EDOF vs. multifocal: Considerations for presbyopia-correcting IOLs
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The decision of which type of IOL to implant in a patient is a multistep process in my practice.
Presbyopia-correcting IOLs are considered for patients who want to reduce their dependence on glasses or contact lenses and have generally healthy eyes, free of corneal, optic nerve or macular changes that would preclude them from achieving good results with a presbyopia-correcting lens.
Source: Barry A. Schechter, MD, FAAO
To set appropriate expectations, it is important that patients understand that they will need glasses for near and intermediate tasks if we do not implant a presbyopia-correcting IOL and target emmetropia.
Once we have determined candidacy and interest in spectacle independence, I consider patient personality, visual demands and light sensitivity. Trifocal or hybrid multifocal extended depth of focus (EDOF) IOLs such as the PanOptix (Alcon) or Tecnis Synergy (Johnson & Johnson Vision), respectively, have the greatest potential to provide a full range of vision from near to far without glasses, but they may induce unwanted night vision symptoms. In patients who are particularly sensitive to or fearful of glare and halo, those for whom night vision problems could significantly interfere with their vocation, and those with observant, finicky or “type A” personalities, I prefer to implant an EDOF lens such as the Tecnis Symfony (Johnson & Johnson Vision). Patient height is also a consideration, as taller individuals with longer arms tend to have a comfortable reading distance that is closer to the intermediate range; these patients may also be well served by an EDOF lens.
In most cases, I do not get into the specifics of IOL brand or type with patients but rather keep the discussion focused on visual needs and outcomes. I tell every patient there may be some situations in which they will still need glasses after surgery.
The case of a commercial pilot
A 63-year-old commercial airline pilot was referred to me by her optometrist, complaining of decreased acuity in the left eye due to cataract. She had undergone prior successful cataract surgery with monofocal IOL implantation in her right eye at another facility. The patient asked specifically about multifocal IOLs because she wanted to reduce her reliance on glasses.
Upon examination, the pseudophakic right eye was 20/25 uncorrected, and the left eye had a 2+ nuclear sclerotic cataract. She was wearing progressive spectacles for near and intermediate tasks. Corneal topography and tomography of the macula were normal, but she was noted to have dry eye. I placed 0.4-mm collagen plugs in both lower puncta and began topical cyclosporine and a 2-week course of a mild topical steroid drop. After 3 weeks of treatment, her ocular surface was significantly improved.
In discussing her visual needs, it became apparent that her primary motivation was to be able to see the instrument panel in her aircraft, which is at an intermediate distance, without spectacles. She spent little time reading or doing very close work, had a practical, relaxed approach, and accepted that over-the-counter readers might be needed for fine detail. Taken together, these characteristics made her a good candidate for an EDOF lens that offers minimal visual disturbances and excellent distance and intermediate vision.
In the past, I might have hesitated to implant any presbyopia-correcting IOL in a pilot who is dependent on her vision. However, the latest iteration of the Symfony lens has been shown to reduce dysphotopsias and improve optical quality through a combination of several technologies, including a high-resolution lathing process and chromatic aberration correction for better contrast sensitivity, both during the day and in dim light at night. It also blocks high-energy violet wavelengths that contribute to night driving problems and frustration with night vision (Figure 1). I felt that this EDOF lens would offer my patient the range of vision she wanted with a low chance of side effects.
A 21 D Tecnis Symfony OptiBlue IOL was successfully implanted in her left eye after uneventful femtosecond laser-assisted cataract surgery (Figures 2a to 2c). On the first postoperative day, the patient saw 20/30 at distance with mild halo due to her still pharmacologically dilated pupil. By the 1-week visit, she had improved to 20/25 at distance, J1 at intermediate and J3 at near.
She was able to return to flying without having to wear corrective lenses for her instrument panel and noted no significant glare or halo when comparing the EDOF eye to her monofocal right eye.
This case nicely illustrates the benefits of the EDOF category of IOLs in general and the particular optical quality-enhancing attributes of the Symfony OptiBlue lens for patients with high visual demands who desire increased spectacle independence.
- 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 Surgery meeting; April 22-26, 2022; Washington.
- For more information:
- Barry A. Schechter, MD, FAAO, of Florida Eye Microsurgical Institute, can be reached at baschechter@me.com.
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