There are nearly 2 billion people living with presbyopia globally,1,2 many of whom are now candidates for cataract surgery. At the 2021 ASCRS Annual Meeting in Las Vegas, a panel of experts gathered to discuss the latest presbyopia-mitigating IOL technology from Alcon. Kerry Solomon, MD, moderated the session and was joined by Iqbal Ike K. Ahmed, MD, FRCSC; T. Hunter Newsom, MD; Sheri Rowen, MD, FACS; and Zarmeena Vendal, MD, to discuss when and where they used the AcrySof IQ PanOptix® and AcrySof IQ Vivity™ IOLs, as well as the results they are seeing in their practices.
Dr. Solomon: Alcon has a portfolio that meets the needs of most cataract patients looking for a presbyopia solution. The Vivity™ IOL utilizes a unique non-diffractive wavefront shaping optical design to provide an extended range of vision from distance to functional near with a monofocal-like visual disturbance profile.3 The FDA study showed that patients bilaterally implanted with Vivity™ IOLs (emmetropia targeted) achieved 20/20 at distance, >20/25 at intermediate (66 cm), and 20/32 at near (40 cm). For my patients who want to be able to see distance, intermediate, and some near, while maintaining limited nighttime vision disturbances, the Vivity™ IOL really provides that. An even greater freedom from spectacles is going to be possible with the PanOptix® IOL. This trifocal IOL utilizes the diffractive optical design, ENLIGHTEN Technology,4 and demonstrates excellent vision (20/25 or better) over quite a wide range, from as close as 33 cm out to distance vision (Figure 1).5 The PanOptix® lens may be associated with some night vision dysphotopsias and may not be ideal for patients with some comorbidities.6
How Do You Select the Best IOL for Your Patients?
Dr. Ahmed: My first goal is always for my patients to achieve freedom from spectacles when possible. I think that is truly life-changing and enhances their quality of life, so I’m first checking to see if the patient is a good candidate for a full range of vision lens, like the PanOptix® IOL. If they are not a candidate, perhaps because they have comorbidities or there is a particular concern about night vision disturbances, then I try to enhance their range of vision as much as possible and move to the Vivity™ IOL. Vivity™ has really filled a nice role in my practice with those patients who I would have had to give a monofocal, but now can give them a greater range of vision.
Dr. Solomon: What are some of the comorbidities that you might take into consideration when you are deciding which lens to offer a patient?
Dr. Rowen: I first assess any concomitant conditions that may affect potential acuity aside from the cataract. In my experience, there are a few conditions that make me consider a non-diffractive EDOF over a diffractive trifocal. For example, a patient with good visual potential but also an epiretinal membrane would be a nice patient for the Vivity™ IOL, and a patient who may have an irregular cornea, but who I thought could still have good vision, would also be a Vivity™ candidate. You really want a healthy cornea and macula to use diffractive IOL technology like the PanOptix® IOL. I would also not consider diffractive IOLs like PanOptix® in a patient with advanced glaucoma.
Dr. Solomon: The Vivity™ IOL is in the category of an extended depth-of-focus (EDOF) IOL. Do you find that the night vision profile of the non-diffractive Vivity™ is similar to other diffractive EDOF lenses?
Dr. Ahmed: EDOF IOLs are not classified based on dysphotopsias, so that makes this an interesting question. We have used some diffractive EDOF lenses that had dysphotopsia concerns,7 so we were a bit skeptical at first with the Vivity™ IOL. I personally watch my patients very closely and ask them pointed questions about their results. After 18 months of using this lens, I can say I have been very pleasantly surprised to find that Vivity™ has a visual disturbance profile very much like a monofocal IOL. I feel very confident telling my patients that.
Dr. Vendal: This EDOF lens is completely different than other diffractive lenses I have used in the past since it isn’t splitting light. My patients report good visual outcomes and a monofocal-like visual disturbances profile. I am able to offer it to a much wider range of patients as a result, which has been very exciting.
Dr. Solomon: To summarize, the PanOptix® IOL is great for patients who desire spectacle independence. It gives excellent near, intermediate, and distance vision with a high level of spectacle freedom. However, patients do have to be able to tolerate some visual disturbances. In contrast, the Vivity™ IOL gives patients great distance and intermediate vision and provides functional near vision with a monofocal-like visual disturbances profile.
