of arc (stereo blindness)[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eFor comparison, patients with myopic diopter in the non-dominant eye postoperatively were asked to have all binocular tests performed twice, once in monovision condition without spectacles, and once with the residual myopia in the non-dominant eye corrected with spectacles (reverting monovision to full distance correction), serving as control group.\u003c/p\u003e\u003cp\u003eAt last, all patients were asked to fill out a questionnaire including their perception of near-visual ability (satisfaction with near visual acuity and reading spectacle independence) and visual disturbance. The second part includes 8 common complaints after refractive surgery: glare, halos, starbursts, blurred vision, monocular diplopia, fluctuation in vision, focusing difficulty, and difficulty judging depth perception. The incidence and severity of respective symptoms were recorded.\u003c/p\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\u003cp\u003eAll statistical analyses were performed using SPSS Statistics for Windows (version 22.0., IBM Corp.). The normality of data was assessed by histogram frequency analysis and the Shapiro-Wilks test. Data were expressed as mean ± standard deviation (SD). The paired samples \u003cem\u003et\u003c/em\u003e-test and the independent samples \u003cem\u003et\u003c/em\u003e-test were performed on normally distributed data, and the Wilcoxon rank-sum test and the Mann–Whitney U-test were performed on non-normally distributed data. The Fisher exact probability test was used for comparisons of categorical variables. P value less than 0.05 was considered statistically significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe study comprised 31 patients (62 eyes). The mean age of the 19 women (61.29%) and 12 men (38.71%) was 42.58\u0026thinsp;\u0026plusmn;\u0026thinsp;3.06 (SD) years (range 40 to 50 years), and the mean addition for binocular near vision was 0.34\u0026thinsp;\u0026plusmn;\u0026thinsp;0.46 D. Supplemental Table 1 shows the preoperative characteristics in dominant eyes and nondominant eyes by group.\u003c/p\u003e\n\u003cp\u003eEfficacy, Accuracy and Safety\u003c/p\u003e\n\u003cp\u003eAt the 3-month follow-up, the mean UDVA was \u0026minus;\u0026thinsp;0.07\u0026thinsp;\u0026plusmn;\u0026thinsp;0.08 in the dominant eye, with a mean residual spherical equivalent (SE) defect of 0.01\u0026thinsp;\u0026plusmn;\u0026thinsp;0.33 D (range: -0.75 to 0.63 D). In the nondominant eye, the UDVA was \u0026minus;\u0026thinsp;0.01\u0026thinsp;\u0026plusmn;\u0026thinsp;0.09, with a mean residual SE defect of -0.38\u0026thinsp;\u0026plusmn;\u0026thinsp;0.36 D (range: 0.13 to -1.00 D).\u003c/p\u003e\n\u003cp\u003eFigure \u003cspan\u003e1\u003c/span\u003e shows the standard graphs for reporting outcomes of refractive surgery in dominant eye. The accuracy of the achieved spherical equivalent compared to the intended target was within \u0026plusmn;\u0026thinsp;1.00 D in all (100%) dominant eye treated, whereas 90% of eyes were within \u0026plusmn;\u0026thinsp;0.50 D (Fig. \u003cspan\u003e1\u003c/span\u003eD).\u003c/p\u003e\n\u003cp\u003eAll surgeries were uneventful, with no infection, inflammation, or intraoperative complications noted in any of the patients enrolled in the study. No eyes lost lines of CDVA at 3 months post-surgery.\u003c/p\u003e\n\u003cp\u003eBinocular visual acuity and defocus curves\u003c/p\u003e\n\u003cp\u003eFor all patients, the mean postoperative uncorrected binocular visual acuity at distance, intermediate, and near was \u0026minus;\u0026thinsp;0.11\u0026thinsp;\u0026plusmn;\u0026thinsp;0.07 logMAR, -0.06\u0026thinsp;\u0026plusmn;\u0026thinsp;0.10 logMAR, and 0.04\u0026thinsp;\u0026plusmn;\u0026thinsp;0.11 logMAR separately. The binocular defocus curve is shown in Fig. \u003cspan\u003e2\u003c/span\u003eA. Regarding the defocus range from 0 D to \u0026ndash; 2.50 D (from far to near distance of 40 cm), the mean uncorrected visual acuity was maintained above 20/25.\u003c/p\u003e\n\u003cp\u003eAfter surgery, 7 patients showed emmetropia status and 2 showed hyperopia status in the non-dominant eye, and there were 2 patients refused to repeat binocular tests with spectacles. Eventually, only 20 patients had residual myopia in the non-dominant eye corrected with spectacles and serving as control group. Postoperative binocular visual outcome in monovision compared to full distance correction are shown in Table \u003cspan\u003e1\u003c/span\u003e. The two groups had comparable mean binocular UINA. For the distant visual acuity, better outcome was achieved in the full distance correction group (P\u0026thinsp;=\u0026thinsp;0.02); for the near visual acuity at 40cm, superior result was observed in the monovision group instead (P\u0026thinsp;=\u0026thinsp;0.04). Similarly, as shown in Fig. \u003cspan\u003e2\u003c/span\u003eB, patients in the monovision group showed significant better results regarding the defocus range from \u0026ndash; 2.00 D to \u0026ndash; 3.00 D (corresponding to a distance range of 50\u0026ndash;33 cm).