March 2020


Device Focus
Clinical experiences shape EDOF and trifocal IOL use

by Maxine Lipner Senior Contributing Writer

“I will work with them to try to choose the appropriate IOL for their individual needs, but it is impossible to be 100% correct in predicting how their brain will process the information.”
—Thomas Clinch, MD

Tecnis Symfony IOL
Source: Daniel Chang, MD

PanOptix IOL
Source: Eric Donnenfeld, MD

As surgeons gain experience with extended depth of focus (EDOF) and trifocal IOLs, they are increasingly identifying patient types who have better visual outcomes with each.
Elizabeth Yeu, MD, has used the TECNIS Symfony EDOF IOL (Johnson & Johnson Vision) since early after its FDA approval and has long used a modified personal approach, which places the Symfony or Symfony toric IOL in the dominant eye and a multifocal in the non-dominant eye.
“Patients have high-quality vision with that combination,” Dr. Yeu said.
Compared to multifocal lenses, she found the first-generation EDOF lenses provided her patients with “an extra quality of vision most notable by the fact that little blips did not cause a dramatic loss in satisfaction with the patient’s vision.” For example, when patients had small amounts of residual dry eye or astigmatism, vision was not drastically adversely affected.
Dr. Yeu emphasized the need for ensuring prospective EDOF lens patients have healthy ocular surfaces, or at least ones that respond well to treatment, but she has noticed that patients can experience less degradation to their quality of vision with postop dry eye issues.
The biggest complaint of the first-generation EDOF IOLs was that they provided insufficient reading vision at near.
“Over time if you offset it or blend it with a multifocal lens implant, you can get more reading vision,” Dr. Yeu said. The distance to computer vision range of the Symfony required development of a specific patient instruction package to underscore its vision parameters.
“Even if we say it verbally, once patients are finished with surgery, they don’t remember that,” Dr. Yeu said. “They expect to be able to read and see distance, especially if they are paying additionally out-of-pocket for that type of technology.”

Enter the trifocal option

The FDA approval of the PanOptix trifocal (Alcon) in 2019 brought another option to the U.S. market that provides a range of vision.
In Dr. Yeu’s experience with PanOptix, it has a similarly forgiving defocus curve with “a nice range of vision where there is no real break but with the benefit of having the added near [vision] at 40 centimeters,” Dr. Yeu said. “I’m able to give my patients that reading vision out to distance, which has helped to simplify the conversation.”
Thomas Clinch, MD, has found EDOF lenses provide distance vision almost immediately, functional intermediate vision within a week, and improving near vision over 3 months. However, Dr. Clinch said most patients require over the counter readers for near tasks, such as fine print reading.
In contrast, the trifocal IOL provides patients with good functioning at all distances within 2 weeks, Dr. Clinch said.

Choosing lenses

Although Dr. Yeu is weighing patient experiences to drive her IOL recommendations, for most patients with healthy corneas looking for a range of vision, she leans toward the trifocal lens at this time because of the fuller range of vision provided binocularly.
However, she recommends EDOF lenses for post-LASIK or RK patients and for those who have done monovision in the past and expressed concerns about night vision and dysphotopsias.
Patients with very regular stromal beds post-LASIK or PRK “do quite well with the Symfony lens,” Dr. Yeu said.
For monovision patients, Dr. Yeu has performed modified monovision to maintain distance with monofocal lenses in their dominant eye and an EDOF with a slightly myopic target in the non-dominant eye. Providing pseudophakic monovision through placement of an EDOF lens in the non-dominant eye maintains “their monovision with greater stereopsis and greater range of vision,” Dr. Yeu said.
Although Dr. Clinch’s greater experience with EDOF lenses and the visual disturbance profile makes him more comfortable with them, both EDOF and trifocal IOLs have an important place in the patient’s decision process, he said.
More “visually discriminating” patients who prefer quality over range may perform better with EDOF IOLs, while those who emphasize function and have an ability to tolerate visual disturbances may do well with trifocals, Dr. Clinch said.
“I will work with them to try to choose the appropriate IOL for their individual needs, but it is impossible to be 100% correct in predicting how their brain will process the information,” Dr. Clinch said. “I try to determine if the patient has a ‘positive’ or ‘negative’ psychological outlook and whenever possible get input from family members.”


Dr. Yeu worries about under estimations of adverse effects on postop satisfaction due to marginal ocular surfaces. She prioritizes examining the meibomian gland architecture with infrared meibography preoperatively.
“I look carefully at the quality of what is coming out of their meibum, their blink, and what the ocular surface looks like before and after vital dye staining because I know from experience that using a presbyopia-correcting lens in patients who have moderate dry eye disease and are not excited about committing to long-term management are the ones coming back, and they have more fluctuations and quality of vision issues postop,” Dr. Yeu said.
In addition to preop treatment, Dr. Yeu forms a “social contract” with patients with well-managed dry eye disease that they will maintain postop, which may include getting lid hygiene interventional therapy in the clinic or prescription anti-inflammatory drops.
“If they are not willing, I won’t use a presbyopia-correcting lens,” Dr. Yeu said.

Dysphotopsia profile

Dr. Clinch has found EDOF IOL recipients often have mild to moderate glare, halos, or spiderwebs in the first 1–3 months. Although such dysphotopsias are usually mild and well tolerated, the symptoms can be exacerbated by uncorrected refractive error. In patients with substantial symptomatology (less than 1% of his patients), correction of the refractive error often reduces the symptoms.
The challenge can be complicated in cases where the capsule cannot be polished sufficiently in the initial surgery.
“It is hard to determine how much symptoms are from the diffractive IOL alone vs. the impact of PCO on the IOL,” Dr. Clinch said. “It is simpler when PCO develops months or years later.”
Dysphotopsias with PanOptix are very different, Dr. Yeu has found.
“There are no starbursts but maybe some glare,” Dr. Yeu said. “If anything, it will be a ring-like halo around light. I do not think it is a severe halo from my experience so far.”

About the doctors

Elizabeth Yeu, MD
Assistant professor
Department of Ophthalmology
Eastern Virginia Medical School
Norfolk, Virginia

Thomas Clinch, MD
Clinical professor
Department of Ophthalmology
Georgetown University
Washington, D.C.

Relevant disclosures

Yeu: Alcon, Bausch + Lomb, Beaver-Visitec International, Carl Zeiss Meditec, Johnson & Johnson Vision
Clinch: Alcon, Johnson & Johnson Vision



Clinical experiences shape EDOF and trifocal IOL use Clinical experiences shape EDOF and trifocal IOL use
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