CASE No. 1
55-year-old Female Teacher With Bilateral Cataracts
- Wants the best near vision (Doesn’t want to wear glasses to grade tests)
- Wants to be able to see faces well in the back of the class
- Uses the computer throughout the day
- Extensive discussion about night driving; prefers near vision
Dr. Newsom: The goal for this patient was really to give her as much near vision as we could, given her daily life, hence my recommendation for the PanOptix® IOL.
Dr. Solomon: A common question is how to target when you are planning your surgeries. What do you target with the PanOptix® IOL?
Dr. Rowen: Using an A-constant of 119.1, I target plano to first minus with PanOptix®.
Dr. Newsom: In my experience with many diffractive IOLs, you start to get more nighttime issues with more myopic residual refractive error. I target PanOptix® between plano and +0.25 D.
Dr. Ahmed: With full range lenses, we want to help our patients have great near and intermediate vision, but we also want to retain that excellent distance vision. With some IOLs, we get a great range of vision but perhaps that comes at the expense of distance vision, maybe related to its tougher landing zone. One thing I noticed with the PanOptix® IOL is that patients do have great distance vision from day 1. To me, this is an important distinction. I am doing the same as Dr. Newsom and targeting plano to maybe the first hyperopic result, but not targeting more than +0.25 D.
Dr. Solomon: I target closest to plano for PanOptix® using my personalized lens constant. Please note, because site-specific biometers and surgeon-specific surgical techniques may result in differences in the effective lens position in each individual patient, it is highly recommended to obtain our own personalized lens constant for a given IOL to reach high refractive accuracy.
Dr. Solomon: In this case, you’ve mentioned long discussions about night driving. What has your experience been with night vision and driving in patients who receive the PanOptix® IOL?
Dr. Vendal: In my practice, after carefully selecting our PanOptix® patients and providing education on potential postoperative visual phenomena, most patients are happy with the outcome; the number of self-reported night vision issues, such as bothersome halo, is low. Residual astigmatism and corneal irregularities are other factors that may contribute to patient dissatisfaction.8 Taking care of these helps to minimize postoperative complaints.
Dr. Solomon: I like to let my diffractive IOL patients know in advance they may notice some rings and halos at night so that they are not surprised, but I also reassure them that the percent of patients who are really bothered and being affected in their daily activities is low.6 If a patient is hesitant about that, I recommend other options such as Vivity™ instead of PanOptix®.
Dr. Rowen: Any time you use a diffractive multifocal IOL, you have to prepare yourself that there will be one or two patients per year that may be unhappy, most often related to halo, and you will have to do an exchange. I am very comfortable knowing that most patients who experience visual disturbances immediately after diffractive multifocal IOL surgeries will improve with time on severity and bothersomeness.9,10 It’s only in rare cases where patients say they just can’t see, then I will remove the diffractive multifocal IOL. With Vivity™, I can now offer them another presbyopia-mitigating option that has a monofocal-like visual disturbances profile and gives them excellent distance and intermediate vision, as well as functional near.
Dr. Ahmed: I want to emphasize here that between the PanOptix® and Vivity™ lenses, the better range of vision is possible with the PanOptix® lens, and I like to go with that first and foremost. It’s worth having the extra discussion with your patients about the value of the range versus the potential risk and impact of halos and glare. Patient selection is everything, and while these lenses are complementary, they really have different roles in meeting patient expectations.
Dr. Solomon: The emphasis here should be on the preoperative discussion. If we educate our patients properly, they are going to make a great decision. I don’t shy away from PanOptix®. I get great results, my patients are happy, and I see high rates of spectacle independence. Dr. Vendal, you mentioned that you really need to nail the astigmatism. How are you measuring astigmatism specifically, and what do you do if you have residual refractive error?
Dr. Vendal: If we are going to be in the premium lens market, we have to start by fixing the ocular surface and making sure our biometry, including keratometry, readings are precise. Next, we use interoperative aberrometry in addition to preoperative biometry measurements to help verify our IOL power calculation and IOL positioning intra-operatively. Every tool does help to improve refractive outcomes. We choose to use a toric IOL as soon as the magnitude of astigmatism is high enough to warrant a toric IOL, especially if it is against-the-rule cylinder.