\u003c/p\u003e\n\u003cdiv align=\"char\"\u003e\u003cbr\u003e\u003c/div\u003e\u0026nbsp;\u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 1\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eComparison of binocular visual acuity between monovision and full distance correction\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eMonovision (n\u0026thinsp;=\u0026thinsp;20)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eFull Distance Correction (n\u0026thinsp;=\u0026thinsp;20)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eRange\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eRange\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUDVA (LogMAR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-0.07 \u0026plusmn;\u0026nbsp;0.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0, -0.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-0.10 \u0026plusmn;\u0026nbsp;0.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-0.08, -0.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.02\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUIVA (LogMAR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-0.03 \u0026plusmn;\u0026nbsp;0.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-0.20, 0.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-0.04 \u0026plusmn;\u0026nbsp;0.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.10, -0.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.68\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUNVA (LogMAR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.07 \u0026plusmn;\u0026nbsp;0.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-0.10, 0.40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.12 \u0026plusmn;\u0026nbsp;0.19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-0.10, 0.70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.04\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\"\u003eUDVA\u0026thinsp;=\u0026thinsp;uncorrected distance visual acuity; UIVA\u0026thinsp;=\u0026thinsp;uncorrected intermediate visual acuity; UNVA\u0026thinsp;=\u0026thinsp;uncorrected near visual acuity;\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cp\u003eAll values are presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation; The Wilcoxon rank-sum test was used to compare differences between the two groups\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e*\u003c/sup\u003e statistically significance\u003c/p\u003e\n\u003cp\u003eCorneal Asphericity, Aberrations, and Image Quality\u003c/p\u003e\n\u003cp\u003eCorneal asphericity and objective image quality before and after treatment are summarized in Table \u003cspan\u003e2\u003c/span\u003e. Compared to preoperative measurements, postoperative examinations showed corneal asphericity was more positive in both dominant eyes and non-dominant eyes (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). The RMS of total HOAs, coma and SA significantly increased after the surgery (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05) when measured over a 6mm pupil. However, the SR value did not show statistically significant changes due to the surgery.\u003c/p\u003e\u0026nbsp;\u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 2\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003ePreoperative and postoperative corneal asphericity, aberrations, and objective image quality (6mm)\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eParameters\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003eDominant Eye (n\u0026thinsp;=\u0026thinsp;31)\u003c/p\u003e\n \u003cp\u003e(Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003eNondominant Eye (n\u0026thinsp;=\u0026thinsp;31)\u003c/p\u003e\n \u003cp\u003e(Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePreop\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePostop\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePreop\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePostop\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQ value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-0.15 \u0026plusmn;\u0026nbsp;0.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.46 \u0026plusmn;\u0026nbsp;0.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-0.15 \u0026plusmn;\u0026nbsp;0.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.63 \u0026plusmn;\u0026nbsp;0.55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTotal HOAs (\u0026micro;m)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.47 \u0026plusmn;\u0026nbsp;0.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.94 \u0026plusmn;\u0026nbsp;0.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.46 \u0026plusmn;\u0026nbsp;0.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.92 \u0026plusmn;\u0026nbsp;0.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSA (\u0026micro;m)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.25 \u0026plusmn;\u0026nbsp;0.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.56 \u0026plusmn;\u0026nbsp;0.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.25 \u0026plusmn;\u0026nbsp;0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.59 \u0026plusmn;\u0026nbsp;0.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eComa (\u0026micro;m)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.23 \u0026plusmn;\u0026nbsp;0.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.61 \u0026plusmn;\u0026nbsp;0.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.23 \u0026plusmn;\u0026nbsp;0.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.55 \u0026plusmn;\u0026nbsp;0.31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.13 \u0026plusmn;\u0026nbsp;0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.15 \u0026plusmn;\u0026nbsp;0.