BLOG: My evolving approach to mix and match
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Key takeaways:
- A surgeon’s approach to mix and match can evolve with experience.
- The violet light filter in the Symfony OptiBlue blocks short wavelength light, which has been shown to reduce driving difficulty.
As IOL technology evolves, my approach to lens selection has been changing right along with it.
In the past, I had always assumed that bilateral implantation would be the most effective way to use full range of vision IOLs such as the Tecnis Synergy (Johnson & Johnson Vision) or PanOptix trifocal (Alcon). These lenses offer the best near vision and the widest range of vision available today, so it seemed that implanting them bilaterally would best serve patients who wanted spectacle independence.
However, the complex optics in these IOLs can be rather unforgiving of residual refractive error. I found that patients implanted bilaterally would often experience glare if they had some residual defocus. Thus, as I detailed in a previous blog post, I began to mix and match two IOLs with the same violet light filter. I typically began by implanting the multifocal Tecnis Synergy in the nondominant eye and then decided whether to implant the same lens or — more commonly — the extended depth of focus (EDOF) Tecnis Symfony OptiBlue (Johnson & Johnson Vision) in the dominant eye. A retrospective study I conducted demonstrated that combining these two IOLs resulted in better uncorrected distance acuity and greater satisfaction with night vision than bilateral implantation of the multifocal IOL.
Over time, I have flipped my starting lens. Now, the most common approach for me to take is to implant the EDOF lens in the dominant eye first. If the patient is happy after that first eye, I will match the lens for the fellow eye, implanting it with the same EDOF lens. If the patient would like better near vision, I implant a Synergy lens in the fellow nondominant eye to improve near vision, knowing that I can still achieve the excellent binocular results shown in my retrospective study. But very often, patients are quite happy with both the quality and range of vision with the EDOF lens, and we ended up with bilateral Symfony OptiBlue IOLs.
The violet light filter in the Symfony OptiBlue version of this lens blocks short wavelength light below 450 nm, which has been shown to reduce driving difficulty. Filtering the short wavelength light, combined with high-resolution lathing, also reduces glare and enhances contrast in challenging light conditions, leading to fewer dysphotopsia complaints and a reduced need for postoperative counseling. I think these quality-of-vision features are what make patients so satisfied with paired EDOF lenses, even though a multifocal lens would ostensibly provide better near acuity.
One example of a patient with whom I took this approach was a young nurse who had developed early central cortical cataracts due to her type 1 diabetes. This was a challenging case for IOL selection because she had not lost much accommodative ability prior to developing the cataracts, and I knew she would depend on those IOLs for more years than the average cataract patient. Of course, she wanted to be spectacle-free for most tasks after surgery. In discussing her day-to-day vision needs, it seemed that most of her work was performed at an intermediate distance or beyond. I implanted a Symfony OptiBlue IOL in the first eye, and she was very happy with the range of vision. We proceeded to implant the same lens in the second eye, which should provide this young patient with a lifetime of glistening-free vision with very high optical quality.
References:
- Chang DH, et al. Ophthalmol Ther. 2023;doi:10.1007/s40123-023-00709-w.
- Chang DH, et al. The effect of violet light filtration and manufacturing improvements on the clinical performance of an extended depth of focus IOL. Presented at: American Society of Cataract and Refractive Surgeons meeting; April 22-26, 2022; Washington.
- van der Mooren M, et al. Clin Ophthalmol. 2023;doi:10.2147/OPTH.S396823.
- Younger JR. Visual result and nighttime glare symptoms with two presbyopia-correcting intraocular lenses: Tecnis Symfony OptiBlue and Synergy. Presented at: Caribbean Eye Meeting; Feb. 3-6, 2023; San Jose del Cabo, Mexico.
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