Dr. Solomon: If someone has residual refractive error, are you performing PRK or LASIK after PanOptix®?
Dr. Rowen: We do either LASIK or PRK (preferably LASIK). Managing any post-cataract surgery residual refractive error with LASIK or PRK can be a useful tool in those rare cases of refractive surprises with PCIOLs, or even when minor touch-ups are necessary based on the patient’s subjective feedback on distance vision.11
Dr. Ahmed: Sometimes if a preoperative IOL calculation predicts low-level residual astigmatism, I like to use either a femtosecond arcuate incision and open them up as I need to postoperatively, or create limbal relaxing incisions postoperatively under the slit lamp. I find that using these techniques for refining the refractive correction is very helpful. I personally like to get my patients to be less than 0.5 D of residual astigmatism with these lenses.
Dr. Newsom: This patient functioned great at all distances without glasses after bilateral PanOptix® implantation and is very happy.
CASE No. 2
65-year-old Retired Business Owner
- Enjoys playing golf
- Uses the computer for social activities
- OK to wear readers occasionally
Dr. Newsom: The distance vision this patient has with the Vivity™ IOL is excellent. He is able to play golf, and he has 20/20- vision at intermediate, allowing him to do most of the things he wants to do without glasses. He does notice that for very near tasks, such as reading medicine bottles, he needs to use readers. But he has no significant complaints of glare or halo, and he has distance vision performance very similar to what I’d expect from a monofocal IOL, but with great intermediate vision as well. That is the strength of the Vivity™ lens.
Dr. Ahmed: People often say they are okay with readers, but if you push them a bit and tell them you can get them out of readers while maybe having some halos and glare, you can possibly take them to the next step and show them the possibilities of the PanOptix® IOL. If they really don’t want to take any chance with halo and glare, then I agree, you stick with the Vivity™ IOL as the preferred IOL. And this is a great example of the classic Vivity™ result.
Dr. Rowen: This is a golfer, which is interesting because reading the subtleties of the greens and course is really important to avid players. The Vivity™ has monofocal-like results at distance plus intermediate vision, but in my opinion this patient could have been a candidate for either lens since they didn’t express any existing issues with nighttime visual performance.
CASE No. 3
42-year-old Hispanic Male
- Well-controlled type 2 diabetic cataract patient
- Very active
- Works full time, spends a lot of time on the computer
- Wants all glare to be gone, especially at night
Dr. Vendal: This case highlights the decision making we face with our younger patients all the time. How do you deliver excellent vision to a young cataract patient who is only minimally presbyopic and expecting to be able to do a lot of computer work without glasses even after cataract surgery? This is always a scenario that makes us a little nervous. The fact that this patient specifically mentioned being concerned with glare, especially at night, is something that stood out. Now, with both eyes open, this young cataract patient sees exceptionally well at distance and intermediate and has functional near vision. He is very happy with the Vivity™ lens, the range of vision he gained, and the improvement in glare and halo.
Dr. Ahmed: We have a patient who has clearly said that he is currently having a glare problem and doesn’t want any glare. In addition, he is a young diabetic patient. Even if the retina is currently normal, it may progress in the future. I am careful with that when making an IOL recommendation. If it is an older patient who has later-onset diabetes, my concern is lower, but a younger patient can unfortunately end up with progressive retinopathy if there are any changes in the effectiveness of their diabetes managment. In addition, he was a smoker, which is another risk factor. Historically, I probably would have given this patient monovision with monofocal IOLs to provide some range of vision. That has changed now with the Vivity™ lens, as it consistently provides an extended range of vision from distance to functional near with a monofocal-like visual disturbances profile. As we’ve all probably experienced, my monofocal monovision rates dropped tremendously after the introduction of Vivity™ because we now have an excellent alternative to monovision with monofocal IOLs based on providing binocular correction.
Dr. Solomon: In the past we have attempted blended or mini-monovision with a diffractive EDOF to extend the range of vision.12 Bala et al13 reported a small cohort of Vivity patients with minimonovision outcomes, that showed slightly extended range of vision without any increased visual disturbances profile compared to a fully emmetropia targeted study population. Some of you have done some studies on minimonovision too. What can you tell us about these studies?