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.15 \u0026plusmn;\u0026nbsp;0.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.14 \u0026plusmn;\u0026nbsp;0.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.50\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\"\u003eHOAs\u0026thinsp;=\u0026thinsp;higher-order aberrations; SA\u0026thinsp;=\u0026thinsp;spherical aberration; SR\u0026thinsp;=\u0026thinsp;strehl ratio; preop\u0026thinsp;=\u0026thinsp;preoperative; postop\u0026thinsp;=\u0026thinsp;postoperative\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cp\u003eAll values are presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation; The Wilcoxon rank-sum test was used to compare differences before and after the operation.\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e*\u003c/sup\u003e statistically significance\u003c/p\u003e\n\u003cp\u003eBinocular accommodation function\u003c/p\u003e\n\u003cp\u003eTable \u003cspan\u003e3\u003c/span\u003e shows the results of the assessment of binocular accommodation function. The postoperative NRA was on average about 0.71 D higher than the preoperative value (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), but binocular minus-lens-stimulated AA and PRA did not show any statistically significant changes before and after surgery.\u003c/p\u003e\n\u003cdiv\u003e\u0026nbsp;\u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 3\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003ePreoperative and postoperative accommodation function\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eParameters\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003ePreop (n\u0026thinsp;=\u0026thinsp;31)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003ePostop (n\u0026thinsp;=\u0026thinsp;31)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eRange\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eRange\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAA (D)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.91 \u0026plusmn;\u0026nbsp;1.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.50, 6.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.58 \u0026plusmn;\u0026nbsp;0.91\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.50, 5.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.08\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNRA (D)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.70 \u0026plusmn;\u0026nbsp;0.52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.50, 2.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.41 \u0026plusmn;\u0026nbsp;0.49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.50, 3.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePRA (D)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-1.41 \u0026plusmn;\u0026nbsp;1.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0, -4.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-1.08 \u0026plusmn;\u0026nbsp;0.91\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0, -3.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.08\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\"\u003eAA\u0026thinsp;=\u0026thinsp;accommodative amplitude; NRA\u0026thinsp;=\u0026thinsp;negative relative accommodation; PRA\u0026thinsp;=\u0026thinsp;positive relative accommodation; preop\u0026thinsp;=\u0026thinsp;preoperative; postop\u0026thinsp;=\u0026thinsp;postoperative;\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eAll values are presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation; P values for comparations before and after the operation of NRA was calculated by paired samples t-test. The Wilcoxon rank-sum test was used to compare differences of AA and PRA before and after the operation.\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e*\u003c/sup\u003e statistically significance\u003c/p\u003e\n\u003cp\u003eBinocular Contrast Sensitivity and Stereoacuity\u003c/p\u003e\n\u003cp\u003eThere were 17 patients showed myopia status in the non-dominant eye after surgery and were willing to have contrast sensitivity and stereoacuity test performed twice. Postoperative binocular contrast sensitivity measurements in the monovision and full distance correction groups at 3, 6, 12, and 18 cpd under photopic and mesopic conditions with and without glare stimuli are shown in Supplemental Fig.\u0026nbsp;1. Compared to the logarithmic scale, contrast sensitivity was generally reduced with monovision compared to binocular full distance correction in most test conditions. This reduction was only of statistically significant at low spatial frequency of 6.0 cpd under photopic and mesopic conditions (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05 for all comparisons).\u003c/p\u003e\n\u003cp\u003eThe binocular distance and near stereoacuity are shown in Supplemental Table 2. Stereoacuity decreased slightly with monovision compared to full distance correction, but the noted differences were not statistically significant (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e\n\u003cp\u003eThe results of stereoacuity were categorized as follows: stereoacuity better than or equal to 60 s of arc (central stereopsis); stereoacuity in the range of 80 to 200 s of arc (macular stereopsis); stereoacuity in the range of 300 to 800 s of arc (peripheral stereopsis); and either stereoacuity equal or above 800 s of arc (stereo blindness).