Visual Disturbances and Satisfaction After Multifocal IOL Implantation

Evaluation of Perception of Photic Phenomena Through Diffractive Multifocal Intraocular Lens Designs by Its Virtual Implantation 

Marx S, Fernandez J, Gerlach M, Schallhorn S, Sickenberger W¹

Industry support for this study: S.M., Employee (Jenvis Research), Research funding (Carl Zeiss Meditec); J.F., Employee (Indaloftal), Research funding (Carl Zeiss Meditec); M.G., Employee (Carl Zeiss Meditec); S.S., Employee and support (Carl Zeiss Meditec), Medical Advisory Board (Optical Express); W.S., Employee (Jenvis Research), Research funding (Carl Zeiss Meditec)

ABSTRACT SUMMARY

This prospective, crossover, double-masked study analyzed the difference in objective and subjective photic phenomena associated with the virtual implantation of three diffractive multifocal IOL designs: Tecnis Synergy (Johnson & Johnson Vision), AcrySof IQ PanOptix (Alcon), and AT ELANA (Carl Zeiss Meditec). The study was conducted at Jenvis Research Germany and involved 74 healthy participants who were 18 to 50 years of age without cataracts. Participants assessed photic phenomena using the VirtIOL device (10Lens),² which permitted them to look through each IOL as if it had been implanted. The size of the starburst pattern was measured in degrees, and subjective preferences were collected through pairwise comparisons of the IOLs under simulated nighttime conditions with glare. 

The starburst pattern was significantly larger with the Synergy (5.54 ±0.62º) than with the PanOptix (3.82 ±0.90º, P < .001) and AT ELANA (3.65 ±0.57º, P < .001). No significant differences in starburst pattern size were found between the PanOptix and AT ELANA lenses (P = .078). Additionally, no significant difference in the induced annular light pattern was found among the three IOLs (P > .05). In a pairwise short-term comparison, 82%, 37.4%, and 30.7% of participants preferred the AT ELANA, Synergy, and PanOptix lenses, respectively (P < .001). 

DISCUSSION

Diffractive presbyopia-correcting IOLs are widely used to increase patients’ spectacle independence by enabling simultaneous vision at multiple focal distances. Suboptimal visual acuity, decreased contrast sensitivity, and photic phenomena such as halos, glare, or starburst—especially under low light conditions—continue to be a problem with these IOLs.3,4 In the study by Marx and colleagues,¹ the Tecnis Synergy was associated with a larger starburst pattern than the other two lenses, which aligns with earlier study findings.5 Patients’ preference for the AT ELANA IOL¹ suggests that its design may mitigate some of the adverse visual effects associated with the Synergy, possibly due to its optical characteristics and light distribution properties. The potential limitations of this study include the requirement for controlled patient positioning during assessments and the influence of participant concentration on results.¹ Further investigation is necessary to confirm the results in clinical settings and elucidate the impact of IOL design on visual disturbances. 

Prevalence of Presbyopia-Correcting Intraocular Lens Satisfaction, Dissatisfaction, and Intolerance 

Susanna BN, Snider MJE, Hammoud B, Ferguson TJ, Randleman JB⁶

Industry support for this study: T.J.F., Consultant (Balance Ophthalmics, Glaukos, RxSight), Research support (Alcon, RxSight)

ABSTRACT SUMMARY

This retrospective cross-sectional study of consecutive patients who underwent surgery between 2017 and 2022 investigated the prevalence of patient satisfaction, dissatisfaction, and intolerance after presbyopia-correcting IOL implantation. The primary causes of patient dissatisfaction and the rate of spontaneous resolution of photic phenomena were also evaluated.

Of a total of 493 patients (970 eyes) analyzed, 87.2% reported satisfaction after IOL implantation. Various lens types were included: diffractive trifocal (PanOptix; 64.1%), diffractive extended depth of focus (Tecnis Symfony, Johnson & Johnson Vision; 19.3%), diffractive bifocal (AcrySof ReStor, Alcon; 3.4%), and nondiffractive extended depth of focus (Vivity, Alcon; 13.2%). 

No significant differences in patient satisfaction rates were observed across different lens types. Dissatisfaction was noted in 12.8% of patients, with 7.7% classified as intolerant of their lenses. The most common reasons for dissatisfaction included blurry corrected vision (73%) and photic phenomena (50.8%). Higher dissatisfaction was linked to greater than 0.50 D of residual sphere or cylinder. 

Photic phenomena were reported by 24.7% of patients at the initial stability visit, with a higher prevalence among dissatisfied patients. The study highlighted that neural adaptation may improve symptoms over time. About 42.9% of patients who reported photic phenomena at the initial stability visit experienced spontaneous resolution within a year, primarily between 6 and 12 months after surgery. In total, 2.4% of patients underwent an IOL exchange.

DISCUSSION

Presbyopia-correcting IOLs have become increasingly popular in refractive cataract surgery due to their potential to reduce patients’ spectacle dependence, but variability in patients’ postoperative satisfaction remains a critical concern. Dissatisfaction arises when visual disturbances interfere with patients’ daily activities. 

A substantial proportion of study participants reported satisfaction and functional visual improvement after receiving a presbyopia-correcting IOL, but blurry vision and photic phenomena caused dissatisfaction in 13%. 

Residual refractive error is a well-known cause of patient dissatisfaction with presbyopia-correcting IOLs.^7,8 Greater than 0.75 D of cylinder has been shown to impair both patients’ distance and near vision with these lenses.⁹

Studies using patient questionnaires have reported high rates of photic phenomena with presbyopia-correcting IOLs.¹⁰ In the study by Susanna et al,⁶ 43% of patients with photic phenomena in the early postoperative period experienced spontaneous resolution. This suggests that a waiting period of at least 6 months might allow for potential neural adaptation before an IOL exchange is considered.

Limitations of the study by Susanna et al included its retrospective design and the absence of standardized patient questionnaires, which limited the evaluation of subjective visual outcomes.⁶