Dr. Newsom: In our study reported at ASCRS 2021, we were targeting -0.75 ± 0.50 D offset in the non-dominant eye, and the sweet spot ended up being the -0.50 D to -0.75 D range.14 We found that patients may give up a few letters in the distance acuity, but they really get a big binocular visual acuity gain up close (> 1 line). About 80% were spectacle free. They may have had lower near vision performance than they would have had with the PanOptix®, but they were extremely happy and had a very low visual disturbance profile.
Dr. Rowen: I have been using the same mini-monovision target for my patients, and most don’t notice the offset in their distance vision because you are giving them good distance in their dominant eye and because of the broad depth of field overlap between the eyes. In addition, these patients report monofocal-like night visual disturbance complaints.15 We could never achieve such an excellent range of vision with monofocal monovision in so many patients, since the offset power typically needs to be higher to provide functional near vision, often resulting in the breakdown of suppression. Now, we are getting J3 easily, often J2 and even J1 in some patients binocularly at near while maintaining distance vision performance.16
Dr. Solomon: I take this same approach, and I find it essential to inform patients in advance that this is what we are doing to give them more range of vision. They know they will have to let their brain adapt. I have the occasional patient who tells me it won’t work for them since they will constantly compare the monocular performance of the two eyes. It is important to educate patients before surgery that their eyes are meant to work together to help avoid the eye comparisons. Although I predominantly have success with Vivity™ mini-monovision, I had one patient at -0.50 D in one eye who was dissatisfied, so we did a LASIK touch-up and now she is very happy. So, issues are not common, but I do think patients need to be part of the conversation.
Dr. Newsom: The following two cases show the use of varying levels of monovision in different patient types.
67-year-old Real Estate Agent
- Frequently drives, mostly during the day
- Extensive computer use for work
- High desire to reduce use of glasses
Dr. Newsom: This is a case where we targeted slight myopia in the non-dominant eye, and binocularly the patient is functioning well at distance and near without glasses except for the smallest print. His visual disturbance profile was similar to my plano-targeted patients and the FDA study results.
Dr. Solomon: This is a great result. This is a patient for whom I likely would have recommended a PanOptix® IOL. It sounds like he was really motivated to be spectacle free, and only a small amount of PanOptix® patients complain about bothersome visual disturbances.
Dr. Rowen: I’ve had a lot of real estate agents for whom I’ve gone with PanOptix® because they are reading small print contracts and they aren’t usually showing houses at night. So, I agree with you, I would have recommended PanOptix® here. The beautiful thing is you got an amazing result with Vivity™ mini-monovision.
Dr. Ahmed: One thing offsetting the Vivity™ does is really allows people to read their cellphones without using super large font size. That is a task that is more functionally near than intermediate.
CASE No. 5
67-year-old Retired, Active Female
- Not a Type A personality
- No history of monovision
- Would like to reduce use of glasses
- High desire for good near vision
Dr. Newsom: This is a patient who could have been a PanOptix® candidate, but we really wanted to push the boundaries of offsetting the Vivity™ lens. We see that the non-dominant eye postop spherical equivalent is -1.13 D. The distance vision starts to drop off (20/50), but the near vision is improved (20/20, J1+) and the patient is happy with her binocular vision. The patient is functioning well at all distances. Although she is aware of the difference between the two eyes, it is not bothering her. Her visual disturbances profile remained similar to my plano-targeted patients.
Dr. Vendal: From day 1 of using Vivity™ in our practice, our Vivity™ patients have been considered for mini-monovision. In so doing, we have seen postoperative refractions of -0.50 D to -1.25 D in the non-dominant eye. We have found that the sweet spot for getting great functional near vision is somewhere between -0.50 D and -0.75 D in the non-dominant eye. We haven’t targeted anyone beyond -1.00 D. For patients who are not looking for this level of near vision or who don’t want too much compromise to distance vision in either eye, we aim for -0.50 D in the non-dominant eye.
Dr. Solomon: Let’s talk more about the patient who already has monovision contacts or monovision LASIK and now is ready for cataract surgery. I have noticed that most patients who already had monovision had distance vision of 20/50, 20/80, sometimes even 20/100 in the non-dominant eye. When I performed cataract surgery prior to having access to the Vivity™ lens, I would tend to set offset at -1.75 D with monofocal IOLs. While most patients adapt to that, I occasionally had patients tell me their eyes didn’t seem to work as well. Have you had a similar experience?