\u003c/p\u003e\n\u003cp\u003eThe Fisher exact probability test was used for comparisons of categorical variables.\u003c/p\u003e\n\u003cp\u003eSubjective Visual Quality and Near Visual Ability\u003c/p\u003e\n\u003cp\u003eFor the near visual ability, 6 patients (19.35%) were fully satisfied with their near visual acuity, 23 patients (74.19%) were moderately satisfied, and the remaining 2 patients (6.45%) were not very satisfied; 24 patients (70.97%) reported that they never required to wear reading glasses while reading or doing close work, 6 patients (19.35%) needed reading glasses in few cases, and only 1 patient (3.23%) needed reading glasses in most cases.\u003c/p\u003e\n\u003cp\u003eSupplemental Table\u0026nbsp;3 shows patients\u0026rsquo; perception of visual disturbance. The three most commonly reported visual symptoms after surgery were blurred vision, glare, and halos with the cumulative number of 20 patients (64.52%), 19 patients (61.29%), and 19 patients (61.29%), respectively, reporting these symptoms \u0026ldquo;occasionally,\u0026rdquo; \u0026ldquo;often,\u0026rdquo; or \u0026ldquo;usually\u0026rdquo;. Besides, subjective problems with depth perception had been found in only 4 patients (12.90%), which was considered closely related to reduction in stereoacuity, and no one considered them severely bothering.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eResults of the study demonstrated that monovision procedure was safe and effective for the treatment of high myopia combined with age-related accommodative deficiency. Binocular vision, which is considered of great clinical significance and simulates better in daily tasks than monocular vision, as patients always function under binocular conditions[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e], was satisfying at whole course 3 months postoperatively. All patients achieved 20/20 or better UDVA, 20/30 or better UIVA, and 20/50 or better UNVA. There were 27 (87.10%) patients achieving unaided far, intermediate, and near visual acuity of 20/25 or better simultaneously. Results of subjective questionnaire were also well related to the functional visual acuity, that the satisfaction rate of unaided near vision was found to be upwards of 94%, and full-distance spectacle independence has also been largely achieved.\u003c/p\u003e \u003cp\u003eIn the current study, a significant mild reduction in the binocular near vision was observed with full distance correction (wearing spectacles in the non-dominant eye) compared to mini-monovision, and although there was a decrease in distance vision with mini-monovision condition, the difference may fail to achieve clinical significance. This further indicates that mini-monovision enables better results for near work while maintaining good uncorrected distance visual function for this subset of patients.\u003c/p\u003e \u003cp\u003eThis study also focuses on binocular visual function. It has been theoretically proven that the abrupt emmetropization with myopic refractive surgery increases the accommodation and convergence demands for near suddenly[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. The binocular function would be hence more altered in high myopia, which raises our concerns of binocular vision impairment or apparent asthenopia in this population with standard physiological function of eye tissue already degraded to some extent[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Regarding accommodation function, the AA and PRA was unaltered, and we even observed a relatively small preoperative NRA that increased after surgery surprisingly. Possible reasons could include the following. Firstly, it has been found that the accommodation demand for myopes is generally lower than in emmetropes owing to the presence of the spectacle vertex distance (the distance between the lens's inner surface and the cornea's vertex) and prism effect of concave lens[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], which also interacted with convergence demand and leads to reduced accommodative convergence accordingly. Studies have shown that myopes with spectacles tended to have increased exophoria deviation when viewing a near target, especially in those with high myopia[\u003cspan additionalcitationids=\"CR24\" citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. As a result, the myopic eye may end up using more of its fusional convergence to maintain binocular single vision. Postoperatively, the accommodation demands increased, inducing more convergence demands and thus less exophoria[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. A previous study also reported that significant decline of exophoria was observed after FS-LASIK, when compared to preoperative exophoria with the corrected lens[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. When adding positive lenses in front of both eyes to relax accommodation, the accommodative convergence decreased, and fusional convergence, which had been heavily used preoperatively, had to further increased to maintain binocular function, thus the preoperative NRA was significantly lower in comparison. Additionally, the increased needs for physiological binocular function might has a training effect on muscles control capability of the brain, thus making binocular function more efficient and coordinated. Moreover, in a state of myopia, people favored near-work activities and putting muscles under high tension for long periods. After the refractive error was corrected, the eye\u0026rsquo;s far point was away from the corneal plane, which helps significantly in relaxing tensed muscles.