Are you happy with your Vivity IOL? Would you recommend it?

It seems to be a physical fact that contrast sensitivity is harder to improve substantively through glasses or contacts (not saying it can't be improved at all), whereas acuity can be modified/optimized easily via readers or any sort of prescription glasses/etc. I'd much rather need glasses occasionally than permanently reduce my CS, though I might not even notice a CS reduction with Vivity lenses.

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Contrast sensitivity is also extremely important to some people personally / professionally - poor nighttime vision is the main issue I have with my cataracts, often in situations where I have no control over ambient light, AND I work in a visual occupation - but CS is also much harder to find useful, realistic data on compared with acuity. Most people don't even really have a vocabulary with which to talk about it clearly.

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For many of us, any IOL is an objective improvement over our cataract lenses when it comes to both acuity and CS, but it's a matter of determining what trade-offs one wants to make - ones that can be adjusted via glasses, or ones that are 'permanent'. Seems like a risk/reward sort of balance, but also combined with a ton of physiological and psychological factors that cannot be predicted.

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All that said, I'm really happy to hear the Vivity lenses are working so well for you! 😃 I'm planning on an Eyhance for distance in my first eye, but very well may go for a Vivity in my second eye once my first eye settles.

Well stated! All IOL's have trade-offs and unfortunately our own high expectations likely exceed the reality of potential surgical outcomes due to individual variability and a surgeon's ability to achieve intended refractive goals.

I too am looking at either a pure monofocal approach due to contrast sensitivity concerns or a possible hybrid combination using Eyhance or Vivity. My surgeon states that the 20-30% decrease in MTF is more associated improper patient selection. Vivity success appears to be very pupil diameter dependent. He states that he only sees a 12-15% decrease in his real-world experience. Night driving dysphotopsia is my second biggest concern in making my choices.

"All IOL's have trade-offs and unfortunately our own high expectations likely exceed the reality of potential surgical outcomes due to individual variability and a surgeon's ability to achieve intended refractive goals."

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Good point, although I think that the cataract clinics and surgeons kind of add to those "expectations" because they don't really tell the whole story when they discuss the options with you, or in the literature they give you. I know when I first left my first consult, I had no idea of the potential side effects of most of the lenses presented, and not a clue about using mono-vision with any of them in order to enhance the results of the surgery. It wasn't until I started researching on my own and questioning people who had had the surgery with a particular lens, that I started to realize that it wasn't going to be a simple and lovely as when first presented to me.

How does your surgeon measure MTF?

He doesn't because it's an optical bench lab test measure of an optical system of image resolution and contrast/modulation of the lens. I am willing to bet he and Alcon are extrapolating in-clinic contrast sensitivity testing as a potential guide of the IOL performance in real world compared to others. It's why you have to take any information with "a grain of salt" and seek second opinions from physicians not just aligned to one manufacturer. Additionally, it is my understanding that no study has found a significant correlation between bench optical image quality and clinical contrast sensitivity. This is why the MTF data in the product labeling has stated the same, yet a warning was later added regarding contrast sensitivity. A theoretical modulation transfer function (MTF) curve can be generated from the optical prescription of any lens and while helpful, it does not indicate the actual, real-world performance of the lens after accounting for manufacturing tolerances.

You said " He states that he only sees a 12-15% decrease in his real-world experience."

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How would he know that if he does not measure MTF?

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The MTF and Visual acuity is well documented in the Vivity Package Insert if you want to see the data from Alcon.

Already speculated likely context of his statement to known fact in previous post.

Hey Ron, as stefan said you can't to MTF with the lens in an eye. That is a test performed in the lab with testing equipment… a "bench test". The way contrast is tested clinically (in the eye) is with a Pelly Robson eye chart test. I don't know if how many lines you can see can be roughly translated to an MTF number of not but I know with Vivity most people lose 2 triplets on the Pelli Robson chart.

The Vivity provides about 0.5 D of extension to the range of focus over a monofocal. A monofocal needs to be targeted to -1.5 D to provide good reading vision. This means a Vivity in the near eye can be targeted to -1.0 D to provide a similar reading acuity as a monofocal targeted to -1.5 D.

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An Eyhance provides about 0.3 D of extension over a monofocal. By the same math, an Eyhance needs to be targeted to -1.25 D to provide good reading vision.

