Optimizing Visual Performance with EDOF IOLs: Why Clareon Vivity is My Personal Choice

In my practice, many cataract patients come to me seeking freedom from spectacles. That spectacle independence is delivered by providing patients with an enhanced range of vision - but how do we reach that extended range of vision? The answer lies in identifying the right intraocular lens (IOL) option for each of our patients.

While diffractive IOLs can provide vision at the near, intermediate and distance ranges, they are not suitable for all cataract patients. Patients with underlying eye diseases, such as glaucoma or macular degeneration, or those who are extremely sensitive about the potential for visual disturbances such as glare and halos, may not be ideal candidates for diffractive multifocal or trifocal lenses.

Thanks to ongoing IOL innovations, I now have the option of recommending a non-diffractive presbyopia-correcting IOL (PCIOL) design¹ - particularly an extended depth of focus (EDOF) IOL - to more of my patients. The Clareon^® Vivity^® extended vision IOL provides excellent distance and intermediate vision, with functional near vision and a consistent low visual disturbance profile.^2-4,#

My initial interest in Clareon^® Vivity^® was driven by the experience and outcomes I had with Clareon^® PanOptix^®, so I was eager to explore Alcon’s innovation. Over the years, I have evaluated numerous EDOF lenses, and I have collected mesopic and photopic defocus curve data, along with contrast sensitivity data from the Function Vision Analyzer (Stereo Optical Company). I find visual acuity, contrast sensitivity, and the level of visual disturbances are the best predictors of patient satisfaction with an EDOF IOL.

With their combination of benefits, it is no surprise that EDOF IOLs are the fastest growing category of PCIOL in the world.⁵ My experience with EDOF IOLs, including newer technologies, has led me to make Clareon^® Vivity^® my lens of choice. I find it consistently delivers outstanding visual quality, low rates of visual disturbances, and reliable results in real-world use.⁴

Evaluating EDOF Options and Selecting the Right Option for Your Practice and Patients

The Alcon AcrySof^® IQ Vivity^® IOL was launched in early 2020 as an extended depth of focus (EDOF) IOL. It achieves its EDOF designation through a revolutionary wavefront shaping optical design (X-Wave™ technology)¹. Numerous clinical studies have demonstrated that it exceeds the published ANSI and ISO standards for EDOF IOLs.^2-4,6-7 The Vivity^® lens has become the most-implanted EDOF lens in the world, with more than 2 million implants at the time of publication.^5†

When the TECNIS PureSee* IOL (Johnson & Johnson) became available in my practice, I implanted several lenses to collect outcomes data. This allowed me to compare my clinical experience with the lens in my practice to the Clareon^® Vivity^® IOL. Results from my assessment were presented at the most recent meeting of the Asia-Pacific Association of Cataract and Refractive Surgeons.⁸ Results have been peer-reviewed and published.⁹

The mean binocular defocus curve, measured three months postoperatively, is shown in Figure 1. With the exception of the -1.0 D vergence (p = 0.072), the Vivity^® IOL showed different values of binocular visual acuity from vergences of +0.50 D to -2.00 D (+0.50 D: -0.00 logMAR; 0.00 D: -0.10 logMAR; -0.50 D: -0.00 logMAR; -1.00 D: 0.08 logMAR; -1.50 D: 0.15 logMAR; -2.00 D: 0.25 logMAR) the most critical range for EDOF lenses (corresponding to expected distance and intermediate vision). The Vivity^® IOL showed strong binocular visual acuity across the whole range^8-9.

Figure 1: Comparative photopic binocular defocus curves of the Clareon^® Vivity^® and TECNIS PureSee^* IOLs, measured three months postoperatively.
N=34 (17 patients in each binocular cohort displayed); pairwise comparisons at each defocus

Monocular contrast sensitivity data measured one month postoperatively is shown in Figure 2. Both Clareon^® Vivity^® and PureSee* performed strong at all measured spatial frequency, including higher frequencies^8-9,º.