\u003c/p\u003e \u003cp\u003eRegarding the optical visual quality, the corneal HOAs at 6 mm pupil increased significantly, which aligned with the principle of myopia correction. Besides, attenuation of contrast sensitivity and reduction of stereopsis were thought to be the major disadvantage associated with monovision[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. In this study, we also found a slight reduction in binocular contrast sensitivity and stereopsis, compared to the full distance correction. However, the optical quality measured on retinal plane did not show significantly worse performance, and the subjective visual function in real-life scenarios did not worsen. These good results may be partly due to the mild myopic refraction targeted in our series[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Moreover, it should be noted that postoperative visual quality also was strongly related to laser platform and ablation profiles used in this procedure, which cannot be generalized to others with different ablation protocol. In our study, a Q-value-guided profile with WaveLight EX500 excimer laser system was used for treatment, in which the Q factor was adjusted intending to better preserve the original prolate shape of cornea, resulting in fewer surgically induced HOAs within the suitable range and resulted in no severe adverse effects on visual quality, as well as better conservation of cornea thickness[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. There are also other lasers available, such as the SCHWIND Amaris laser, with different ablation model and geometric modelling, thus postoperative visual quality cannot be predicted.\u003c/p\u003e \u003cp\u003eIn this study, patients at the early stage of presbyopia were included[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e], and the mean age was relatively younger compared with relevant studies. One reason was that, as the median age would reach 40 years by 2050 under the backdrop of an ageing global population[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e], it is expected that the number of patients aged around 40 years seeking for refractive surgery will continue to grow. Besides, most patients at this age made the firm choice to choose monovision protocol after being fully informed, rather than full correction in our clinical experience.\u003c/p\u003e \u003cp\u003eIn this study, major limitation is the lack of a control group (for example, the binocular full distance correction). Besides, we focused only on accommodation function, and attention should be paid to other aspects of binocular visual function, such as the aggregation function.\u003c/p\u003e \u003cp\u003eIn conclusion, FS-LASIK with mini-monovision appeared to be safe and effective in treating high myopia combined with age-related accommodation insufficiency to get satisfying visual quality at distant and at near.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eAA= accommodative amplitude, CDVA= corrected distance visual acuity, HOAs= higher-order aberrations, NRA= negative relative accommodation, PRA= positive relative accommodation, RMS= root mean square, SE= spherical equivalent, SR= Strehl ratio, UDVA= uncorrected distance visual acuity, UIVA= uncorrected intermediate visual acuity, UNVA= uncorrected near visual acuity, FS-LASIK= femtosecond laser-assisted in situ keratomileusis,\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eDisclosures:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNone of the authors has a financial or proprietary interest in any material or method mentioned.\u003c/p\u003e\n\u003cp\u003eSupported by a grant from The Key Clinical Innovation Program of Peking University Third Hospital, Category A (Grant No. Y65495-05).\u003c/p\u003e\n\u003cp\u003eThis study adhered to the tenets of the Declaration of Helsinki and received approval from the Ethics Committee of Peking University Third Hospital. Informed consent was obtained from each subject.\u003c/p\u003e\n\u003cp\u003eConsent for publication: Not applicable\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials: All data generated or analysed during this study are included in this published article.\u003c/p\u003e\n\u003cp\u003eCompeting interests: None of the authors has a financial or proprietary interest in any material or method mentioned.\u003c/p\u003e\n\u003cp\u003eFunding: Supported by a grant from The Key Clinical Innovation Program of Peking University Third Hospital, Category A (Grant No. Y65495-05).\u003c/p\u003e\n\u003cp\u003eAuthors\u0026apos; contributions: Ruiyu Zhang, Yifei Yuan and Yu Zhang participated in the design of the study, Ruiyu Zhang performed the statistical analysis and revised the manuscripts. Yueguo Chen conceived of the study, and participated in its design and coordination and helped to draft the manuscript. All authors read and approved the final manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAcknowledgements: Not applicable\u003c/p\u003e\n"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eKollbaum PS, Bradley A: \u003cstrong\u003eCorrection of presbyopia: old problems with old (and new) solutions\u003c/strong\u003e. \u003cem\u003eClinical \u0026amp; Experimental Optometry \u003c/em\u003e2020, \u003cstrong\u003e103\u003c/strong\u003e(1):21-30.