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I think using a monofocal in the distance eye targeted to -0.25 D is a good idea. It will ensure good contrast sensitivity at distance and will compensate to some degree for the potential halos of the Vivity and to a lesser degree with an Eyhance.

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It is worthwhile to keep in mind that MTF or contrast sensitivity follows along with visual acuity. If you target a monofocal to distance the maximum MTF will be at distance. If targeted to -1.5 D, then maximum MTF or contrast sensitivity for that eye will be at 1/1.5 meters or about 2 feet. This gives peak contrast sensitivity for both near and far with the combined vision of the two eyes.

If you read the posts, some people report greater contrast loss with the Vivity in a mini-mono configuration and Alcon's own data shows that a binocular setup provided better optimal distance acuity compared to a straight monofocal configuration. The use of a straight monofocal lens in the dominant eye is to offset contrast loss and optimize distance acuity especially at night. Not everyone is simply interested in range of vision, but quality of vision potentially supported by glasses. Monovision (mini) has its own issues in patient ability to handle the image differences through neuroadaptation challenges and the creation of problems in contrast sensitivity, stereopsis, depth of field perception, and binocular visual acuity.

"If you read the posts, some people report greater contrast loss with the Vivity in a mini-mono configuration"

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If you look at the MTF curves for the Vivity compared to a monofocal you will see that the peak MTF is significantly reduced compared to a monofocal. However, at closer distance the MTF is actually better than a monofocal at those distances. Contrast sensitivity is spread out over a range of distances rather than at just one distance. If you use the Vivity in a mini-monovision configuration the contrast sensitivity will be spread out over the range of distances and will be significantly better at closer distances.

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"Alcon's own data shows that a binocular setup provided better optimal distance acuity compared to a straight monofocal configuration."

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Any lens used in a binocular configuration will be better than a single lens. The increase is measurable but small.

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"Monovision (mini) has its own issues in patient ability to handle the image differences through neuroadaptation challenges and the creation of problems in contrast sensitivity, stereopsis, depth of field perception, and binocular visual acuity."

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Those issues have been well studied and as long as you keep anisometropia at less than 1.5 D, the loss of stereopsis and depth of focus perception are very minimal. Contrast sensitivity is actually increased with monofocal lenses across the depth of focus. See this article as an example. Graphs are provided to quantify the impact of anisometropia.

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Optimal amount of anisometropia for pseudophakic monovision.

Ken Hayashi, Motoaki Yoshida, +1 author H. Hayashi Published 1 May 2011 Medicine Journal of refractive surgery

-Lab testing, clinical trials, and real-world results are not necessarily the same.

-The Vivity trials used monofocals as the comparator and thus demonstrated that better acuity was achieved in a binocular configuration. Monovision (mini) intentionally departs from that optimal visual acuity configuration.

-Please refer to ryan13242, david98963, fred23984, and others posts regarding Vivity real-world experience.

-Monovision (mini) is not a one size fits all model due to simple fact that no two patients or cases are the same. Like other IOL patient selection, equal attention is required for the proper selection of traditional monovision or mini-monovision candidates factoring the surgeon’s confidence & ability to achieve intended refractive goals based on patient corneal irregularities, ocular pathology, the aberration profile of the selected IOL and patient tolerance to neuroadaptive, depth of field, & visual acuity issues. Execution of mono or mini-monovision is not without its own risks despite your assertions.

"Like other IOL patient selection, equal attention is required for the proper selection of traditional monovision or mini-monovision candidates factoring the surgeon’s confidence & ability to achieve intended refractive goals based on patient corneal irregularities, ocular pathology, the aberration profile of the selected IOL and patient tolerance to neuroadaptive, depth of field, & visual acuity issues."

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Pure bafflegab! Where did you copy that from?

It's standard surgical management and academy of ophthalmology practice. Take a look at the following publication for your reference: Elizabeth Yeu , Matching the Patient to the Intraocular Lens: Preoperative Considerations to Optimize Surgical Outcomes, Ophthalmology, Volume 128, Issue 11, November 2021, Pages e132-e141. Healthcare providers almost always use some sort of assessment to determine patient appropriateness and potential outcomes regarding any medical intervention including IOL's.

I would just point out that I am not a Vivity recipient… although I have, in the past, posted a LOT about it and about other people's real world experience with it. I have Eyhance in one eye. Second should be done this spring some time.