Figure 2: Photopic monocular contrast sensitivity 1 month postoperative (n = 53 eyes in each group)
Abbreviations: cpd - cycles per degree

The Impact of Decentration and Visual Disturbances

While clinical data remain the primary source of evidence, bench testing can provide additional insights into how IOL design may influence the likelihood of visual disturbances—particularly under slight decentration, a common clinical occurrence. Laubichler et al calculated a mean crystalline lens decentration of 0.2 mm, and they suggest that decentrations of up to 0.3 mm represent normal physiological variation. They also estimated that about 5% of eyes would have a lens decentration greater than 0.4 mm.¹⁰

The TECNIS PureSee* IOL is marketed as a refractive EDOF IOL designed to maintain a monofocal-like dysphotopsia profile utilizing refractive optics similar to that of the earlier TECNIS Eyhance* monofocal IOL. Both lenses include asphericity on the anterior surface, which is augmented in the case of the Eyhance lens to increase depth of focus. The PureSee* lens does not include this additional asphericity but adds a continuous change of power on its posterior surface.¹¹

The specific posterior surface design is proprietary. Early in 2025, the Journal of Refractive Surgery published bench data showing that the measured effective power of PureSee* increases relatively uniformly from the center of the lens in a radially symmetrical fashion, peaking over 3.0 D above the nominal power of the IOL at a radius approximately 0.9mm from the center of the lens.¹²

A power analysis of the Clareon^® Vivity^® IOL published in Graefe's Archive for Clinical and Experimental Ophthalmology shows several peaks and troughs over about a 1.1 mm radius from the center of the lens.¹³ This is achieved through the combination of a slightly elevated plateau (≈1 µm in height), with a small curvature change across the entire 2.2-mm central optic—allowing nearly 100% of the incoming light energy to be used.

Images of the PureSee* and Vivity^® IOLs were captured at the same magnification under similar lighting conditions as part of my assessment. The results are shown in Figure 3. The relative height change on the surface of the PureSee* lens appears more pronounced and more concentrated, forming a single annulus—in contrast to the broader elevation profile of the Clareon^® Vivity^® IOL.

Figure 3. Magnified image of the PureSee* and Vivity^® IOLs

The left side of Figure 4 shows results from imaging a point source through each IOL. The images were obtained by mounting the IOLs in a model eye with 0.28 μm of corneal spherical aberration and an external pupil, scaled to provide a 4.5 mm effective aperture at the IOL plane.¹⁴ In this test method, bench testing showed that when centered, both PureSee* (top left image) and Vivity^® IOLs (bottom left) produced halos of similar magnitude. However, the PureSee* IOL exhibited discernible concentric rings, while the Vivity^® IOL did not. Both lenses were well centered in the optical system.

Figure 4. Comparison of halos from the Vivity^® (bottom) and PureSee^* (top) EDOF lens, centered (left) and decentered by 0.5 mm (right). Based on bench testing.

Decentration and tilt are known to affect lens performance and can be impacted by optical design.¹⁵

To investigate further the limits of the optics of the lenses, a second image, with the lenses decentered by 0.5 mm, was captured. The right side of Figure 4 shows the results of decentering the PureSee* and Vivity^® IOLs by 0.5 mm. Under 0.5 mm decentration, the PureSee* IOL (top right) displayed a distinctive asymmetric flare in the halo pattern, suggesting a directional light scatter consistent with coma. This effect was not observed with the Vivity^® IOL (bottom right), which maintained a more uniform halo profile. It appears that the PureSee* halo becomes asymmetric when decentered, while the Vivity^® halo remains relatively unaffected by decentration. The difference in behavior on decentration is attributed to the differences in optical design of the two IOLs.¹⁴

The bench testing above suggests that PureSee* optics may be more sensitive to producing visual disturbances. Further clinical studies would be needed to explore this effect further. These findings are important to me because it is nearly impossible to implant a lens with no decentration on the optical axis. The IOL is generally centered in the capsular bag, and as noted above the mean decentration of the crystalline lens in the eye’s optical system is about 0.2 μm, but with some variability. The levels of decentration noted here are consistent with my clinical experience.

Given that perfect centration is difficult to achieve in real-world surgical settings, this sensitivity of the PureSee* lens to decentration is worth exploring in terms of clinically relevant limitations¹⁴. Data from a recent randomized, masked, clinical trial of the PureSee* lens indicated that 12% of subjects (7/60) reported halos more often than ‘sometimes’¹¹.

Given the sensitivity of refractive EDOF designs like PureSee* to lens alignment, the clinical relevance of this characteristic should be evaluated further. Bench testing results for the two EDOF IOLs here suggest some modest differences in optical performance¹⁴. My clinical results, and patient feedback, also show modest differences between the IOLs. For me, the Clareon^® Vivity^® provides reliable, consistent results and high patient satisfaction - key reasons why it remains my EDOF IOL of choice.