She had been told of cataracts at a check-up a month earlier and advised to have surgery, and first visited us in February 2023 for consultation about surgery with multifocal lenses.
She had had LASIK in both eyes 12 years earlier, so naturally the bar for multifocal candidacy was high, and since she had no data at all from before LASIK, the risk of refractive error was also high; but leaving lens type aside, we first carried out a preoperative evaluation.
Both eyes had ordinary moderate cataracts, but the left eye had predominantly central cortical opacity, and as the OPD-Scan III corneal topography/aberration analyzer results below show, internal aberrations from lens opacity were very large: 0.202 in the right eye / 1.190 in the left eye (red frame in the left column below), and corrected vision had fallen to 0.5. Distance vision in the right eye was relatively good at 0.9 uncorrected / 1.2 corrected, so we suggested operating on the left eye alone first, but both eyes had shifted toward hyperopia and uncorrected near vision had fallen to 0.09 right / 0.06 left, so she wished to have surgery on both eyes.
Corneal topography/aberration analysis (OPD-Scan III), essential for judging multifocal candidacy, showed that the laser ablation was not markedly decentered, and, surprisingly, both corneal spherical aberration and higher-order aberrations were low; her corneas were clean for post-LASIK eyes, so we judged that multifocal function could work. In the preoperative interview, she said her hobbies were knitting and piano, and that she drives (sometimes at night), so we recommended Clareon Vivity, which we were then planning to use ahead of release; it causes almost no halos or glare and is said to have few disadvantages for post-LASIK patients. However, she said she had already accepted halos and glare and really wanted to see things at hand closer than Vivity's near range, so she strongly wished for PanOptix, and wanted to consider other lenses, including Vivity, for the right eye depending on the left eye's course. Her dominant eye was the right eye, so PanOptix in the non-dominant left eye with Vivity or a monofocal lens set for distance in the dominant right eye seemed "workable," and, as she wished, we proceeded to calculate and select the lens power for surgery on the left eye with PanOptix.
In my experience, people who had a lot of cornea removed by LASIK have a higher rate of unexpected refractive error (refractive surprise) after cataract surgery. Her corneal thickness, however, was 524 µm right / 533 µm left, the same as in ordinary people who have not had LASIK (about 530 µm), so she was probably either not very myopic or had regressed after LASIK. She had no pre-LASIK data, but when we narrowed down candidate lens powers using several post-LASIK power formulas, also accounting for the posterior cornea, the results were almost the same, so we predicted that choosing the power additionally with the ORA system, an intraoperative wavefront aberrometer, would allow even more accurate surgery.
First, left eye surgery. Lens removal went without problems, and we moved on to measurement with the ORA system. Before surgery, 20.0 D had been the leading candidate for emmetropia, but, as shown below, ORA recommended 19.5 D (→ +0.08 D) as the power closest to emmetropia. However, the ORA system also has tendencies of error, so after some hesitation, based on our experience and our clinic's regression analysis, we chose 20.5 D → −0.56, and the surgery was completed without problems.
Refraction testing the day after surgery in post-LASIK patients always makes my heart race, so I was relieved that, as in the right column below, the next day's spherical equivalent was +0.125 D, almost emmetropic (−0.25 D at 3 months). Uncorrected vision was also very good, 1.2/1.2p distance and near, so I thought PanOptix would naturally be fine for the right eye too, but she said she was bothered by halos and glare and wished for Vivity in the right eye. Fortunately, to be safe, we had left about three weeks before right eye surgery, so we watched her course; the halos and glare lessened but still bothered her, so she still wished for Vivity in the right eye, with a target more toward distance than the left eye. In terms of refraction, the left eye was already sufficiently set for distance, so going further toward distance meant setting it slightly hyperopic, and we explained that with Vivity's lower add, near vision would be even harder to obtain. She said she was satisfied with near vision in the left eye and wanted to prioritize distance vision for things like driving.
Next, right eye surgery. Lens removal again went without problems, and based on ORA system measurement we used a 19.5 D lens targeting −0.06 D, 0.5 D more toward distance than the left eye as she wished (preoperative predicted refraction +0.14 D); the surgery was completed without problems as usual.
Postoperative refraction is shown in the left column of the figure above. With Vivity, the central add zone affects measurement, so autorefractometer readings tend to show 0.25–0.75 D more myopia than the actual refraction. In other words, a measured (objective) value of −0.50 D is roughly an actual (subjective) 0.0 D, so the right eye's subjective refraction came out, as calculated, more toward distance than the left eye and slightly hyperopic. After surgery she was pleased that she noticed no halos or glare at all with the Vivity in the right eye, unlike the left, and that it felt brighter than the left, reconfirming Vivity's specification of having almost no photic phenomena, much like a monofocal lens. However, for one to two months after surgery she still occasionally noticed halos and glare in the left eye, and complained that the right eye somehow saw less well at distance; uncorrected distance vision fluctuated between 1.0 and 0.8 (near 0.6–0.9). The post-LASIK cornea may of course be a cause, but the central add zone of Vivity may also be one reason for unstable distance vision.
Also, Vivity is an extended depth of focus (EDOF) lens that is, in theory, continuously in focus anywhere from distance to about 60 cm (0 to about 1.5 D add), so, depending on pupil size and position, daily habits and other conditions, making full use of that range of focus may require what is, unscientifically, called "getting used to it." It is a lens one is sometimes tempted to shift slightly toward near to compensate for its weak near add, but special care seems necessary in cases where distance vision tends to drop. As an aside, ALCON's ActiveFocus, unfortunately discontinued, was a low-add (about 2.0 D) diffractive lens that, opposite to Vivity, devoted the lens center to distance only, reducing halos and glare and securing good distance vision; it was a good lens.
She had also had overcorrected glasses of −0.75/−0.5 D made at an optician on her own and was using them for driving and the like. As noted above, Vivity is EDOF, so glasses of any power from −1.5 to 0.0 D can be worn if desired, but that means giving up use of part of the add zone and risks forming odd habits. Wearing them only when needed may not be much of a problem, but until refraction and vision stabilize it is better to be careful with glasses, so we recommend consulting your doctor properly about when to make glasses and what power. At 3 months after surgery, her uncorrected vision had settled at 1.2 distance / 0.7p near, matching Vivity's specifications, and she was satisfied with good uncorrected binocular vision of 1.2 at both distance and near.
The figure above shows her Vivity's wavefront-shaping zone and PanOptix's diffraction grating, photographed to make them stand out. In this case there was the option of a lens with fewer halos and glare than the PanOptix in the left eye, so we used Vivity in the right eye; of course, with a longer follow-up, PanOptix's halos and glare might also have become acceptable.
With multifocal lenses, especially diffractive lenses, photic phenomena such as halos, glare and starbursts can never be zero. As surgeons, we strive to minimize photic phenomena by properly evaluating ophthalmic conditions such as the cornea and pupil size, as well as the patient's lifestyle, and by keeping refractive error as small as possible. But whether they will be tolerable also involves personality factors, so at present it is difficult to tell completely before surgery.
Next time we will publish a case in which a patient who had surgery with PanOptix at another clinic, despite good vision of 1.2/1.0 at distance and near, found the halos and glare intolerable and disrupting daily life, so we performed an exchange to Vivity. To provide information, we have published Vivity cases with distinctive features where possible, including patients in their 50s to 70s, eyes from hyperopic to highly myopic, and cases combined with MIGS, but to avoid bias in our cases, the next one will be our last Vivity case for a while; thank you for your understanding.
2023.9.24