We experienced many challenges in 2020. However, in the midst of a pandemic that has forced us to make many alterations to our daily routines, surgeons have also been adapting — happily — to new technology IOL options. The latest innovations include Alcon’s presbyopia-correcting lenses, the Panoptix trifocal and the Vivity extended depth-of-focus (EDOF) lens. In addition, Johnson & Johnson Vision has released a new Tecnis Toric II lens platform that reportedly improves rotational stability, and Bausch + Lomb has developed a preloaded toric Envista platform. The long-awaited light adjustable lens from RxSight has finally arrived as an adjustable technology for the difficult refractive targeting case (see page 36).

Thankfully, despite everything that happened in 2020, there was no lack of innovation from industry to continue to make our surgical outcomes more reproducible and consistent. In this article, I will focus on the new presbyopia-correcting lens technologies and explain how surgeons may position them and select appropriate patients.

PANOPTIX IOL

How it works

U.S. surgeons have had a little over a year to become familiar with a true trifocal lens technology. Fortunately, we also have been able to query our colleagues outside the United States to understand how this lens has functioned for them, since they were able to use the lens well before us. One of the questions frequently discussed in our many virtual meetings these days is what patients are good candidates for this type of technology.

The Panoptix lens employs proprietary Enlighten technology to allow 88% light utilization while allocating light through three zones, directing 50% to distance, 25% to intermediate and 25% to near vision.¹ The central optic of the Panoptix is slightly larger (1.164 mm) than previous bifocal diffractive IOLs, which may also render it less sensitive to high angle kappa concerns. It also has a larger central diffractive optic (4.5 mm) than the previous Restor platform of multifocal lenses, allowing for better low-light near vision and less dependence on pupil size for near function. The outer 1.5-mm full refractive zone helps to reduce halo and glare when the pupil dilates widely, such as during night driving, as opposed to other full-diffractive optic multifocal lenses.

The patient profile

So, what types of patients may benefit from this new trifocal technology? Having used high-add and low-add multifocal lenses over many years, my impression of the Panoptix lens is that it combines some of the best features of both platforms without any significant increase in nighttime visual disturbance complaints. Therefore, any patient I would have deemed appropriate for a higher-add bifocal lens, such as the Restor SN6AD1 (+3.00 add) lens, would be an excellent candidate for a Panoptix (+3.25 near add, +2.17 intermediate add).

Patients with a high desire for spectacle independence for computer use, reading or both may potentially benefit from the full range of vision provided by this lens. With focal points ideally placed at 40 cm and 60 cm, unlike other lenses, the intermediate and near requirements for most patients are both effectively met.

Lookout for pathology

Screening for pathology that may impact contrast sensitivity is important with any diffractive lens technology, of course. This includes glaucomatous optic nerve damage, macular issues or corneal pathology, such as significant guttata or significant anterior basement membrane dystrophy. Fortunately, Panoptix does not greatly reduce contrast sensitivity, based on binocular contrast sensitivity data from the pivotal FDA trial that showed no clinically significant reduction compared to the monofocal control.¹ This again is likely a reflection of the proprietary Enlighten optical technology employed and the high light utilization of the lens.

The past refractive surgery issue

Prior refractive surgery patients are often interested in premium IOL offerings such as Panoptix. Reviewing their corneal topography and wavefront aberrometry can help determine candidacy in this population. If patients have significant high-order aberrations, such as high corneal coma or high root-mean-square (RMS), there may be higher risk for reduction in visual quality with any diffractive lens technology.² I have used corneal coma of 0.3 or lower and RMS of 0.5 or lower as guideline thresholds for caution.

However, with the excellent optical quality and light utilization of the Panoptix lens, those numbers are helpful — but not an absolute cutoff in my practice. Surgeons should consider other mitigating factors, including reproducibility of measurements, patient personality, refractive error and density of cataract. Plano presbyopes with minimal cataract and significant glare complaints would be less than ideal to consider for any diffractive lens, in my opinion.

