An eye check-up had pointed out cataracts, and an ophthalmologist at a nearby university hospital recommended our clinic, so she first visited us.
Both eyes were long, over 28 mm (high myopia), so I assumed nuclear cataracts, but the nucleus was only about grade 1.5, and there was cortical opacity in the left eye. Corrected vision in the left eye had fallen to 0.6, while the right eye still had relatively good corrected vision of about 1.0–1.2 with effort.
Left eye preoperative slit-lamp photo Left eye preoperative fundus photo
Surgery on the left eye only was also an option, but she always wore glasses rather than contact lenses, so we explained that in that case the treatable high myopia would have to be left untreated to match the right eye; and that since her uncorrected distance vision was poor at 0.03 and, at her age, accommodation was zero, there was almost no disadvantage to operating on the right eye too, although its cataract was still mild.
After discussion, since she works as a piano teacher, she wished for surgery on both eyes with multifocal lenses so that she could see far, near, and sheet music at 60–70 cm without glasses.
As the blue frames in the OPD-Scan III below show, the left eye's internal higher-order aberrations had increased greatly to 0.728 µm due to cortical opacity (left column), and the black dot is badly distorted, showing reduced vision (right column). Corneal spherical aberration and higher-order aberrations in the red frames were low, with a clean corneal shape; but both eyes showed optic nerve changes suggestive of glaucoma, so after confirming before surgery that there was no glaucomatous field loss, we judged her a candidate for multifocal lenses.
Left eye OPD-Scan III
When we discussed lenses, she said she had no occasion to drive at night, so, aiming to cover the sheet music distance and live without glasses, we proposed TECNIS Synergy, a multifocal lens that gives continuous vision from 30 cm to distance.
Surgery began with the left eye, which had poor vision; the target refraction was set exactly for distance without sacrificing it, and after surgery there was no refractive error and, as hoped, very good uncorrected vision of 1.5 distance / 1.2 near.
Left eye postoperative slit-lamp photo Left eye postoperative fundus photo
After surgery, however, she said that playing the piano herself was fine, but "when teaching, standing behind a student, the sheet music is harder to see than I expected." Reading small print on sheet music from 60–70 cm is a fairly high hurdle even normally, but according to the manufacturer's defocus curve, although TECNIS Synergy has a slight dip at about 1 m, vision of 0.8 or better can be secured at 60–70 cm, so, aiming for the binocular summation effect, the right eye was operated on in the same way, set exactly for distance.
The right eye also had very good postoperative uncorrected vision of 1.5p distance / 1.2 near, but even with both eyes, the difficulty reading sheet music while teaching did not improve to a satisfactory level. We hoped she would adapt, but her dissatisfaction remained a month after surgery, and she ended up having glasses made just for seeing at 60–70 cm; I am very sorry that, unfortunately, the result did not meet her expectations.
Through this case I remembered one other patient with TECNIS Synergy who, despite good distance and near vision of 1.2 or better, said that things around a desktop computer at about 60 cm were somewhat hard to see. And with PanOptix, which on the manufacturer's defocus curve should be slightly inferior to TECNIS Synergy, in my experience there have been no complaints at all of difficulty seeing at about 60–70 cm.
(*For the defocus curves, see https://morohoshi-ganka.com/news/741 (Japanese).)
The diffractive trifocal PanOptix is actually quadrifocal in structure, focusing at 40 cm / 60 cm / 120 cm / distance, but since 120 cm is included in distance it is sold as a "trifocal lens." Typical trifocal lenses until now set the intermediate focus at 80 cm, but a distinctive feature of PanOptix is that it is set at the more practical 60 cm (arm's length). It is also said to give vision at 80 cm equivalent to other companies' trifocals. This is only speculation, but unlike the manufacturer's data mentioned above, I think that around 60–70 cm, PanOptix, with a pinpoint focal peak there, may feel easier to see.
PanOptix defocus curve (provided by ALCON)
In October–November 2021, 63% of those wanting multifocal lenses at our clinic chose TECNIS Synergy, attracted by its novelty and superior specifications, "the widest range of vision" and "seeing down to 30 cm"; 26% chose LENTIS Comfort, and the remaining 11% chose other multifocal lenses. But people like her, who consider vision at around 60–70 cm more important than near at 30 cm, might do better to choose PanOptix for reliability.
Diffractive multifocal lenses are increasing in variety and are close in performance, and patients must find it hard to decide. If you cannot find a deciding factor, I think choosing by each lens's characteristic focal distance, TECNIS Synergy for 30 cm, PanOptix for 60 cm, the pentafocal INTENSITY for around 1 m, and by the importance of the distances you want to see, will give a result you won't regret. Of course we will also advise you from a specialist's perspective, so please do consult us at your examination.
2021.11.28