For certain cataract patients, implanting two different IOLs during surgery — called the “mix-and-match” approach — can result in optimal outcomes. It can provide patients a wide range of independence in their vision and a personalized approach. “All lenses have inherent weakness,” says Mark Kontos, MD, senior partner and ophthalmic surgeon at Empire Eye Physicians in Spokane, Wash. “By using lenses in combination, we try to neutralize the weakness of one lens with the strength of a different one. This personalized approach can create a more seamless vision progression from distance to near, which is what most patients desire.” He estimates he chooses mix-and-match for about 60% of his premium IOL patients.

Adds Margaret Liu, MD, ophthalmologist and CEO at San Francisco Eye Institute, within the Pacific Vision Eye Institute, “Patients appreciate the range of vision that can be achieved with this approach and the opportunity to customize their overall results after surgery to their first eye.”

But not every patient is a good candidate for this approach. Surgeons need to consider a variety of factors, including a patient’s refractive, medical and surgical history; personality and lifestyle; and their eyes’ health, anatomy and dominance, says Dr. Liu.

MIX-AND-MATCH: THE PROCESS AND CONSIDERATIONS

First, check off the usual criteria

When identifying patients who are suitable for mix-and-match, those interviewed recommend surgeons first follow the usual criteria for choosing a specific IOL for a patient:

• Ask patients about their activities and hobbies to understand what range of vision is their greatest priority, Dr. Kontos says.
• In addition to a complete dilated exam, including refraction, evaluating preferred reading distance, pupil size and dominance, all cataract consults receive biometry, topography and OCT macula testing, Dr. Liu says.
• Factor in other conditions that affect lens selection, such as astigmatism or ocular surface disease, Dr. Kontos says.
• Have a thorough conversation with patients about their expectations. “Some patients might think that they’ll never have to wear glasses again, which might not be realistic given today’s technologies,” says Dr. Kontos. “It’s important to ensure that we’re both on the same page regarding what’s possible.”
• When a patient has cataracts in both eyes, Dr. Liu develops a plan for both eyes, such as the mix-and-match approach, before the first surgery. “However, during the same conversation, it is important to highlight the opportunity to modify the plan based on the patient’s results from the first surgery,” she says. She estimates she opts for mix-and-match for less than 10% of patients.

Good and bad candidates

Ideal candidates for the mix-and-match approach to IOLs are patients who otherwise have healthy eyes; have a strong desire for a wider range of uncorrected vision; are accepting of having two different IOLs and therefore different vision in each eye; and feel that the cost of a premium IOL and risks — such as glare, halos and not achieving target range of vision — are worth the chance for decreased dependence on glasses or contact lenses.

“Patients who have undergone cataract surgery in one eye with a premium IOL but didn’t achieve a satisfactory range of vision are often very interested and are likely strong candidates for the mix-and-match approach,” Dr. Liu says.

In addition to patients who are not interested in spectacle independence, other poor candidates have medical contraindications such as significant dry eye disease, macular degeneration, epiretinal membranes or advanced glaucoma, notes Dr. Liu.

Individuals who have had prior refractive surgery, such as photorefractive keratectomy or LASIK surgery — which left them with an irregular cornea or irregular astigmatism — usually aren’t good candidates either. “Their quality of vision may not be what they expect,” says Dr. Kontos.

According to Dr. Liu, if a patient is absolutely satisfied with their range of vision achieved after their first cataract surgery, they will strongly consider using the same IOL in the fellow eye instead of the mix-and-match approach.

“A physician should give each patient about 3 weeks to evaluate their first eye after cataract surgery to see if they really love their choice,” says Ahad Mahootchi, MD, surgeon-in-chief at The Eye Clinic of Florida in Zephyrhills.

As for potential downsides

Dr. Kontos reports that some patients and surgeons are concerned about whether having a different lens in each eye will be problematic, such as possible differences in overall quality of vision in each eye or the magnitude of nighttime disturbances. Although this has not been his experience in practice, it could be a potential barrier to acceptance.

In addition, all presbyopia-correcting lenses create some vision challenges, such as seeing glare or halos. Quality of vision overall issues — say, objects not being as sharp or clear as desired — can also occur, Dr. Kontos says. This can happen regardless of whether a lens is paired with a different lens or it’s used bilaterally.

Here’s a look at nine tried-and-true options to use in the mix-and-match approach to IOLs.

THE MIX-AND-MATCH MENU

1. PanOptix (Alcon)

This lens’ advantages include offering the best near performance of any presbyopia-correcting IOL, Dr. Mahootchi says. Compared to other IOLs, it has fewer unwanted side effects and offers refractive predictability, he adds, and provides very good intermediate and distance vision.

The PanOptix lens “does a good job of delivering near vision at short distances, making it a good choice for shorter patients,” he says. Dr. Mahootchi explains that shorter people tend to hold objects closer to their eyes than taller people.