About angle kappa

Angle kappa — the distance between the pupil center and visual axis — should be a consideration for implantation of multifocal lenses. A large angle kappa may result in the displacement of light through peripheral diffractive rings rather than the center of the diffractive optic, which may increase the risk of visually aberrant photic phenomena.³ Multiple studies have validated this theory when analyzing outcomes of multifocal IOL patients.^4-6

Thus, angle kappa remains a metric to evaluate for potential diffractive IOL candidacy. Fu et al have suggested that if angle kappa is greater than half the diameter of the central optical zone, a multifocal IOL should not be implanted.⁴ Based on this calculation, it may be reasonable to consider 0.58 mm as an angle kappa threshold for this lens. Intraoperatively, it is also important to position the central optic as close as possible to the visual axis by employing patient-assisted fixation on a coaxially fixated light source in the surgical microscope.

Addressing haloes

Patients should be advised of the potential for nighttime haloes with Panoptix, just as with any other diffractive lens. Consider showing simulated haloes during their consult; this is simple enough if there is a computer in your exam lane with access to the Internet. Many of my active patients as well as professionals presenting for cataract surgery have done very well with the Panoptix, including appropriate refractive lens exchange patients.

Implanting a Panoptix in the non-dominant eye first allows for the option of another technology (monofocal/low-add/EDOF) in the dominant eye if the patient were to have concerns with haloes in the postop period. I have employed this strategy on rare occasions with other diffractive lenses in the past as well and found that the Panoptix is certainly no worse — and probably slightly better from a visual disturbance perspective — than other high-add multifocals.

Presbyopic hyperopes present an ideal scenario for refractive lens exchange (RLE) with Panoptix, if they understand the potential for haloes, as a tradeoff for visual freedom. However, I would urge extensive discussion and documentation if considering implanting this type of lens in occupational night drivers or pilots. I avoid Panoptix in these patients because there are less risky approaches for them, such as a light-adjustable, accommodating, low-add multifocal or EDOF lens.

VIVITY IOL

How it works

Another new lens option is the EDOF Vivity IOL from Alcon. Launched in January, the Vivity IOL utilizes proprietary non-diffractive wavefront-shaping technology to allow functional intermediate and improved near acuity compared to a monofocal lens; it also creates less halo potential due to its non-diffractive optic design. In fact, the FDA pivotal trial data demonstrated a visual disturbance profile for Vivity comparable to an Acrysof IQ monofocal lens.⁷

The patient profile

So, where do we position this lens in our arsenal and how do we determine candidacy for this new platform? Any patient for whom surgeons may have a potential concern with diffractive light-splitting technologies would benefit from being considered as a candidate for other options.

After having implanted newer low-add multifocals such as the Activefocus Restor +2.5 (Alcon) and Tecnis Symfony EDOF lens (Johnson & Johnson Vision) in patients who may not have been ideal for a high-add multifocal, I have come to recognize that patients definitely benefit from a customized lens strategy depending on their needs and anatomy. Fisher et al have also demonstrated that outcomes can be excellent with low-add multifocals in post-refractive patients.⁸

The Vivity lens has the potential to provide even fewer visual disturbances than previous technologies with the possible exception of the Crystalens (Bausch + Lomb), which is a non-diffractive accommodating IOL. However, the advantage of the Vivity IOL over an accommodating lens, like other one-piece IOLs, should be the refractive predictability and stability of the platform.

After implanting this lens in a series of patients we are studying, I have been impressed with the lens’ visual quality and the lack of complaints regarding photic phenomena, while maintaining intermediate and near performance similar to that of the Activefocus Restor +2.5 and the Symfony EDOF IOL.

Patients who do not like the concept of gaining near vision at the expense of night driving haloes are excellent candidates for the Vivity IOL. Additionally, patients with borderline anatomic findings such as significant dry eye, slightly elevated corneal higher-order aberration or prior corneal refractive surgery may be good matches for a Vivity IOL.

