Never before have surgeons had as many IOL choices as they do now. Beyond the sheer number of IOLs from different manufacturers, we now have distinct optical technologies that can be used to engineer unique solutions for our patients. Monofocal, monofocal-plus, pseudo-accommodating, multifocal, trifocal, extended depth of focus (EDOF) as well as diffractive, non-diffractive and toric versions of these IOLs abound in this expanding space. Moreover, it is possible to mix and match these IOLs to broaden the scope of our patient’s visual experience. Cataract consultations certainly haven’t been one-size-fits-all for some time, but today’s consultations are careful exercises in patient education and designing lasting visual solutions by leveraging the IOL technologies at hand.

Here, we’ll review the newest IOLs and briefly overview the familiar IOLs and how they may be utilized alongside these new technologies.

MONOFOCAL-PLUS IOL

Though categorized as a monofocal IOL, the Eyhance and Eyhance Toric IOL (Johnson & Johnson Vision) aim to provide a slight increase in depth-of-focus (Figure 1). FDA approved in February 2021, the Eyhance can be described as a monofocal-plus IOL that is essentially indistinguishable from its counterpart monofocal IOL, the ZCB00, in appearance. Distinct here is a continuous change in power from the periphery to the center of the lens, which creates a unique anterior surface that improves intermediate vision but maintains distance image quality comparable the ZCB00. Specifically, contrast sensitivity and photic phenomenon was comparable to the other monofocal IOLs — for larger pupil sizes, the Eyhance was found to have better contrast sensitivity than other contemporary monofocal IOLs. The Eyhance is available in a toric platform with the same squared and frosted haptics design available in the ZCU (Tecnis Toric II) platform, which provides excellent rotational stability. For surgeons comfortable with the familiar Tecnis platform (Johnson & Johnson Vision), the Eyhance is a natural addition to the armamentarium. The lens is only available in the United States on the preloaded Simplicity delivery system.

For patients wary of or unsuitable for diffractive IOLs’ potential for glare and halos, the Eyhance can provide around one line of improvement in the intermediate and near range, which is a key benefit. Utilizing this IOL for a blended-vision surgical design can provide especially effective outcomes with the potential to leave patients with only the need for OTC readers for smaller print. Incorporating this IOL into my practice has given me much greater confidence in the outcomes, particularly for my blended-vision and monovision patients.

NON-DIFFRACTIVE EDOF IOL

The first and only non-diffractive EDOF IOL, the Acrysof IQ Vivity (Alcon) was FDA approved in June 2020 (Figure 2). Available in toric versions and composed of hydrophobic acrylate/methacrylate copolymer with UV and blue light filtration, this IOL follows the release of Alcon’s PanOptix IOL and is the company’s latest offering.

The goal of the Vivity is to provide monofocal IOL-like distance vision, excellent intermediate vision at 26 inches and functional near vision at 17 inches. Given the IOL is non-diffractive, it achieves these goals without the burden of typical glare and halos by stretching and shifting the wavefront in two ways. First, a slightly elevated (~ 1µm), smooth plateau stretches the focal range. Second, a slight curvature change across the central 2.2-mm region shifts the wavefront to use all available light energy. As the dysphotopsia profile is similar to a monofocal and the IOL is pupil independent, the Vivity aims to provide crisp vision at distance and intermediate levels day and night.

We are often aware of patients who may be at risk for exaggerated dysphotopsias either by way of personality, large pupil size or lifestyle. I utilize this IOL for those patients who are happy to wear OTC readers for smaller print but cannot afford any measurable instance of glare and halo. Surgeons should take note that this IOL is not available under the power of 15 D, which is atypical and might exclude some moderate to high myopes.

Mixing and matching this IOL with the PanOptix is feasible, similar to mixing and matching a Tecnis Symfony (diffractive EDOF) with a Tecnis Multifocal IOL (Johnson & Johnson Vision). This can provide improved near vision but reduced risk for glare and halo when the Vivity is implanted in the dominant eye. I avoid cross-mixing these IOLs as the IOL material and color differ across the Tecnis and Acrysof platforms and have distinct aging characteristics.

TRIFOCAL IOL

Approved in 2019, the PanOptix IOL from Alcon is the only trifocal available in the US market and available in toric versions. Unlike diffractive EDOF IOLs, which excel primarily in distance and intermediate range vision leaving a need for OTC readers for micro-near, the PanOptix aims to provide all three visual zones: near at 16 inches, intermediate at 24 inches and distance, achieving a high degree of spectacle independence. Light allocation by way of redistribution of the intermediate focal point to distance and a third focal point at near provides a wide range of vision, and patients are generally satisfied with their unaided near vision.

An advantage of bilateral implantation of the PanOptix is visual summation as, unlike mix/match IOL surgical designs, each eye can be set for emmetropia. Similar to other diffractive IOLs, this lens is not immune to dysphotopsias and reduction of visual acuity at near in dim light. Moreover, compared to EDOF IOLs, which offer a broader peak of the defocus curve, trifocal IOLs are less forgiving when refractive targets are missed, residual astigmatism is significant or the ocular surface is sub-optimal. For surgeons looking to offer better functional near vision, the PanOptix provides a worthwhile alternative.

