Two years earlier an optician had been unable to correct his vision fully and had recommended he see an eye doctor; he first visited us in October 2023 for consultation about cataracts.
Advanced cortical opacity in both eyes had reduced uncorrected visual acuity to 0.4 and corrected visual acuity to 0.5–0.6, but there was no other eye disease, so we told him surgery could improve his vision. He wished for multifocal lenses and booked surgery for December.
He passed our multifocal lens candidacy tests with good results. In the preoperative questionnaire, he said he is a professional guitarist and prioritizes near, at music-stand distance, over distance; he does not drive but wanted to avoid strong photic phenomena such as halos and glare. Since he was originally hyperopic, we first recommended surgery on the left eye with PanOptix set exactly for distance, and he agreed to the goal of reliably securing music-stand distance.
In left eye surgery, the pupil dilated somewhat poorly, but lens removal went without problems, and we decided the power using the ORA system, an intraoperative wavefront aberrometer. His axial length was somewhat long at just under 25 mm, but his eyes were hyperopic because corneal power was flat at 41–42 D, proportions prone to refractive error. This time we therefore adopted the ORA system's proposal for the power, inserted the PanOptix, and completed the surgery without problems.
Left eye uncorrected vision was 0.8p distance / 1.2 near on the day after surgery → 1.5 distance / 1.5p near on day 4; the refractive error we had feared did not occur, and he was pleased with good vision at zero refraction. However, at the day-4 visit he complained strongly that "I can see well, but distant lights at night glare and bother me." We explained that the right eye would see less well up close than the left, but that the left eye's near vision would not decrease, and after discussion he chose surgery on the right eye with Vivity.
Since the right eye would receive Vivity, for which power optimization was not yet sufficient, we decided the lens power from our clinic's regression formula using the ORA system's intraoperative total ocular aberration as the explanatory variable, and the surgery was completed without problems.
Uncorrected vision in the right eye was 1.2 distance / 0.7 near on the day after surgery and 1.5 distance / 1.0p near on day 10, near vision better than expected. He also found that he noticed halos and glare less than with the left eye, and was satisfied.
At the one-month visit, vision was good in both eyes, but he still found halos and glare on the PanOptix side (left eye) occasionally bothersome. At the recent six-month visit, he said they bothered him less than before.
From our clinic's experience so far, we have found a tendency: when PanOptix is implanted first and the patient is dissatisfied with halos and glare, so Vivity is used in the fellow eye, they tend to remain relatively aware of PanOptix's photic phenomena after surgery; whereas when Vivity is implanted first and the patient is dissatisfied with near vision, so PanOptix is used in the fellow eye, they tend to notice neither Vivity's near shortfall nor PanOptix's photic phenomena. So when the patient's conditions allow, considering not only the degree of cataract but also eye dominance, astigmatism, preoperative refraction and so on, we use Vivity first.
This may owe more to individual personality and psychological factors than to medical or ophthalmological ones, but using Vivity first has almost no downside: if the patient is satisfied with Vivity, which has weaker near vision but good quality of vision, the option of Vivity in both eyes remains open.
Of course, we often use Vivity shifted toward near (mini- or micro-monovision), and from the surgeon's standpoint of reliability, using the same lens in both eyes makes refractive error and postoperative vision easier to predict, so honestly I too prefer to use the same lens in both eyes where possible. At our clinic, not only with Vivity, we have long measured, before surgery on the fellow eye, a shift the patient is satisfied with before deciding the power. That amount differs from person to person, and for those not satisfied with near or distance vision even with a 0.75 D shift, it is difficult to obtain satisfying binocular vision with Vivity alone, so the only option is to consider mix-and-match, using a different type of lens to make up for the shortfall. Incidentally, the further the shift toward near, the greater the glare-like light spreading from defocus (people with myopia will understand this from how distant streetlights spread when they take off their glasses at night), which also reduces the benefit of choosing Vivity; this is one concern about using it shifted toward near.
It is easy to imagine that using different lenses in each eye works well enough when both are diffractive, such as TECNIS Multifocal with TECNIS Synergy or TECNIS Symfony, TECNIS Synergy with PanOptix, or PanOptix with FineVision, and our clinic sometimes uses lenses this way. However, I was skeptical about mix-and-match of lenses with different multifocal mechanisms, Vivity and PanOptix, wavefront-shaping and diffractive, one in each eye. But good results seem to be obtained even in the car society of the US, and our clinic has adopted it in selected cases, so far with safe results and higher satisfaction than expected (safe meaning also for the surgeon). Until now I thought the best choice was one where the same lens in both eyes satisfies the patient without mix-and-match, but recently there have been reports that, compared with bilateral PanOptix, Vivity/PanOptix mix-and-match gives equivalent visual acuity (bilateral Vivity has significantly weaker near vision) and that satisfaction was higher with mix-and-match (Journal of Cataract & Refractive Surgery 50(2):p 167-173, February 2024.). It is true that Vivity is weak at near, but almost all diffractive bifocal and trifocal lenses other than EDOF lenses show a slight dip in vision at about 1 m, and the fact that Vivity covers that dip, though not much talked about, seems worthy of recognition.
With mix-and-match, it may be preferable to use Vivity in the dominant eye, but eye dominance changes relatively easily (dominant switch), so it is by no means the top priority. In fact, many people have switched dominance because a cataract developed in only one eye, so it seems more useful to choose lenses giving priority to the amount of astigmatism and to the original difference in refraction between the eyes.
To achieve the above, the fundamental premise is to operate to the target without refractive error. Apart from preoperative judgments of candidacy and target setting, when surgery is performed above a certain level, I feel that the biggest factor in differences in postoperative uncorrected vision and satisfaction is how well one chooses lenses that avoid refractive error and performs reproducible surgery. With advances in surgeons' skills and equipment, cataract surgery has become a highly refined procedure, and, to put it a little bluntly, these days I feel that postoperative refractive error is about the only thing that differentiates surgeons, so our clinic places emphasis on this.
For reference, finally, here are the monocular defocus curves (modified) of Vivity and PanOptix in AcrySof, the predecessor of the Clareon material. Binocular summation is not simply the sum of the two, but it seems unlikely to be negative, so if you are interested, including in your candidacy, please feel free to consult us. Next time, for comparison, we plan to publish a case with Vivity in both eyes.
2024.04.10