\u003c/li\u003e\n\u003cli\u003eKatz JA, Karpecki PM, Dorca A, Chiva-Razavi S, Floyd H, Barnes E, Wuttke M, Donnenfeld E: \u003cstrong\u003ePresbyopia - A Review of Current Treatment Options and Emerging Therapies\u003c/strong\u003e. \u003cem\u003eClinical Ophthalmology (Auckland, NZ) \u003c/em\u003e2021, \u003cstrong\u003e15\u003c/strong\u003e:2167-2178.\u003c/li\u003e\n\u003cli\u003eGarcia-Gonzalez M, Teus MA, Hernandez-Verdejo JL: \u003cstrong\u003eVisual outcomes of LASIK-induced monovision in myopic patients with 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\u003cstrong\u003e68\u003c/strong\u003e:124-143.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-ophthalmology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"boph","sideBox":"Learn more about [BMC Ophthalmology](http://bmcophthalmol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/boph","title":"BMC Ophthalmology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"visual quality, mini-monovision FS-LASIK, high myopia, age-related accommodative deficiency","lastPublishedDoi":"10.21203/rs.3.rs-4269833/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4269833/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eTo evaluate clinical outcomes and visual quality 3 months after mini-monovision femtosecond laser-assisted in situ keratomileusis (FS-LASIK) for correction of high myopia in patients with age-related accommodation deficiency.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003ePatients who had mini-monovision FS-LASIK for high myopia (spherical equivalent [SE] \u0026lt; -6.0 D) and aged between 40 and 50 years were included. At the 3-month postoperative visit, we evaluated full range of visual acuity; defocus curve; optical quality; accommodation function, contrast sensitivity and stereopsis. Binocular tests were done twice, once in mini-monovision condition and once with the residual myopia in the non-dominant eye corrected. Subjective visual quality was evaluated with questionnaire.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eClinical data of 31 cases were analyzed. The average patient age was 42.58\u0026thinsp;\u0026plusmn;\u0026thinsp;3.06 years. At the 3-month follow-up, the mean uncorrected binocular visual acuity at distance, intermediate, and near was \u0026minus;\u0026thinsp;0.11\u0026thinsp;\u0026plusmn;\u0026thinsp;0.07, -0.06\u0026thinsp;\u0026plusmn;\u0026thinsp;0.10, and 0.04\u0026thinsp;\u0026plusmn;\u0026thinsp;0.11 logMAR separately. In comparison, full distance correction group achieved better UDVA (P\u0026thinsp;=\u0026thinsp;0.02), and the monovision group achieved superior UNVA (P\u0026thinsp;=\u0026thinsp;0.04). FS-LASIK induced significant increases in higher-order aberrations (HOAs) (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). For accommodative function, only the negative relative accommodation (NRA) improved significantly after surgery (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). A slight decrease in contrast sensitivity was observed at low spatial frequency with monovision (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Questionnaire demonstrated high satisfaction with near vision and visual quality.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eFS-LASIK with mini-monovision appeared to be safe and effective in treating high myopia combined with age-related accommodation deficiency to get satisfying visual quality at distant and at near.\u003c/p\u003e","manuscriptTitle":"Full range of vision and visual quality after mini-monovision FS-LASIK in high myopic patients with age-related accommodative deficiency","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-04-25 16:46:49","doi":"10.21203/rs.3.rs-4269833/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-04-25T12:10:44+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-04-18T03:40:27+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-04-18T03:40:27+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Ophthalmology","date":"2024-04-15T12:46:47+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-ophthalmology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"boph","sideBox":"Learn more about [BMC Ophthalmology](http://bmcophthalmol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/boph","title":"BMC Ophthalmology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c9f441da-4457-4498-8e75-c8b3e8854e3c","owner":[],"postedDate":"April 25th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-10-07T16:00:58+00:00","versionOfRecord":{"articleIdentity":"rs-4269833","link":"https://doi.org/10.1186/s12886-024-03698-x","journal":{"identity":"bmc-ophthalmology","isVorOnly":false,"title":"BMC Ophthalmology"},"publishedOn":"2024-09-30 15:57:16","publishedOnDateReadable":"September 30th, 2024"},"versionCreatedAt":"2024-04-25 16:46:49","video":"","vorDoi":"10.1186/s12886-024-03698-x","vorDoiUrl":"https://doi.org/10.1186/s12886-024-03698-x","workflowStages":[]},"version":"v1","identity":"rs-4269833","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4269833","identity":"rs-4269833","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}