Excellent surgical planning, optimization of the ocular surface (for any lens) and patient preparation is key to achieve success with this IOL. I anticipate surgeons continuing to stretch the utility of the trifocal by complementing it with an EDOF — likely the Vivity, as it has a similar color and material.

DIFFRACTIVE EDOF AND MULTIFOCAL IOLS

Just as with the Vivity, the Symfony EDOF IOL alone provides excellent distance and intermediate vision, but the near vision is generally not sufficient to allow true spectacle freedom. Low-powered OTC readers are part of the discussion early on. Near-plano targeting bilaterally was a common strategy soon after its release, but this limited unaided near vision efficacy as the IOL design would predict, which offered a limited add-power to prioritize distance and intermediate vision in a continuous range (given the limited add power in the lens design).

To overcome this inherent limitation of the EDOF technology, surgeons quickly evolved their technique to either blended vision-like targets (near plano in the dominant eye and mild myopia in the non-dominant eye) or mix and match the EDOF in the dominant eye with one of the Tecnis multifocal IOLs (ZKBOO +2.75D Add, ZLBOO +3.25D Add, ZMBOO +4.00D Add) in the non-dominant eye. Johnson & Johnson Vision termed this latter mix/match as “Personalized Vision.” I utilize this method with significant success, achieving excellent distance, intermediate and near-vision metrics. Given that the Tecnis multifocal IOL in the non-dominant eye can vary in their add power, I am able to customize the near point of fixation based on the patient’s anatomy and visual needs.

As with any diffractive technology, glare and halos cannot be overlooked, and these continue to be a mainstay of discussion despite the paucity of patient complaints and rarity of IOL exchanges. As long as patients know about and understand the pros and cons of current presbyopia correcting IOLs, patients accept the compromise of dysphotopsia when given the possibility of minimal spectacle dependence. I have found that most patients who are not tolerant of dysphotopsia are those who have not been adequately informed about the incidence.

Anecdotally, and supported by the observations of fellow surgeons I’ve spoken to, the incidence of glare and halo with Personalized Vision has been significantly less than with bilateral Symfony IOL implantation. This may be because the blended targets employed early on created a blur point and more perceived glare. With Personalized Vision, each eye is targeted for plano, possibly reducing glare and halo. Nonetheless, I use discretion with whom I implant these technologies, and the patients make IOL choices based on all the facts.

Finally, the latest IOL to be approved in May 2021 is the Synergy (Johnson & Johnson Vision). This IOL brings a new dimension to the current repertoire. A natural extension of aforementioned Personalized Vision would be to incorporate both the multifocal and the EDOF technology into one platform. The Synergy IOL does just this and further bolsters the platform by incorporating a new violet-filtering chromophore, which reduces halos, especially with LED headlights that are common these days. The defocus curve is quite broad without gaps, allowing a continuous range of focus from distance to ~33cm.

Given my patients’ success with Personalized Vision, I feel that the Synergy will be a natural replacement in those patients. Moreover, given the continuous range insinuated by the defocus curve, the trifocal IOL’s gaps can be overcome by the Synergy and those patients, too, may benefit. As we get a few dozen cases under our belt, we will begin to get an idea of its real-world benefits and limitations. Based on the superb optics of this platform — acrylic that maintains clarity over time, low chromatic aberration and stability of the new toric versions after haptic modifications — I expect my patients to have positive outcomes and a higher uptake of these IOLs in our practice.

EMPOWERING THE PATIENT

The premise behind successfully implementing any of these technologies is that, as a surgeon, you’ve discerned which IOL technology is appropriate for the patient based on any ocular disease — modifiable and non-modifiable — patient lifestyles and patient desires.

A few years ago, I moved away from the paradigm wherein the surgeon “recommends” a lens. At times, I found the recommendation to be somewhat hollow as it was not inclusive of myriad facets in the patient’s life, which can’t always be covered in consultation. Instead, as a practice we focused on empowering the patient with simply presented but comprehensively scoped information that they could use to make their own decision. Recently, we’ve worked to provide patient education videos, which include comprehensive IOL information well in advance of their visit with the surgeon. Once their consultation was completed, patients found it very useful for me to eliminate IOL options that I deemed suboptimal for them based on ocular disease, lifestyle or voiced preference (ie, “I tried blended vision in the contact lenses and just couldn’t get used to it”). As such, when patients are well educated and make their own choices, they also take ownership when they encounter any visual challenges.

CONCLUSION

Meticulous surgical planning is the foundation for all the above. Utilizing the best formulae and achieving high quality and repeatable biometry and tomography is expected and a prerequisite to delivering the outcomes both we, as surgeons, and our patients expect. Though the landscape of IOLs will continue to broaden and deepen, a foundational understanding of IOL design and a patient-centric consultative process will enable success for you and your patients. OM

About the Author

Niraj Desai, MD, is a cataract, refractive and cornea surgeon at Milan Eye Center in north Atlanta.

Disclosures: Dr. Desai revealed relationships with Bio-Tissue, Glaukos and J&J Vision.