I am frequently asked if the new class of EDOF (extended depth of focus) IOLs can be used in eyes with corneal disease, retinal disease, and even glaucoma. The two types of EDOF IOLs which are commonly used in the USA are the diffractive EDOF IOL (J&J Tecnis Symfony) and the beam-shaping EDOF IOL (Alcon AcrySof Vivity) and both of these designs provide good visual performance and a wider range of vision without glasses when compared to monofocal IOLs.
For both of these EDOF IOLs, there is a loss of contrast sensitivity as measured by MTF (modulation transfer function) along with a corresponding increase in depth of focus as seen on the defocus curve. For a normal, healthy eye, this is a reasonable trade-off and it is worth it for patients who want to have more spectacle freedom.
However, if we have an eye with pre-existing ocular co-morbidities such as ocular surface disease, an irregular cornea, macular lesions, or optic neuropathies like glaucoma, it may not be the best decision to implant an IOL that will sacrifice some visual quality. In eyes with significant pre-existing disease, my preference is to stick with a monofocal IOL to maximize the image quality and tell the patients to expect to use spectacles to extended their range of visual focus.
Remember that even though the Alcon Vivity does not produce significant nighttime glare like diffractive iOLs, there is still a manufacturer’s warning that comes with the IOL:
I am happy to have more and more IOL options available because it allows us to truly tailor the surgery to suit the patient’s anatomy and desires. I welcome all new IOL designs with the understanding that it is my job as the surgeon to choose what is best for each patient. So can you use the EDOF IOL in your patient with pre-existing ocular disease? You tell me — you are the boss in that situation!
click to watch this video and learn the logic behind patient selection for the EDOF IOLs:
Would you put an EDOF lens in a post Lasik eye, assuming the eye is otherwise completely normal? Thanks.
it depends on the cornea. if it was 20 years ago with a broad-beam laser without gaussian correction, then the spherical aberration can be very high. Also depends on the degree of prior excimer ablation. If the K values are very low (36 or less), then be very cautious!
I appreciate your video and insights into the Vivity lens. Alcon is marketing this lens as the compromise between a multifocal and monofocal for patients with ERMs and glaucoma that want some extended range of vision. Since you aren’t implanting Vivity in these patients, do you offer them mono-vision? Do you feel the same way about the Eyhance lens?
Also, how are you determining which patient gets a Vivity lens vs a Panoptix lens? Does it depend on who drives at night?
I encourage you to read the package insert in the IOL box and also look at the FDA clinical trial. Mono-vision is great since it can be undone with glasses as needed. Still getting more info about eyhance. Vivity vs PanOptix depends on the patients and the compromises that each is willing to accept.
I’m starting to use Rayner EDOF that they have brought into the market as a “monofocal” it seems to be similar to the eyhance. I was wondering if you’d use these with Pt who has had mild mac edema from PDR in the past. Its now stable, but the retina is not pristine.
I would just do a monofocal and get 100% of the light at the one focal point with glasses for near/intermediate. But with that said, likely no issue in using that IOL