Dr. Vendal: Definitely. That was the impetus for us to take prior monovision patients and talk to them about Vivity™ as the lens of choice for mini-monovision. We rarely see an issue with adjusting to the visual disparity in these patients as the non-dominant eye is only -0.50 to -0.75.
Dr. Rowen: A lot of previous monovision patients will tell you they are happy, but then if you really pull it out of them, they realize their distance vision isn’t as good as they would like it to be. That’s when I bring in PanOptix® or Vivity™ and tell them I can give them a lens that will allow them to see up close like they are used to, but will also give them great distance vision in both eyes.
Dr. Ahmed: I agree. That is exactly why we rarely use monofocal monovision. Patients still like the idea of mini-monovision with Vivity™ because they feel like you are not changing too much, but then they are also benefitting from the reasons we’ve just mentioned. I think no matter where you sit, whether you’ve used the Vivity™ IOL or not, it is truly a revolutionary technology. It does take some experience to appreciate that this is the real deal. I’ve been in practice for a while, and I don’t like to use this phrase a lot, but this is truly game-changing technology.
CASE No. 6
74-year-old Active White Male
- Retired traveler and tennis player
- Does not want to use glasses for computer or sports
- Diagnosed with mild primary open-angle glaucoma (POAG) for the first time at the cataract surgery evaluation*
*The safety and efficacy of Vivity™ or PanOptix® has not been established in patients with glaucoma. Sound clinical judgment should be used before implanting Vivity™ or PanOptix® in these patients.
Dr. Vendal: This cataract patient was diagnosed with mild open-angle glaucoma with cup/disc asymmetry, mild OCT changes at retinal nerve fiber layer (RNFL), and a little bit of early peripheral visual field loss in the right eye (Figures 2 and 3). In the past, this is someone who would not have had a good option to correct his intermediate and near vision with IOLs. However, in our practice for cases with mild glaucoma and peripheral visual field loss, we now consider using newer IOL technologies. The Vivity™ lens with -0.50 D offset provided good results, and he is very happy with his binocular vision. Also, his glaucoma is well-controlled with medication (Xelpros, Sun Ophthalmics, OU qhs). Thanks to the non-diffractive nature of this lens, this patient now walks away satisfied that he was able to take advantage of advanced technology even though he has glaucoma.
Dr. Ahmed: Let’s speak to the reasons why some surgeons are hesitant using a trifocal or multifocal IOL in a glaucoma patient, and it is primarily related to contrast sensitivity. It is true that even with early visual field damage there can be some loss of contrast. But if you look at the FDA trial of the PanOptix® compared to the SN60AT monofocal lens, there was no clinically meaningful difference in binocular contrast sensitivity.†6,17 For Vivity™, I think we can agree that it performs similar to the monofocal AcrySof IOL in terms of quality of vision and visual disturbances.3,13 That being said, I do agree with you that glaucoma can be progressive, and we want to maximize vision and do no harm. For me, this patient is a candidate for PanOptix® or Vivity™.* A 74-year-old with mild visual field damage is unlikely to become a progressive advanced glaucoma patient in their lifetime. If the patient had been a 45-year-old, given that I don’t know the rate of progression since only seeing him for the first time, I would be more cautious.
†Per PanOptix® DFU, a reduction in contrast sensitivity as compared to a monofocal IOL may be experienced by some patients and may be more prevalent in low lighting conditions. Therefore, patients implanted with multifocal IOLs should exercise caution when driving at night or in poor visibility conditions.
*The safety and efficacy of Vivity™ or PanOptix® has not been established in patients with glaucoma. Sound clinical judgment should be used before implanting Vivity™ or PanOptix® in these patients
Dr. Vendal: Another thing to point out is, as Dr. Newsom shared, this patient’s spherical equivalent in his left eye is -1.25 D, and yet he is not complaining of blurry vision at distance or halo. This case and others that I presented at ASCRS highlight that the Vivity™ IOL may be a viable choice for your borderline and mild well-controlled glaucoma patients. I think many more doctors will more readily go there because of the profile of this lens.