On the downside, he notes, this lens has unwanted side effects such as glare, rings around lights, starburst around lights and reduced contrast sensitivity in dim light that can be unexpected and hard to simulate pre-op. “It’s disadvantageous to only be able to describe these symptoms and not be able to demonstrate them to patients,” Dr. Mahootchi explains.

Furthermore, Dr. Liu says some patients may still require readers with this lens, especially in dim lighting.

2. Restor +2.5 with Active Focus (Alcon)

This lens offers good distance and intermediate vision but has limited near vision. It works best when implanted in the dominant eye, Dr. Liu says. In her experience, patients do well when this IOL is matched with a Restor +3.0.

3. Restor +3.0 (Alcon)

Although this IOL offers good distance and near vision, it provides limited intermediate vision. It works best when implanted in the non-dominant eye for patients desiring strong near vision with a theoretical near distance of 40 cm (15.74 inches), Dr. Liu says. This lens is best paired with a Restor +2.5 with Active Focus lens.

4. TECNIS Multifocal +2.75 (J&J Vision)

According to Dr. Liu, this lens provides good distance and intermediate vision but limited near vision. It should be implanted in the dominant eye. She finds that patients do well when this IOL is matched with a TECNIS Multifocal +3.25 or +4.00.

5. TECNIS Symfony (J&J Vision)

The Symfony IOL provides excellent intermediate and distance vision but is not as strong for near vision. It will lessen some issues that patients have had with multifocal lenses, such as nighttime glare. Unlike other presbyopia-correcting IOLs, this lens can be used successfully in certain patients who have had prior refractive surgery, Dr. Kontos says.

A good partner for this lens is a TECNIS Multifocal, which offers three different powers to choose. “When these two lenses are used together, patients can achieve excellent vision at all distances,” Dr. Kontos says. One option is TECNIS Multifocal +3.25, which has a stronger reading component. “This is a great choice for someone who does close work like needlepoint; they’re also able to see a computer or smartphone clearly,” he explains.

6. TECNIS Multifocal +3.25 (J&J Vision)

This lens also offers good distance and near vision but limited intermediate vision, according to Dr. Liu. She says it works best when implanted in the non-dominant eye for patients desiring strong near vision with a theoretical near distance of 42 cm. This IOL is best paired with a TECNIS Symfony or TECNIS Multifocal +2.75 lens.

7. TECNIS Multifocal +4.00 (J&J Vision)

On the upside, this IOL also offers good distance and near vision; however, intermediate vision is limited. It is best to implant it in the non-dominant eye and ideal for patients desiring strong near vision with a theoretical near distance of 33 cm, Dr. Liu says. This lens pairs well with a TECNIS Symfony or TECNIS multifocal +2.75 lens.

8. Crystalens/Trulign (Bausch + Lomb)

“These lenses offers excellent distance and intermediate vision and don’t have any undesirable nighttime visual phenomenon,” Dr. Mahootchi says. “Near vision is fairly good, but even better if made -0.75 in the non-dominant eye. It is very well tolerated, even if conditions such as AMD, glaucoma, dry eye or mild corneal problems coexist or develop in the future,” he continues.

Furthermore, this lens’ material clarity holds up for the long term — it doesn’t become less clear with time, unlike some IOLs that have had many published cases of glistenings and opacity.

On the downside, near vision is 20/30 to 20/40 for many patients if their refraction is plano. If a patient takes pain or psychiatric medicine, their ability to focus from distance to near may be diminished, according to Smith and Buncic (https://uwpress.wisc.edu/journals/pdfs/AOJ_49_178.pdf ).

In addition, this lens is less commonly available in higher amounts of astigmatism (more than two diopters).

Dr. Mahootchi recommends this lens for patients who have pathology, have low cylinder requirements and desire to see well when driving at night. It also works well for tall patients because they have longer arms and usually hold near reading material farther out — almost at an intermediate distance where all lenses work well.

This lens pairs well with PanOptix in the non-dominant eye since Crystalens/Trulign work well in night-driving conditions, Dr. Mahootchi notes.

9. Envista and Envista Toric (Bausch + Lomb)

These two B+L offerings are very tolerant of imperfections in refractive outcomes. “That quality seems to result in very good intermediate vision and distance vision most of the time,” Dr. Mahootchi says. These lenses treat lower severities of astigmatism than other monofocal lenses. Their limitations are that they are not true presbyopia-correcting IOLs.

The lenses pair well with almost any lens but work particularly well with Crystalens/Trulign and Panoptix. The difference between the eyes isn’t as noticeable with these combinations, Dr. Mahootchi says.

LESSONS LEARNED

The mix-and-match approach allows surgeons a second opportunity in the fellow eye to improve the overall range of the patient’s vision after cataract surgery.

“Aim to underpromise and overdeliver,” Dr. Liu says. “When using the mix-and-match method, choose lenses from within the same family of IOLs for the best complementary pair and be sure to match the color of the IOLs to decrease the differences noted between the two eyes.” OM