Now that the launch of Clareon® Vivity™ in Japan appears to be largely settled, here is a case in which the patient was torn between Vivity and another lens.
She first visited us in June 2022 for consultation about cataract surgery in both eyes. She lives overseas and came during a temporary stay in Japan. She had already seen an ophthalmologist in her country of residence, who had recommended TECNIS Eyhance and Vivity, which was then scheduled for release in Japan as well.
As for the cataracts, the right eye had age-appropriate cortical cataract, while the left eye had advanced nuclear cataract plus dense cortical opacity extending into the pupillary area; the cataracts were clearly different between the two eyes. She also had a history of head injury, so it seemed we would need to take its effects into account during surgery.
Regarding visual acuity, the right eye still had good corrected visual acuity of 1.5 despite the cataract, but the left eye had fallen to 0.5. Fundus examination showed no other disease that would clearly reduce vision, so we explained that the left eye was "an eye in which cataract surgery can be expected to improve vision." At her request, we also evaluated her candidacy for multifocal lenses, including Vivity, with corneal wavefront analysis. Higher-order aberrations were low, and the result indicated a high likelihood that the multifocal effect would work well.
At that time, Vivity was already in use in the country where she lives. Rather than waiting indefinitely for a lens whose availability in Japan was uncertain, we recommended that, if she had made up her mind, she have surgery with Vivity there. We did not schedule surgery at the first visit so that she could take time to decide, and asked her to return if she wished to have surgery at our clinic.
About six months later she returned, saying that after reading Case No. 54 she wanted Eyhance. A posterior subcapsular opacity had been added to the cataract in her left eye, and corrected visual acuity had fallen further to 0.3. Eyhance and Vivity have some structural similarities, but the add power is reported to be about 0.5 D for Eyhance versus about 2.0 D for Vivity, slightly stronger than LENTIS Comfort (about the same as TECNIS Symfony), so I think comparing the two on equal terms makes no sense. At the preoperative examination she had myopia of about −1.5 D and had hopes for near vision as well as distance vision, so we told her again that Vivity would be more certain to meet those hopes. However, her near visual acuity had already fallen to 0.2–0.3. When we explained that even with Eyhance, by carefully choosing the target refraction, she would very likely see better than at present, and if things went well, better than her right eye at both distance and near, she finally chose Eyhance with no regrets, and surgery was scheduled.
Her pupils were somewhat small to begin with, so we could also expect pseudo-accommodation from the pinhole effect and corneal astigmatism (aberrations). Since her right eye still had relatively good uncorrected distance vision of 0.8–0.9, we set the target for the left eye at −0.5 D (about 2 m). This setting aims for distance vision equal to or better than the right eye, reliable, effortless vision at 2 to 1 m thanks to Eyhance's 0.5 D add, and, for closer distances, relies on the extended depth of focus from the small pupil. A target slightly more toward near was possible, but because the right eye had become hyperopic at about +1.0 D, the difference between the eyes was also a concern, and we operated aiming for −0.5 D.
Her corneal power was somewhat strong relative to her axial length, so we prepared several lenses in consideration of the risk of a myopic shift, and in the end determined the lens power with reference to the results of the ORA system, an intraoperative wavefront aberrometer. The surgery was completed without problems. At our clinic, we use the intraoperative wavefront aberrometer (ORA system) in every case, regardless of the risk of refractive error. After surgery her near vision was better than expected, and she was delighted, saying "The way I see now is the best!" Initially, with balance in mind, we had scheduled the right eye for the following week, but she said "I'm already satisfied enough!" and so, in the end, the right eye was not operated on (^^;).
I consider ordinary cataract surgery to be not an urgent operation but one for "people who want to improve their vision, even if it means having surgery." The indication and timing for surgery are therefore not uniform but depend on each patient's circumstances, and we do not recommend surgery to people who are satisfied with glasses. As in this patient's case, waiting for a new lens to be released is also an option for this condition, so patients may find it hard to decide when to have surgery; and from the surgeon's side, as long as safety permits, we can wait until the last moment. Distance/near vision, independence from glasses, contrast, halos and glare, approval in Japan, cost, and so on: priorities differ from person to person. If you are unsure, please do not rush into surgery until you are convinced, and feel free to consult us first.
Finally, here is the defocus curve of Vivity published by the manufacturer.
As shown, binocular visual acuity of 0.8 or better is maintained down to just under 50 cm, almost the same as TECNIS Symfony (about 0.4 for monofocal lenses), and photic phenomena such as halos and glare are reportedly about as few as with monofocal lenses. In addition, as shown below, it is reported that functional vision is maintained, allowing reading of more than 80 words per minute even at an 8-point font size (in English).
When TECNIS Symfony appeared as the first extended depth of focus lens, it was, from the surgeon's side, tolerant of power errors and astigmatism, and thus easy to use even for doctors who had never used multifocal lenses before; my impression was that it broadened the base of users. I expect a similar trend with Vivity, but now that coverage under advanced medical care insurance no longer applies, I think the question will be what it will cost.
Although the material is different, Vivity in AcrySof material has been on the market in the US for almost two years, and many reports of its use, including long-term outcomes, have already been published. Recently it has also been reported that setting the non-dominant eye to −0.75 D, or using the trifocal PanOptix in that eye, can make glasses almost unnecessary. We will continue to update information on the characteristics of the lens and how to use it.
2023.01.25