CASE No. 7
- History of myopic LASIK‡
- Wants clear distance vision, especially good nighttime driving vision (no increase in halos)
- OK with reading glasses but desires some near vision performance
- Family history of age-related macular degeneration (mother)
‡The safety and efficacy of Vivity™ or PanOptix® has not been established in patients with history of corneal refractive surgery. Sound clinical judgment should be used before implanting Vivity™ or PanOptix® in these patients.
Dr. Rowen: In patients with prior refractive surgery, it’s always a little bit more difficult to hit the refractive target. They also tend to be more demanding and have high expectations for their visual performance. This patient also had dry eye secondary to meibomian gland dysfunction (MGD). I started by performing eyelid thermal pulsation treatment and then put her on an anti-inflammatory immunomodulating eye drop until I felt that her ocular surface was stable and I could accurately and consistently get biometry data. Topography also showed her LASIK ablation was centered. This patient really did not want any risk of halos, but again, she expressed a desire for the best possible near vision. I targeted plano in her dominant eye, and she was J3 for near in that eye. By targeting -0.50 D in the non-dominant eye, she was J1 at near and able to achieve J1 OU.
Dr. Solomon: For these ‘want all’ post-refractive patients, what are the things you look for to see if they are even candidates for one of these lenses? To me, the ablation has to be centered, myopic, or hyperopic. What about astigmatism, especially those with any irregular astigmatism and higher order aberrations? What is your cutoff?
Dr. Ahmed: I don’t know if there’s a specific cutoff I have. Centration of the ablation is important, as is excluding ocular surface issues. From there, it’s very much a subjective assessment. I do look to see if the astigmatism is asymmetrical versus regular astigmatism. I don’t worry about symmetrical astigmatism at all with the Vivity™, and to be honest, I would use PanOptix® as well.‡
Dr. Solomon: I don’t think any of us would hesitate to put a monofocal IOL on a post-refractive patient, and it sounds like this panel is pretty comfortable considering implanting a Vivity™ lens, and even PanOptix® to some extent. I think the teaching point here is to be cautious and make sure the ablation is well centered.
CASE No. 8
63-year-old Post-LASIK Patient With Ocular Surface Pathology
- History of myopic LASIK in 2002; 20/15 immediately after LASIK and progressively became far-sighted‡
- Diagnosed with cataract, Salzmann’s nodular degeneration, and dry eye disease
- Wants to be spectacle independent
- Prior to cataract surgery, performed superficial keratectomy to remove Salzmann’s nodules and treated dry eye with Restasis (AbbVie/Allergan) and lid treatments
- Repeated topographies demonstrated improved ocular surface, and stable biometry measurements were collected afterwards
Dr. Rowen: This was another challenging post-refractive case with a patient asking for spectacle independence. I couldn’t perform cataract surgery on this patient without first taking care of the ocular surface pathology. After superficial keratectomy to remove Salzmann’s nodules and dry eye treatment with Restasis, her corneas were much improved and showed the nicely centered ablation without many higher order aberrations in either eye. I discussed and recommended the PanOptix® lens to the patient. The patient had a small amount of astigmatism, +0.85 D in the right eye and +0.26 D in the left eye. For the right eye, I picked PanOptix® and used the ORA System (Alcon). It did not recommend a toric lens, nor did I use arcuate incisions. The patient came out reporting spectacle independence for almost all tasks, minimal visual disturbances, and a high level of satisfaction with her visual quality. I maintained her on Restasis for the long-term management of her dry eye.
Dr. Ahmed: Examining the cornea is so critical, and admittedly, sometimes we all glance through it too quickly. Picking up ocular surface issues such as anterior basement membrane dystrophy is important for hitting the refractive target, as well as for dealing with potential issues postoperatively. The use of phototherapeutic keratectomy or superficial keratectomy is important in those patients. You saw a nice case of peripheral corneal degeneration that you managed well. I’m a big fan of that. Patients sometimes don’t like the delay, but I really reinforce the importance of taking care of the cornea and taking the time and doing cataract surgery right once.
Dr. Vendal: It’s also a good example of why sometimes surgeons may comment that they do not achieve good results with diffractive lenses. It is quite possible that they are not addressing these ocular surface issues or residual astigmatism.
