He first visited us in February 2020 for consultation about cataract surgery because both eyes were hard to see with. Cortical opacity had reduced corrected visual acuity to 0.8p, so we told him, "If it interferes with daily life, surgery is an option, but if not, observation won't increase the risk of surgery much," and asked him to return if he wished to have surgery. After that he came about once a year for follow-up, and in September 2023, after a gap of a year and three months, he returned saying that things had become harder to see, as if he had become more myopic, and booked surgery.
He used multifocal glasses but said he had originally been able to see in the distance without glasses, so we considered that, in addition to cortical opacity, nuclear cataract had also progressed and caused a myopic shift.
In the preoperative questionnaire, his priority of distances was 1. intermediate > 2. far > 3. near; he drives frequently, including at night, and plays golf as a hobby. He understood that even a monofocal lens could be chosen with a power improving uncorrected distance and near vision over the preoperative state, and we explained that if he wanted to reduce the use of glasses as much as possible, Vivity was the most suitable among multifocal lenses. He agreed to a flexible plan: first set Vivity in the right eye exactly for distance to reliably secure intermediate to distance vision, his priorities, and then, depending on the result, decide whether to adjust the left eye with Vivity as well or use PanOptix to secure near vision with the goal of not wearing glasses. Surgery followed.
The right eye dilated somewhat poorly, but cataract removal went without problems. We measured with the intraoperative wavefront aberrometer (ORA system) and entered the intraoperative total aberration value into a regression formula to decide the appropriate power. (Perhaps because optimization of Vivity is still insufficient, ORA's recommended values for it deviate more than for other lenses, so our clinic also uses a regression formula to minimize refractive error.)
After surgery, as targeted, subjective refraction was zero (objective refraction −0.50 D). On the day after surgery vision was 1.5 distance / 0.3 near, poor near vision, and he did not yet seem to be making good use of Vivity's near zone, but by day 4 it had improved to 1.5 distance / 0.7p near. Subjectively, he said distance looked very good but he still found his smartphone hard to see; he noticed no halos or glare at all and saw things very sharply. When we explored a target that would let him see his smartphone without problems, adding +0.75 D in front of the right eye with Vivity gave near vision of 1.0p, which he found comfortable. However, shifting 0.75 D toward near reduced distance vision to 0.3, and he was not keen on shifting the same Vivity toward near, so after discussion he chose surgery on the left eye with PanOptix, a trifocal lens that reliably lets him see his smartphone without sacrificing distance, set exactly for distance to minimize photic phenomena.
Incidentally, with lenses whose power varies by zone, such as Vivity, LENTIS Comfort and Eyhance, objective refraction differs depending on how much of the pupil the add zone occupies. Our clinic's analysis shows that in eyes with Vivity and zero subjective refraction, objective refraction is −0.45 D. In other words, an autorefractometer value of −0.45 D means exact distance focus. In addition, our clinic has found differences between subjective and objective refraction (perhaps including pseudo-accommodation) of −0.51 D with Eyhance and about −0.20 D even with monofocal lenses.
For the left eye, likewise, we decided the lens power with the ORA system after cataract removal, and the surgery was completed without problems. Again, as targeted, subjective refraction was zero, and from the day after surgery he smoothly achieved good vision of 1.5p distance / 1.2 near; he was satisfied that he could see his smartphone well too.
At one month, distance vision was 1.5 in both eyes and near vision was 0.8p right / 1.2 left; he had fully adapted to the multifocal lenses and was delighted with a life in which he could enjoy work, driving and hobbies without glasses. Out of personal interest, I also asked about differences between the eyes in photic phenomena such as halos and glare due to the different lenses, and received an interesting answer contrary to my expectations: "I don't notice it at all; it has never bothered me."
His first visit was in 2020, so as it turned out, putting off surgery for three and a half years allowed him to have surgery with more satisfying lenses, Clareon Vivity and PanOptix. Most ordinary cataract surgery is not urgent, so, as in his case, as long as daily life is not affected, there is no need to rush into surgery unless the risk increases substantially, and with technological progress, as for him, you may be able to have surgery with lenses offering more added value.
Thus the mix-and-match combination of Vivity in one eye / PanOptix in the fellow eye seems a very good combination that can take "the best of both," as long as the patient's wishes are confirmed after the first eye through a staged implant approach and the lenses are used correctly without refractive error. Of course, from the surgeon's side, using different lenses in each eye loses the advantage of applying the first eye's postoperative refractive error to the fellow eye, and reduces the accuracy of predicting the fellow eye's refractive error, so we would rather avoid it if possible. In other words, I believe it should not be a choice decided in advance before surgery but one decided only by satisfaction after the first eye.
In areas where driving is essential, many people may give up on multifocal lenses to avoid halos and glare at night, but this approach seems suitable for them too, so if you are interested, please feel free to consult us. Its tendency to give high postoperative satisfaction (= few complaints) also seems beneficial for surgeons, but in our clinic's experience the order of surgery tends to affect satisfaction, so next time we will publish a case in which PanOptix was used first and Vivity second.
2024.03.24