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It is a very very good point that range of vision is not everyone's goal. Ron is very helpful to a lot of people on here and he is clearly very happy with his monovision setup but it's important to remember that it is not for everyone.

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Also although a -1D offset for Vivity would theoretically give you full range of vision, from the hours of webinars I've watched (and even occasionally sat in on live, no one the wiser that I was not an ophthalmologist) and also academic studies, no one does a -1D offset with Vivity. The top surgeons from around the world from Toronto to the to the US to Australia simply never use Vivity that way in practice. The manufacturer recommends plano in both eyes and a HALF diopter offset is a VERY common "off label" practice for a slight functional near boost without strongly compromising distance and contrast… but not a full diopter.

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Yes maybe mix and match with a standard monofocal in the distance eye would be a strategy but I'm not sure how often that is done either (depends on the doctor… some are strongly against mix and match… others are fine with it)… but there is no data / studies on such a combo.

This article may be of interest.

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The Effect of Spectacle-Induced Low Myopia in the Non-Dominant Eye on the Binocular Defocus Curve with a Non-Diffractive Extended Vision Intraocular Lens

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"Conclusion: Significant gains in binocular near vision, with only a nominal effect on distance vision, can be achieved with the Vivity IOL by leaving the non-dominant eye of patients with 0.50 D or 1.00 D of myopia."

Absolutely agree that opinion doesn't always match practice and that interventions need to be tailored to the patient, which no two are alike.

They also stated that "the subjects’ longer-term tolerance to the different levels of monovision could not be assessed."

I'm going by the McCabe Vivity study done for the FDA as well as the recommendations of one of the top surgeons in my area, and Ike Ahmen in Toronto, Catherine McCabe herself, John Berdahl from Australia and countless other top surgeons. None of them have ever suggested a 1D offset with Vivity. Of course it can be done (and thanks for the link above Ron) and in theory will give you full range vision but I'd be VERY wary of doing more that 0.5D with an IOL that has been shown on the bench to have HALF to peak contrast of a monofocal. I also personally spoke to a Vivity recipient who only had the typical 0.5D offset and he was very unhappy with his distance vision in low light as a result of contrast issues with his offset and now wears a .5D contact all the time to correct it. That is anecdotal and very specific to his lifestyle requirements (watching indoor soccer) but it's still worth considering. I would leave the bigger monovision offsets to the standard monofocals (like Ron has) and only ever do a micro offset (0.5D) with Eyhance and Vivity. Especially Vivity since it's monocular peak MTF is so low.

When you look at the pros and cons, using EDOF lenses in a mini-monovision configuration really does not add much in the way of visual acuity. The main benefit is a little better distance vision in the near eye, but I would question the value of that when the other eye can see much better at distance. Mini-monovision works very well with just monofocal lenses, and without the acuity losses/risks associated with an EDOF.

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A neutral asphericity monofocal lens like the B+L enVista may be as good as any for mini-monovision. It is a also a lens that is more tolerant to less than perfect eyes and perhaps less than perfect surgical placement in the eye.

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My most recent refraction this past week show my eyes have drifted a little, although it may be just test to test noise.

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Right: -0.375 D SE

Left: -1.625 D SE

Anisometropia: 1.25 D

Cataract surgeon Dr. John Berdahl is with Vance Vision in South Dakota, USA

However, since you mentioned Australia, this article written 5 days ago by an Australian cataract surgeon's experience with Vivity may be of interest. He has been very pleased with it.

"How Alcons Vivity is disrupting the Australian IOL landscape"

Ah thank you for the correction! I watched a webinar 2 years ago with a bunch of surgeons, one oh whom was from Australia (and John) and I guess I mistakenly remember it as him. Must have been someone else on the panel. Anyway the point stands… I've never heard of one of these top surgeons using anything more than a half diopter offset with Vivity. I think if you're going to do more than that you are better off sticking with standard monofocal lenses.

How Alcons Vivity is disrupting the Australian IOL landscape

Vivity is a great lens. Its revolutionary I'd say. And I VERY strongly considered getting it myself. I just would not offset them at all. Maybe one step (0.5D) at most.

Well, I didn't want to spend the money on a premium lens. Also, I had a very dense cataract and I wanted my surgery to be simple and quick. My Tecnis 1 monofocal targeted for intermediate vision in both eyes has given me excellent distant and computer vision, and good near vision, although I wear readers for sustained close up reading.