CASE No. 9
58-year-old Male Truck Driver
- Uses his phone a lot and loves to read on his iPad
- Very motivated to not need glasses
- Very bothered by posterior subcapsular cataracts with glare, starbursts, and blurred vision
Dr. Ahmed: This is a relatively young patient, a truck driver who is motivated to have spectacle independence. His posterior subcapsular cataract was creating glare at night that was really bothering him. We routinely do macular OCT for all our cataract surgery patients to avoid missing subtle macular changes, and we found the presence of an epiretinal membrane (ERM)§ in his right eye (Figure 4). We also noticed that this patient had relatively large pupil size (5 mm). Corneal topography showed asymmetrical astigmatism and moderately high level of coma (0.74 µm horizontal, 0.85 µm vertical). This is the case many would not consider a candidate for a PCIOL due to ERM and the preop high order aberrations. However, I felt comfortable moving forward with this case since the axial maps were fairly regular, there were no areas of thinning in the pachymetry maps, and the overall magnitude of astigmatism was not high (Figure 5). As mentioned previously, many surgeons consider a high order aberrations cutoff of 0.5 µm.
§The safety and efficacy of Vivity™ has not been established in patients with retinal pathology such as ERM. Sound clinical judgment should be used before implanting Vivity™ in these patients.
Dr. Vendal: A diffractive lens is definitely not something I would consider for this patient. This could be a Vivity™ toric candidate for me. I would definitely counsel him on the difference between the two eyes because of the presence of ERM in the right eye.
Dr. Rowen: Vivity™ has performed very well for me in patients that have ERM.
Dr. Solomon: So for me, the presence of an epiretinal membrane alone is not an issue. The presence of some high order aberrations does concern me more. This is a commercial truck driver. I would put a monofocal toric lens in the right eye. If he’s uncomfortable with the quality of vision, I’d consider a topography-guided procedure afterward because you don’t know how symptomatic he’s going to be. I would also consider a Vivity™ IOL in his fellow eye if he wanted to be a little less dependent on glasses, at least to see his dashboard.
Dr. Ahmed: There is no question that utilizing a monofocal would not be a wrong choice, but this case has an opportunity to push the boundaries a bit with proper informed consent and a backup plan. Most likely he’s had the ERM for many years and has coped with compromised vision just fine. What is new are the posterior subcapsular cataracts and likely the night vision disturbances. The normal concern here would be quality of vision, and compared to a monofocal, there might be a numerical difference in contrast with the Vivity™. However, I feel comfortable with the slight difference that was found in the binocular contrast sensitivity studies13 and feel that it would not be clinically significant. With proper counseling, we did go with the Vivity™ and targeted plano in the dominant eye and -0.50 D in the non-dominant eye. We were fortunate in this case that his left eye is the dominant eye. He is very happy after surgery. He can read his iPad without glasses and is still driving trucks.
Dr. Solomon: These cases provide some clarity on the options. PanOptix® delivers the higher spectacle freedom, but there are going to be some night vision rings and halos that the vast majority of patients will tolerate with no issues. Vivity™ provides great vision at distance and intermediate, and if we do a little blended vision, you can slightly shift the depth of focus of the non-dominant eye toward near distance, and therefore, slightly extend the binocular range of vision. Patients are not quite as free from spectacles as with PanOptix®, but the night vision symptoms are similar to a monofocal IOL. The good news is we have strong options for our patients that not only allow them to have great quality of vision, but also enable them to be less dependent on glasses for most, if not all, of their activities.
1. Fricke TR, Tahhan N, Resnikoff S, et al. Global Prevalence of presbyopia and vision impairment from uncorrected presbyopia: Systematic review, meta-analysis and modelling. Ophthalmology. 2018;125(10):1492-1499.
2. Wolffsohn JS, Davies LN. Presbyopia: Effectiveness of correction strategies. Progress in Retinal and Eye Research. 68 (2019) 124–143.
3. AcrySofTM IQ VivityTM DFU.
4. Modi et al. Visual and Patient-Reported Outcomes of a Diffractive Trifocal Intraocular Lens Compared with Those of a Monofocal Intraocular Lens. Ophthalmology. 2021;128(2):197-207.
