BLOG: Mix and match that actually works
Key takeaways:
- A combination of the Synergy and Symfony OptiBlue IOLs improves range of vision.
- Patients with the Synergy-Symfony combination ranked their night vision performance as better than those with bilateral Synergy.
In the past, I have tried the “mix-and-match” or “personalized vision” approach. However, I preferred in most cases to implant the same lens bilaterally.
But I have now found a combination that, for the first time, makes the extra “decision tree” effort of personalizing the pair of lenses worthwhile to me.
I had heard from colleagues who found great success implanting a combination of Tecnis Synergy (DFR00V) IOL in the nondominant eye and Tecnis Symfony OptiBlue (DXR00V) in the dominant eye (both Johnson & Johnson Vision). This approach takes advantage of the high level of forgiveness and limited night vision impact of the extended depth of focus (EDOF) lens, as well as the full range of vision available with the EDOF-multifocal hybrid. While the near vision we can achieve with Synergy or a PanOptix trifocal IOL (Alcon) is desirable, there is no question that these lenses have more complex optics that are less forgiving of residual error.
I decided to evaluate the effect of this IOL combination on postoperative refractive error, uncorrected near and distance visual acuity, and patient-reported night vision performance in my own practice. I had been using the Synergy IOL bilaterally, but once the new Symfony version was released last year, it made sense to incorporate it.
I retrospectively evaluated a case series of 39 patients who received bilateral Synergy IOLs and 15 patients who received the Synergy-Symfony combination. I used the Barrett II formula for all IOL power calculations in both groups. All eyes had femtosecond laser-assisted cataract surgery with scanned capsule centration of the capsulotomy, iris registration, and laser incisions for correction of astigmatism when needed.
There was a statistically significant difference in uncorrected binocular distance vision, with a mean 0.06 ± 0.07 logMAR in the Synergy-Symfony combination patients compared with 0.11 ± 0.10 logMAR in the bilateral Synergy patients. Both groups had very strong binocular near vision at 40 cm, with no significant differences, as would be expected since the near vision with the Synergy is so strong, whether placed in one or both eyes.
At 2 months, patients were asked to rank their level of discomfort with night driving due to glare, halos and/or starbursts as mild/not bothered at all, moderate or severe. Patients with the Synergy-Symfony combination ranked their night vision performance as significantly better (P < .05) than the bilateral Synergy group.
Decision-making for presbyopia-correcting-IOLs
Based on this experience, I now routinely mix and match these two lenses. In my practice, patients with regular corneal topography, normal levels of higher-order aberration on aberrometry, and a normal or near-normal OCT of the macula qualify for presbyopia-correcting IOLs.
If both eyes have cataract, my preference is to implant the Synergy IOL in the nondominant eye first. At the 1-week postoperative appointment, I ask the patient how they are doing. Some patients really do “get it all” with this lens — and if that is the case, I will implant the same lens in the fellow eye. However, if they would like better distance vision or have complaints about night driving, I implant the Symfony OptiBlue lens in the dominant eye. When I start with the dominant eye first, I implant the Symfony and base the fellow eye decision on the patient’s satisfaction with near vision.
For the first time, I feel that surgeons can use this combination of lenses, both of which offer violet-light filtration and advanced lathing to improve contrast and decrease glare, with confidence. For patients who want freedom from glasses, I feel it is worth the surgeon’s time with customized IOL planning and decision-making in order to give patients a full range of vision.
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