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The problem with the Vivity in the close eye is that you will be well short of good reading with only a 0.5 D offset.

That's not a problem if you don't expect reading vision from it. If excellent glasses-free reading / near is of utmost importance to a person I'd go with panoptix, traditional monovision with monofocals, or maybe a myopic target in both eyes… as long as they are well aware of the trade-offs with each. I would not do bilateral Vivity with a 1D offset and I suspect you may habe a hard time finding a surgeon that would do that anyway.

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Again a 0.5D Vivity offset is commonly done and can give you pretty good functional near (not perfect and not always glasses free but good enough for most quick tasks) which seems like a pretty good balance of trade offs. Personally with it's low MTF scores though if it were MY eyes and I decided to do Vivity I would do bilateral plano, understanding that I would need readers.

My opinion would be that a Vivity with only a 0.5 D offset would be a waste of money. A bilateral Vivity targeted to plano would be an even bigger waste of money. If the surgeon would not do the 1.0 D offset I would go to someone else or use another solution such as monofocal monovision. I also would not do the Vivity in both eyes, only the near eye. A friend has bilateral PanOptix and still needs +1.75 readers, so that is not a sure thing either. When you look at the full picture it is hard to beat mini-monovision with monofocals.

First, I found your discussions on the Vivity and Eyhance from 2 yrs ago and I'm amazed at how similar we are having the same conversations even now. Great insight from both of you (Ron and David) and I agree that your both likely right depending on patient and expectations. I'm all for the best quality vision including having no induced spatial depth of field ocular disparities that departs from normal human vision standards. For me, Monovision (mini) is a deviation from normal ocular vision biological design as intended, so just because it can be done doesn't make it right or desirable. I do agree with Ron however, as to whether it is worth paying for a form of vision correction that may not achieve its restorative goals owing to a comorbidity or visual acuity compromise. Patient value may literally be in the "eye of the beholder"! I currently seem to be gravitating more toward 2 x Eyhance or a Eyhance with Tecnis plus readers for near as needed.

Stereoacuity is insignificantly impacted as long as you keep anisometropia at 1.5 D or less. Much of the data/opinions on monovision is based on anisometropia of 2.0 D or more. That much is not a good idea.

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Ron,

You mentioned that Vivity provides about 0.5 D of extension to the range of focus over a monofocal. Does it mean that if I were to get a monofocal set to -0.5 D then I should get the same midrange and possibly near range as Vivity without the associated issues with EDOF? I understand that I will be losing 0.5 on the far range but in theory this should allow a person to walk around without glasses most of the time and one can put on distance glasses if needed for driving at night, etc. Am I missing something or is it really this simple?

Yes, that is correct. A monofocal set to -0.5 D is going to give you about the same nearer vision as a Vivity set to plano. That said the normal practice is to target a distance set lens to -0.25 D to give a margin of safety against going positive (far sighted) which hurts the near vision. So if the Vivity hits the target of -0.25 the result is a total increase in depth of focus of 0.75 D. And if the monofocal hits the target of -0.5 D then you will be a little short of where the Vivity would be.

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One strategy would be to target full distance (-0.25) for the first eye with a monofocal and then if you achieve it, target the second eye for closer, once you have distance vision "in the bag".

This makes me wonder why would one then even consider an EDOF with associated risks? As someone else mentioned, you can correct acuity with glasses but you can't do that with loss of contrast. If similar results can be achieved with some minor tweaking of monofocal then that makes more sense.

Yes, that is why I like monovision. You have one option for vision without glasses, and can still get a full range of useable vision. And, you can have a pair of glasses to fully correct both eyes for the situations where you want the very best distance vision in both eyes.

Monofocal IOL's really do seem to be the best path to avoid the issues of EDOF or multi-focal lenses. However, there is still one major drawback to the monovision philosophy with monofocals. You don’t have the use of binocular vision as you would have when both eyes are corrected equally. In addition, not everyone can adjust to the neuroadaptive requirement for the dual image blur processing, and it often also results in a loss in near stereopsis, which can affect depth perception. In my mind, monovision creates visual compromise only to achieve an extended range of vision by sacrificing retinal image quality with the hope of being eyeglass free. It’s simply an approach that can meet select patient needs at the expense of optimum visual acuity.