5. Maxwell, Martinez. Post-Operative Visual Outcomes with a Diffractive Trifocal Intraocular Lens: A Meta-Analysis of USA and Worldwide Patients. Presented at the Annual meeting of the ASCRS. Las Vegas, NV. July, 2021.
6. AcrySofTM IQ PanOptixTM DFU.
7. TECNIS Symfony DFU.
8. Schallhorn SC, Hettinger KA, Pelouskova M, et al. Effect of residual astigmatism on uncorrected visual acuity and patient satisfaction in pseudophakic patients. J Cataract Refract Surg. 2021;47(8):991-998.
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IMPORTANT PRODUCT INFORMATION - AcrySof® IQ PanOptix® and Vivity Family of IOLs
CAUTION: Federal (USA) law restricts this device to the sale by or on the order of a physician.
The AcrySof® IQ PanOptix® Trifocal IOL, AcrySof® IQ PanOptix® Toric, AcrySof® IQ Vivity™ Extended Vision IOL and AcrySof® IQ Vivity™ Toric IOLs are indicated for visual correction of aphakia in adult patients following cataract surgery. In addition, the AcrySof Toric IOLs are indicated to correct pre-existing corneal astigmatism at the time of cataract surgery. The AcrySof® IQ PanOptix® lens mitigates the effects of presbyopia by providing improved intermediate and near visual acuity, while maintaining comparable distance visual acuity with a reduced need for eyeglasses, compared to a monofocal IOL. The AcrySof® IQ Vivity™ lens mitigates the effects of presbyopia by providing an extended depth of focus. Compared to an aspheric monofocal IOL, the lens provides improved intermediate and near visual acuity, while maintaining comparable distance visual acuity. All of these IOLs are intended for placement in the capsular bag
WARNINGS/PRECAUTIONS: Careful preoperative evaluation and sound clinical judgment should be used by the surgeon to decide the risk/benefit ratio before implanting a lens in a patient with any of the conditions described in the Directions for Use labeling. Physicians should target emmetropia, and ensure that IOL centration is achieved.
For the PanOptix® Toric and Vivity™ IOLs, the lens should not be implanted if the posterior capsule is ruptured, if the zonules are damaged, or if a primary posterior capsulotomy is planned. Rotation can reduce astigmatic correction; if necessary lens repositioning should occur as early as possible prior to lens encapsulation.
For the AcrySof® IQ PanOptix® IOL, some visual effects may be expected due to the superposition of focused and unfocused multiple images. These may include some perceptions of halos or starbursts, as well as other visual symptoms. As with other multifocal IOLs, there is a possibility that visual symptoms may be significant enough that the patient will request explant of the multifocal IOL. A reduction in contrast sensitivity as compared to a monofocal IOL may be experienced by some patients and may be more prevalent in low lighting conditions. Therefore, patients implanted with multifocal IOLs should exercise caution when driving at night or in poor visibility conditions. Patients should be advised that unexpected outcomes could lead to continued spectacle dependence or the need for secondary surgical intervention (e.g., intraocular lens replacement or repositioning). As with other multifocal IOLs, patients may need glasses when reading small print or looking at small objects. Posterior capsule opacification (PCO), may significantly affect the vision of patients with multifocal IOLs sooner in its progression than patients with monofocal IOLs.
For the AcrySof® IQ Vivity™ IOL, most patients implanted with the Vivity™ IOL are likely to experience significant loss of contrast sensitivity as compared to a monofocal IOL. Therefore, it is essential that prospective patients be fully informed of this risk before giving their consent for implantation of the AcrySof® IQ Vivity™ IOL. In addition, patients should be warned that they will need to exercise caution when engaging in activities that require good vision in dimly lit environments, such as driving at night or in poor visibility conditions, especially in the presence of oncoming traffic. It is possible to experience very bothersome visual disturbances, significant enough that the patient could request explant of the IOL. In the AcrySof® IQ Vivity™ IOL clinical study, 1% to 2% of AcrySof® IQ Vivity™ IOL patients reported very bothersome starbursts, halos, blurred vision, or dark area visual disturbances; however, no explants were reported.
Prior to surgery, physicians should provide prospective patients with a copy of the Patient Information Brochure available from Alcon informing them of possible risks and benefits associated with these IOLs.
ATTENTION: Reference the Directions for Use labeling for each IOL for a complete listing of indications, warnings and precautions.