Q:

I have a long-time patient who is moderately myopic, and now cataracts are interfering with reading and driving at night. She spends most of her time on the computer and wants to rely less on glasses. What IOL should I recommend?

A:

“There are some new lens implants available, depending on the patient’s goals and lifestyle,” says Lawrence Woodard, MD, medical director of Omni Eye Services of Atlanta. Optometrists must educate patients on their choices so their surgeon doesn’t surprise them. 

There are only a few presbyopia-correcting IOL options, so inform patients on the procedures and technologies their surgeon uses. Not all surgeons take advantage of the latest techniques and technologies, so steer patients to those who are on the cutting edge and deliver consistent results.

The Vivity lens could be the latest choice to discuss with presbyopic patients. Image by Alcon. Click image to enlarge.

The Multifocal Menu

For those wishing to rely less on reading glasses, there are both older and newer options. The Symfony lens (Johnson & Johnson Vision), introduced in 2016, is a hybrid extended-depth-of-focus and multifocal IOL that provides good distance and intermediate vision with modest near vision. It also corrects moderate astigmatic errors. However, the reading distance is not as close as many patients prefer, so reading glasses are needed in certain situations. Some patients may also experience significant glare and halos at night. 

The PanOptix lens (Alcon) was introduced in 2019 and is the first true trifocal lens available in the United States. This lens provides good near vision as well as good distance and intermediate vision. Because it is a trifocal, patients are generally happy with their quality of vision throughout the near and intermediate ranges. This lens does not diminish contrast sensitivity as much as prior generations of multifocals did, so vision quality in low light conditions is improved. 

With a trifocal, there is still the potential for halos at night due to the rings etched into the lens. This has not been a significant issue for Dr. Woodard. “The powers are limited, so be aware if it is available in the appropriate powers before presenting this option,” he recommends. Astigmatism can be corrected up to about 2.00D.

The newest presbyopia correction option is the Alcon AcrySof IQ Vivity lens, an extended-range-of-vision IOL that provides high-quality distance and intermediate vision and functional acuity at near. Because this lens is not a multifocal, it doesn’t split light but stretches and extends it. Patients who have ocular pathologies such as dry eye, mild macular pucker or age-related macular degeneration may benefit from this lens design. Near vision may not be as good as the PanOptix, but, compared with other multifocal and trifocal lenses, Vivity patients report less glare and halos post-op.¹ Like the PanOptix, astigmatism correction is available up to about 2.00D. 

The Vivity was introduced to a limited market in October 2020 but will be widely rolled out soon to interested surgeons. “Any patient who qualifies for a monofocal lens qualifies for Vivity, with the added bonus of some intermediate and perhaps reading vision,” says Dr. Woodard.

Warn Your Myopes

With this patient and any who are nearsighted, it is crucial to mention that the near vision they have without glasses will go away completely after surgery unless they choose one of the options mentioned. “If this isn’t made clear to them in advance, these patients will be unhappy, and post-op visit chair time will increase significantly,” says Paige Foster, OD, of Clarkson Eyecare in Conyers, GA.  

As with any premium IOL, there is a significant out-of-pocket cost to the patient. No insurance company, commercial payer or Medicare, will cover it. If the patient is not willing to spend the money, rest assured that you did your job by discussing their choices and documenting what you told them.  

“At the end of the day, you don’t want patients coming back upset that they weren’t given all their options,” advises Dr. Foster. 

Dr. Woodward is a key opinion leader for Alcon.

Dr. Ajamian is the center director of Omni Eye Services of Atlanta. He currently serves as general chairman of the education committee for SECO International. Dr. Ajamian has no financial disclosures.

1. Alcon. AcrySof IQ Vivity extended vision UV absorbing intraocular lenses product information.