This is a somewhat older case, but to avoid bias in the lenses we feature, here is a single-eye case with the MiniWELL Ready.
She first visited us with a referral letter because her right eye had been hard to see with for the past few years. Both eyes had extreme myopia exceeding −10.0 D, and because of advanced nuclear cataract in the right eye only, internal higher-order aberrations in the left column of the OPD-Scan III results below were high at 0.700 µm, and corrected visual acuity had fallen to 0.2. The left eye also had some cataract but still reached 1.5 with glasses, so we proceeded with single-eye surgery on the right eye only.
If someone wears only glasses in daily life, we may have to deliberately leave high myopia to avoid anisometropia. She was a contact lens wearer, however, so in addition to a monofocal lens set for reading distance, and since corneal higher-order aberrations were low at 0.111 µm as shown below, we told her she was also a candidate for multifocal lenses and gave her time to consider.
She herself is an internal medicine physician, and her husband, who referred her, is a senior member of a university hospital ophthalmology department; he had confirmed that there were currently no glaucomatous optic nerve changes. So, if she wanted a multifocal lens, we proposed TECNIS Synergy if she prioritized near distance, or MiniWELL Ready if she prioritized minimal difference in quality of vision from her unoperated left eye. We explained the characteristics, advantages and disadvantages of the other lenses to her husband, a fellow ophthalmologist, and the two of them discussed it. Also considering her future risk of developing glaucoma given her age, she finally chose the MiniWELL Ready.
As the lens power calculation below shows, her axial length exceeded 30 mm while her corneal power was below 40 D, a shape much like an eye after LASIK. She understood that postoperative refractive error was very likely in such an eye, and we prepared several backup lenses for surgery.
Her husband, as a fellow ophthalmologist, well understood the technical difficulty (risk of complications) of operating on an eye with advanced nuclear cataract and such proportions, and our wish to avoid targeting emmetropia for distance if possible in view of what would happen if refractive error occurred, so our preoperative explanation also covered the possibility of lens exchange.
For lens power calculation, in addition to the Barrett Universal II (BU II) and SRK/T formulas built into the measuring devices, we also calculated with the AI-based Hill-RBF and Kane formulas, and planned to make the final overall decision based on the results of the intraoperative wavefront aberrometer (ORA system).
As for the surgery itself, nuclear hardness was advanced, but the nucleus was relatively small, and despite the instability typical of highly myopic eyes, lens removal went smoothly. We also inserted a capsular tension ring (CTR) to improve the stability of the MiniWELL Ready and to reduce risk if exchange became necessary, then performed intraoperative wavefront aberrometry.
The crucial measurement gave a troubling result, recommending a lens power that the preoperative calculations predicted would make the eye hyperopic. MiniWELL Ready had not yet undergone global optimization on the ORA system and its prediction accuracy was not high, so, taking into account the error between our past experience with an optimized dummy lens and the ORA system, we took a bit of courage and chose 8.0 D, which BU II predicted would be hyperopic at +0.17. Incidentally, ORA predicted a postoperative refraction of −0.57 D with the 8.0 D lens.
Lenses for making highly myopic eyes emmetropic for distance are usually low-power lenses, but MiniWELL Ready lenses of 10.0 D or less are made only in 1.0 D steps. In case a fine power choice became necessary, we had also prepared the weakest cylinder power of the MiniWELL Ready Toric, which is made in 0.5 D steps, but in the end we did not need it.
After surgery I looked at the refraction result with my heart pounding, and I remember the relief when it read −0.375 D. We would almost never have chosen 8.0 D from the preoperative tests alone, so this time the ORA system came to our rescue.
Immediately after surgery she said that, by feel, near was somewhat hard to see, but on testing, visual acuity was 1.5p distance / 1.2 near, with no numerical problem. By one month after surgery she said her near vision had subjectively improved too, and she was very satisfied.
MiniWELL Ready has a unique extended depth of focus design and is characterized by vision close to that of a monofocal lens, with almost no photic phenomena; with accurate power selection, it is an attractive lens that lets you see down to about 40 cm. This time, however, I would like to discuss posterior capsule opacification as a disadvantage, or rather a point needing attention.
Posterior capsule opacification (sometimes called "secondary cataract") is a phenomenon in which lens epithelial cells migrate and proliferate on the posterior capsule, the back wall of the capsular bag holding the intraocular lens, causing the posterior capsule to become cloudy and vision to become hazy again, as with the original cataract. It can occur with any lens, but treatment by YAG laser posterior capsulotomy is well established and can restore the state right after surgery painlessly in a few minutes, so it is rarely a clinical problem. Previous reports roughly suggest that one in five people (about 20%) need laser treatment by three years after surgery, but with MiniWELL Ready there seems to be a tendency to need treatment for posterior capsule opacification sooner. Rather than opacification by lens epithelial cells as described above, it seems that, owing to the lens's optical characteristics, even a slight loss of transparency of the posterior capsule itself readily reduces visual function. This patient developed reduced vision due to posterior capsule opacification exactly one year after surgery, and we recently performed a laser posterior capsulotomy. After treatment, because one membrane, the posterior capsule, is physically gone, some patients, including her, say they see even better than right after surgery. YAG laser posterior capsulotomy is a safe procedure, but depending on the lens type, you should assume that after the laser it is almost impossible to exchange for the intraocular lens you want, so please note that the order of treatments can be important.
As this shows, no perfect intraocular lens currently exists that provides the same visual function as the natural lens; each lens has its strengths and weaknesses, so choosing a lens that matches your own wishes is important for satisfaction after surgery. MiniWELL Ready has obtained the CE mark (approved in EU countries) but is not approved in Japan, so it is used as fully self-pay treatment with lenses imported through an agent, and the power must be decided and ordered one month before surgery. At our clinic the surgery costs 660,000 yen (including tax); the fee includes the lens cost including one backup lens, a capsular tension ring (CTR) in cases where we consider it necessary, and examinations, tests and medications up to 3 months after surgery. If you are interested, please feel free to consult us.
Finally, a word on ALCON's Vivity, about which we receive many inquiries. Our clinic has already used it in several cases, including hyperopic eyes, myopic eyes, post-LASIK eyes, and PanOptix in one eye/Vivity in the fellow eye, with more than a month of follow-up. My impression so far is that, for better or worse, the range of clear vision and photic phenomena are as per the specifications. We plan to publish individual case reports after its general release; thank you for your understanding. This is not limited to multifocal lenses: it goes without saying that one should choose a lens after judging whether the eye can deliver results matching the specifications. At our clinic, we understand the characteristics of each patient's eyes, consider their lifestyle, and strive right up to the last moment during surgery to deliver results that feel better than the specifications. We look forward to continuing to serve you.
2023.05.31