Refractive: YES Connect
July 2021
by Liz Hillman
Editorial Co-Director
The past several months have brought new advances in IOL technologies available for use in the cataract and refractive surgeon’s armamentarium. Understanding these new “ringless” EDOF IOLs can help us in fulfilling our patients’ goal of spectacle independence without some of the shortfalls of previously available IOLs. In this YES Connect column, we further explore the topic of the newly FDA approved “ringless” EDOF IOLs with a focus on postop expectations, indications, and pearls from three experts.
—Soroosh Behshad, MD, MPH
YES Connect Co-Editor
Enhanced monofocal and “ringless” EDOFs are a couple of the names floating around for a newer type of IOL designed to extend depth of focus while maintaining, as much as possible, the quality of distance vision provided by a monofocal IOL.
There are a few new non-diffractive IOLs available in the U.S., Vivity (Alcon), Eyhance (Johnson & Johnson Vision), and RayOne EMV (Rayner).
“This is a whole new category of lenses that offer increased quality of vision in patients who want to try to achieve more spectacle independence at near and intermediate ranges,” said William Lahners, MD, who has experience with Vivity and Eyhance.
With these lenses, Deepak Sobti, MD, put it, “we simply have more tools in our belt now to help patients achieve their goals.”
Dr. Sobti, who has experience with Eyhance, described the lens as having a slight central steepening that adds additional plus power and, therefore, some intermediate vision. Dr. Lahners pointed out that Eyhance, a monofocal IOL with some additional intermediate vision and a little near vision, does not have presbyopia-correcting status from the FDA, whereas Vivity does, with more powerful near vision ranges, he said.
“As a more powerful near lens, the Vivity does have more potential for mesopic and scotopic dysphotopsia than Eyhance,” Dr. Lahners said.
When using a near card with patients, Dr. Lahners said he shows them what they can expect with J5 to J6 vision with a Vivity lens, compared to J6 to J7 with Eyhance or, on the other end of the EDOF spectrum, J4 to J5 with the Symfony OptiBlue (Johnson & Johnson Vision).
“This near vision conversation is quite a simplification of reality; some patients do a little better and some do a little worse, but at least it offers a way to compare the lenses,” he said. “We do have a conversation about intermediate vision, but it is a little harder to quantify in the clinic like we can with a near card.”
As a non-diffractive lens, Dr. Lahners said Vivity has some advantages in terms of reduced night dysphotopsias that historically have been associated with diffractive EDOF lenses (though he noted that newer techniques have reduced these issues even in traditional diffractive lenses). While Vivity might have a better contrast sensitivity and glare profile at night, “there is no free lunch in optics,” Dr. Lahners said.
“Because of our volumes, we have had several explantations of both Symfony and Vivity lenses for night dysphotopsias,” he said, noting that they haven’t explanted any Eyhance IOLs yet.
The best patients for Eyhance and Vivity lenses, according to Dr. Lahners, are those who place primary importance on quality of vision (particularly night vision), even if it means wearing readers for fine print or heavy reading. While he wouldn’t consider a patient with corneal irregularities, epiretinal membrane, or other ocular issues that could interfere with quality of vision for a diffractive EDOF lens, he said he has a bit more latitude with Vivity, but he’s still cautious.
“We have seen patients with severe night disturbances, even with Vivity. Generally, the best use of Symfony OptiBlue and Vivity is in eyes that are capable of high-quality vision. I think that the more the envelope is stretched, the less likely we are to make the patient happy,” he said. “I use the Eyhance more like a monofocal and would be comfortable offering it to anyone capable of good quality vision.”
Dr. Sobti said he balances the goals of the patient with their risk tolerance in helping them decide on an IOL.
In general, Dr. Sobti said most patients are candidates for Eyhance.