With full binocular distance vision, you can expect to have dramatically enhanced distance vision with spectacular clarity, acuity, improved visibility in low light, and stereopsis. This option will not correct presbyopia, so patients will still need to wear readers to view things at close range. It’s another approach, but it aligns with natural optimal vision quality.

you can correct acuity with glasses but you can't do that with loss of contrast

I think it is just a matter of personal preference. This same idea is why I decided against a Vivity for my first eye, but someone less particular about contrast / low-light performance might be happier with greater EDOF since they'd likely have noticeably increased uncorrected range.

Actually that is not a fair characterization of mini-monovision. Based on personal experience I have full binocular vision from 20" out to 10 feet or so. That is the overlap of very good vision with both eyes. My distance vision is 20/20+, and my near vision is Jaeger J1 in good light. This is with a differential (anisometropia) of about 1.25 D between the eyes. Of course one can use less than that if one is willing to sacrifice some distance or near. And with glasses I have perfect vision near and far.

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With EDOF or MF lenses one risks less than good vision near or far, or both. And eyeglass correction can be more difficult.

"You don’t have the use of binocular vision as you would have when both eyes are corrected equally."

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I (and my optometrist) would have to disagree with you on that. I have Eyhance implanted in both eyes with a mini-monovision of 1.0D difference (targets rounded out at -1.25D and -0.25D). After a myriad of tests at my five week checkup, the optometrist concurred that I am experiencing full 3D binocular vision. The results showed me at 20/20 in the "distance" eye and 20/40 in the "near" eye, reading J1 and better at 14". And while the vision in each eye individually is doing a great job of what they tested for -- but together, things really meld -- my overall vision is indeed enhanced, from near to far with no need for glasses (except for maybe tiny tiny print, though I often can still figure that out). They really work together quite flawlessly with no sense of which eye is doing which job. The optometrist said I could get progressive glasses made up for difficult weather driving if I really wanted, but saw no real reason for it.

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There was no neuroadaptive adjustment needed on any level (I didn't do a monovision trial before surgery either) since the difference between both eyes is within an accepted range for mini-monovision -- which was then further aided by the very slight EDOF (+0.3D) the Eyhance offers so I didn't have to lean very far onto the myopic side of things to get what I wanted. My surgeries seemed to have been pretty much "plug n play". I'm not experiencing any loss of contrast in dim light situations (still wandering around in the dark by just a night light at most). I have no problems with driving or walking down moonless dark roads, etc. I have no artifacts, no problems with depth perception, no loss of clarity and the colours are true. The night sky is awesome, as is everything else around me, day or night, that I've been making a regular point of looking at very analytically for the past seven weeks post surgery. I have a background in design so all of the above things are very important to me. These "new" eyes of mine so far have been freaking peachy keen, lol.

anecdotally, I totally agree with @karbonbee and their optometrist.

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my binocular vision is noticeably better than either of my monocular visions, even at ranges where one of my eyes is quite out of focus. for example, I only see 20/30 corrected in my right eye at distance and my left eye (recent post-op, Eyhance) tested right around 20/20 (I think it was 20/20-1 with some ghosting), but both eyes open is better than either alone at distance.

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similar effect for near vision, where my Eyhance eye is very blurry but my natural eye is clear: binocular summed is better than either alone.

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at any distance, binocular depth perception is better than monocular, and the hard-to-articulate 3D/stereoscopic effect is noteworthy, too.

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there's certainly a threshold where an out-of-focus eye is not helpful to acuity/depth perception/etc., which I became well aware of when my left eye degraded...but it's not accurate to say that one's eyes need to be equally corrected for binocular summation to be of significant benefit.

I'm glad your not experiencing issues, but research studies say otherwise. Clinical studies have shown that binocular vision gives the best optical correction and is significantly better than a monocular dominant eye condition, and the monocular non-dominant eye states. These findings are consistent across other studies and also support the fact of better depth perception with best-corrected binocular correction than with monocular vision. Results are dependent on individual factors, such as degree of ocular defocus differences, aperture centration, and/or sensitivity to mesopic conditions.

Study findings also suggest that our visual system compensates for habitual optical aberrations through neural adaptation or plasticity and thereby can optimize stereovision uniquely by individual again limited by small optical aberrations and by neural adaptation to one’s own optics.