October 2018


Getting better reading vision with EDOF lenses

by Liz Hillman EyeWorld Senior Staff Writer

Symfony IOL placed with a refractive error of –0.50 D in the nondominant eye for nanovision
Source: Eric Donnenfeld, MD

“[T]here was a significant
improvement in reading for
these patients without
compromising distance.”
—Eric Donnenfeld, MD


Ophthalmologists describe nanovision and recent studies that showed a good range of vision at all distances, including improved reading vision

Monovision—induced via contact lenses, as a laser refractive surgery, or as a pseudophakic lens-based procedure at the time of cataract surgery—is a well-known method of increasing reading vision in the nondominant eye of presbyopes while maintaining good distance vision in the dominant eye. Nanovision, on the other hand, is a relative newcomer to the conversation of surgical presbyopia correction.
Three paper presentations,1,2,3 at the 2018 ASCRS•ASOA Annual Meeting, which have been submitted to peer-reviewed journals, describe the technique, which was found to provide good vision at near, intermediate, and distance and resulted in high patient satisfaction.
Nanovision, as explained by Eric Donnenfeld, MD, Ophthalmic Consultants of Long Island, Rockville Centre, New York, who was involved in the research, capitalizes on the good distance vision of low add multifocal or extended depth of focus (EDOF) lenses. The nondominant eye is left about 0.5 D myopic to induce a “nano” version of monovision to improve reading vision further.
“The concept of nanovision is to add reading vision without sacrificing binocular distance vision, and I think it speaks to the lack of technology to meet the needs of patients in the United States who want to have spectacle independence and also maintain their distance,” Dr. Donnenfeld said. “This is just one way of achieving that type of spectacle independence. You could go to a higher add multifocal, but you get the drawback of increased halo and glare at distance. We don’t have trifocals available in the United States, but they have become successful in Europe, and they solve this problem.”
Dr. Donnenfeld called nanovision a “temporary solution that gives patients good visual quality with little sacrifice.” Just how much sacrifice is that? That’s what Dr. Donnenfeld and others sought to establish in an investigator-initiated trial regarding nanovision and its use with the Tecnis Symfony (Johnson & Johnson Vision, Santa Ana, California) EDOF lens. The research, a prospective, multicenter, randomized study, investigated visual acuity outcomes of eyes with the Symfony toric IOL targeted for emmetropia or nanovision. Researchers also evaluated defocus curve and reading speed results in patients with Symfony toric lenses targeted for emmetropia in both eyes or nanovision.
The research enrolled 120 patients with regular astigmatism who had the potential of achieving 20/30 or better and 0.5 D residual astigmatism or less postoperatively. Visual acuity was assessed at 1 and 3 months postop at 4 m, 66 cm, and 40 cm at uncorrected and best distance corrected. While there was no significant difference in binocular UCVA between the two groups at distance and intermediate, uncorrected near visual acuity was significantly better in the nanovision group by half a line on average.
Reading speed was also assessed and found to be slightly better in the nanovision group, though no significant difference was seen between the two groups. There was no difference in defocus curves between nanovision and emmetropia.
Kerry Solomon, MD, Carolina Eyecare Physicians, Mount Pleasant, South Carolina, who was involved in the study, said the results, for the most part, were expected, but there were a couple of surprising factors.
“What was a surprise is the intermediate vision was measured better in the nanovision eyes; that wasn’t expected, but it was a real finding,” Dr. Solomon said, adding later, “The even bigger surprise finding was when we gave patients a questionnaire on how they think their vision in the distance, intermediate, and near was compared to the patients with both eyes set for distance. … The patients with nanovision felt their distance vision was better compared to how the distance vision patients rated their distance vision. Even though I know the distance vision measures slightly worse in the nanovision group, they weren’t bothered by it. The take-home message for me was functional vision. If I can give someone better functional vision for intermediate, computers, and reading, they’re happy with their distance vision even if there is a little bit of a distance blur.”
“I think that the take-home message is that this technique was well tolerated by patients and there was a significant improvement in reading for these patients without compromising distance,” Dr. Donnenfeld said. “It met the needs of our patients.”
Drs. Donnenfeld and Solomon said nanovision has become a regular part of their conversation with patients. Dr. Donnenfeld said with older generation multifocal lenses, there was a concern about quality of vision at distance, which led him to, at the time, place the lens in the nondominant eye first to see how the patient might tolerate the optics. Newer low-add multifocals and the Symfony EDOF provide such quality of vision at distance that this is less of an issue, he said.
“I’ve changed my mindset, and now I place the EDOF lenses in the dominant eye first, and what I want to know is how happy they are with their reading,” Dr. Donnenfeld said. “If they come back and say they’re happy with their distance and their reading is good, I put the same lens in their nondominant eye. If they come back and they say they like the distance but they don’t think they have enough reading, I can either do nanovision with the Symfony lens or I can place a Tecnis 3.25 D lens that will give more reading.”
Dr. Solomon said he discusses nanovision all the time with his patients who are seeking spectacle independence. “What I tell them is their distance vision will be a little worse, but it’s in an effort to give them a better range of vision at intermediate and near. They’re going to have a little more haloing of lights with nanovision because you get that with a little bit of distance blur, but as long as they know that on the front end, they won’t be as bothered by it. A lot of patients choose it,” he said.
Dr. Solomon said he also has positive outcomes with patients who have an EDOF lens in one eye and a multifocal, like the Tecnis 3.25 D, in the nondominant eye, allowing both eyes to be set to plano but the nondominant eye functioning at a slightly higher add for reading. Dr. Donnenfeld has taken this approach as well, but his preference is to use the same platform in both eyes.
Like anyone being considered for a multifocal or EDOF lens, Dr. Solomon said he assesses the patient’s personality, among other factors.
“I don’t do [nanovision] in type A patients or patients who are constantly going to compare one eye to the next, or anyone who is not an EDOF or multifocal candidate (those with irregular astigmatism, macular degeneration, diabetic retinopathy),” he said, adding that it is important to optimize the ocular surface, obtain accurate preoperative measurements, and optimize surgeon factors. “It’s going to be even more critical for the dominant eye that you hit plano because if both eyes are off target, patients aren’t going to be as happy. In nanovision and monovision patients, it’s critical to get the dominant eye on target for distance.”

1. Donnenfeld ED, et al. Visual acuity outcomes post-implantation of an extended depth of focus toric IOL targeted for emmetropia or nanovision. Paper presented at the 2018 ASCRS•ASOA Annual Meeting.
2. Slade SG, et al. Extended depth of focus (EDOF) toric IOL targeted for emmetropia in both eyes or nanovision: defocus curve and reading speed results. Paper presented at the 2018 ASCRS•ASOA Annual Meeting.
3. Sandoval H, et al. Visual and refractive clinical outcomes with a new extended depth of focus toric intraocular lens targeted for binocular emmetropia or slight myopia in the nondominant eye. Paper presented at the 2018 ASCRS•ASOA Annual Meeting.

Editors’ note: Dr. Donnenfeld has financial interests with Johnson & Johnson Vision and Alcon (Fort Worth, Texas). Dr. Solomon has no financial interests related to his comments.

Contact information

: ericdonnenfeld@gmail.com
Solomon: kds@cepmd.com

Getting better reading vision with EDOF lenses Getting better reading vision with EDOF lenses
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