Obviously, surgeons should choose easy-going and reasonable candidates first, to gain experience with refractive targeting and develop a comfort level with the platform.

Multiple strategies

We have employed a mini-monovision strategy with this platform similar to what has been published with other low-add⁹ and EDOF lenses, targeting -0.25 in the dominant eye and -0.5 to -0.6 in the non-dominant eye.

I have also utilized a mix-and-match strategy with Panoptix in patients where one eye may have mild pathology or to provide less halo risk in a dominant eye. Additionally, the added near function of the Vivity may be appealing for toric lens candidates as it is also available in a toric platform for up to 2 D of corneal astigmatism.

Presbyopia game-changers

The perfect lens technology does not exist. However, with newer presbyopia-correcting lenses, surgeons are able to customize lens choice, as well as potentially broaden the pool of eligible patients in order to reduce the burden of absolute presbyopia that results from implanting a monofocal IOL. In fact, I anticipate these new lens options will significantly alter the way refractive cataract surgeons approach presbyopia correction in both our cataract and RLE patients. OM

REFERENCES

1. Alcon FDA Summary of Safety and Effectiveness Data. AcrySof IQ PanOptix Trifocal Intraocular Lens; AcrySof IQ PanOptix Toric Trifocal Intraocular Lens. https://www.accessdata.fda.gov/cdrh_docs/pdf4/P040020S087B.pdf . Accessed Nov. 20, 2020.
2. Allen Q. “Diffractive multifocal IOLs.” Phacoemulsification and intraocular lens implantation: Mastering techniques and complications in cataract surgery. 387-393. WJ Fishkind, ed. Thieme; 2nd ed, 2017.
3. Prakash G, Prakash DR, Agarwal A, et al. Predictive factor and kappa angle analysis for visual satisfactions in patients with multifocal IOL implantation. Eye (Lond). 2011;25:1187-1193.
4. Fu Y, Kou J, Chen D, et al. Influence of angle kappa and angle alpha on visual quality after implantation of multifocal intraocular lenses. J Cataract Refract Surg. 2019. 45:1258-1264. https://journals.lww.com/jcrs/Abstract/2019/09000/Influence_of_angle_kappa_and_angle_alpha_on_visual.9.aspx . Accessed Jan. 12, 2021.
5. Moshirfar M, Hoggan RN, Muthappan V. Angle kappa and its importance in refractive surgery. Oman J Ophthalmol. 2013;6:151-158.
6. Qi Y, Lin J, Leng L, et al. Role of angle k in visual quality in patients with a trifocal diffractive intraocular lens. J Cataract Refract Surg. August 2018. 44:949-954.
7. Alcon FDA SSED data. AcrySof IQ Vivity Extended Vision Intraocular Lens; AcrySof IQ Vivity Toric Extended Vision IOLs; AcrySof IQ Vivity Extended Vision UV Absorbing IOL. https://www.accessdata.fda.gov/cdrh_docs/pdf/P930014S126B.pdf . Accessed Nov. 20, 2020.
8. Fisher B, Potvin R. Clinical outcomes with distance-dominant multifocal and monofocal intraocular lenses in post-LASIK cataract surgery planned using an intraoperative aberrometer. Clin Exp Ophthalmol. 2018;46:630-636. https://pubmed.ncbi.nlm.nih.gov/29360197 . Accessed Jan. 12, 2021.
9. Hovanesian JA, Lane SS, Allen QB, Jones M. Patient-reported outcomes/satisfaction and spectacle independence with blended or bilateral multifocal intraocular lenses in cataract surgery. Clin Ophthalmol. 2019;13:2591-2598.

About the Author

Quentin B. Allen, MD, practices at Florida Vision Institute, in Stuart, Fla. Email him at qallen2000@gmail.com.

Disclosure: Dr. Allen is a consultant for Alcon.