“Patients with mild retinal disease or mild to moderate glaucoma would traditionally not be good candidates for multifocal IOLs. However, since the Eyhance does not significantly change contrast sensitivity and is more forgiving, we could consider this,” he said. He’s found Eyhance especially useful for patients who want to have monovision or mini-monovision, with it providing a more natural result. Dr. Sobti said Eyhance seems to be more forgiving in helping meet the refractive goals of post-LASIK/RK patients in whom IOL calculations can be difficult.
Dr. Lahners compared lenses to investing. High risk can equate to high reward, and conversely, lower risk can equate to lower reward.
“The Symfony OptiBlue lens, being the most powerful, has the most potential for night symptoms, although with the new OptiBlue these have been very mild,” he said. “The Vivity fits in the middle both in terms of performance and night disturbances. The Eyhance is the closest to a classic monofocal with less near performance but near monofocal-like night vision.”
ARTICLE SIDEBAR
- Vivity: This lens, FDA approved in 2020 and nationally launched in January 2021, is described by Alcon as a non-diffractive EDOF that delivers “monofocal-quality” distance vision, “excellent” intermediate vision, and “functional” near vision.
- Eyhance: This lens, FDA approved and nationally launched in February 2021, is described by Johnson & Johnson Vision as a next-generation monofocal lens that slightly extends range of vision due to its shape.
- RayOne EMV: This lens, FDA approved in March 2021, is a non-diffractive IOL that helps provide “enhanced” monovision, according to Rayner.
ARTICLE SIDEBAR
A look at the recently approved RayOne EMV
FDA approved in March 2021, the RayOne EMV (Rayner) is described as a non-diffractive IOL that enables enhanced depth of field.
Jerry Hu, MD, Texas Eye and Laser Center, Fort Worth, Texas, said his experience with the lens is admittedly in the early stages, but his overall impression thus far is positive.
“The most obvious advantage of RayOne EMV is its innovative optic design that combines the benefits of both positive and negative spherical aberration within a single platform. As we know, an IOL with positive spherical aberration can extend the depth of focus and induce a small myopic shift, whereas an IOL with negative spherical aberration offsets the positive spherical aberration of the cornea to improve quality of vision such as contrast sensitivity,” Dr. Hu said. “RayOne EMV incorporates positive spherical aberration in the central portion of the optics to increase the effective add power in a photopic environment, and it transitions to negative spherical aberration in the periphery to improve image quality and contrast sensitivity in mesopic conditions. The end result is monofocal image quality with added intermediate vision to the tune of +1.25 D.”
Dr. Hu said he offers this lens to patients who desire spectacle independence but who are not necessarily good candidates for multifocal IOLs, including those with mild corneal abnormalities, early dry AMD, well-controlled mild glaucoma, and previous history of refractive surgery. He said he would avoid offering the RayOne EMV to patients who already have higher positive spherical aberration than usual, such as those who have had myopic LASIK or PRK.
When it comes to patient discussions, Dr. Hu said he doesn’t explicitly advertise the enhanced intermediate vision of the IOL because it is approved as a monofocal lens. He instead includes the RayOne EMV in some of his advanced surgical packages, such as those with femtosecond laser cataract surgery and intraoperative aberrometry.
In a message to young eye surgeons, Dr. Hu said to “always be on the lookout for new technologies.”
“Be willing to try new technologies on appropriate candidates but do so gradually and with caution,” he said. “The most important message is follow your outcomes closely. Make a spreadsheet of your first group of patients and fill in their 1-month postop data when available. When you are convinced by these early personal data, you can hit the ground running and begin offering the new technology in mass.”
Relevant disclosures
Hu: None
Contact
About the physicians
William Lahners, MD
Center for Sight
Sarasota, Florida
Deepak Sobti, MD
Texas Eye and Cataract
Waxahachie, Texas
Relevant disclosures
Lahners: Johnson & Johnson Vision
Sobti: None
Contact
Lahners: wjlahners@centerforsight.net
Sobti: info@TECeyecare.com
