Extended Depth of Focus (EDOF) vs. Trifocal intraocular lenses (IOL) and confusing lens choices
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Hi all,
BACKGROUND
I am a middle aged guy in his 50s with Dysfunctional Lens Syndrome (DLS). I have had enough of glasses as they are the bane of my existence and have given me never ending grief.
I am sad to admit it, but I am clumsy. I sit on them, bend them, lose them, break them etc. With humidity and my excessive sweating, the damned things fall off my face into my food, onto the floor etc.
The last few years (thanks to high dose Prednisolone corticosteroid for an inflammatory ear disease and its hideous multiple side effects) I have suffered more rapid worsening of vision quality. Only in beginning of 2018 I had near perfect distance vision and only needed glasses for reading.
I now have progressive lens glasses to help with near to distance vision (although I feel more comfortable not wearing glasses for driving and outdoor activities). And they just do not seem to last long before I need to get new scripts to adjust the lens. Has been getting expensive. I am in Thailand stuck here for the foreseeable future because of COVID and am wearing bent frame glasses with one lens that is scratched and a chunk of glass missing LOL.
TWO SURGEON RECOMMENDATIONS - LISA & LENTIS
I saw two separate opthamologist eye surgeons recently here in Thailand. They have both concluded I have DLS after eye examinations. The very beginning of cataracts it seems.
My family has a history of caratacts so it is basically set in stone.
As such the surgeons assessed me for the suitability of intraocular lens replacement surgery. They asked me questions about my lifestyle to assess the type of IOL implant most suitable for me.
Usual day to day living:
- Reading - computers, phone - several hours per day (close to mid distance)
- Activities - walking, jogging, gym workouts, treadmill, cardio (close to mid distance for safety - hand/eye coordination)
- Driving - day and night time, with night driving limited to short trips (since I am currently medically retired). Motorbike riding (close to mid to far distance)
- Other activities - evening socialising indoor and outdoor settings, cooking, shopping etc (variations of mid to far distance)
- Watch TV about 2-3 hours or more per evening (mid distance)
- I enjoy star gazing, sky viewing, landscapes (would appreciate strong black contracts as opposed to hazy)
The first surgeon recommended a trifocal intraocular lens (IOL) from Carl Zeiss manufacturer named 'AT LISA'. Version 839MP
He claimed it meant I would no longer need glasses as I would be able to read up close, computer, TV, drive.
The downside he explained was the 'halo' effect that it can cause at night (I also read starbust, glare as well) and that unless the patient was well prepared and learned to accept and ignore it, then it could cause problems adapting to it. He explained neural adaptation being a very important part of the process.
He explained that depending on the patient, it could be weeks to months or more before you can adapt well enough to function at night (such as driving) and that over time the brain will largely ignore the visual disturbances. He claimed that for the vast majority of patients, they adapted well enough to the point of not even noticing the issues and were extremely happy with the outcomes.
The second specialist I saw at another eye clinic had a different opinion about the type of IOL lens that he prefers to recommend to his patients. He claimed that the main issue with trifocal IOL lenses was the visual disturbances at night/low light.
His recommendation was the 'LENTIS' multifocal lens (by Oculentis). He claims that with improved technology, the issue with night glare, halo etc. had been vastly improved. The trade off he explained in comparison to the LISA trifocal IOL, was that the LENTIS was a mid-strength IOL.
I later researched the LENTIS lens and realised that there are several models of the LENTIS IOL. I am not sure which one he was referring to at this time.
THE TWO MAIN CHOICES OF IOL FOR MULTIFOCALS - THE TRIFOCAL AND EDOF
After an exhaustive night of reading online, watching YOUTUBE videos, I have realised that the IOL world is complex and has a vast selection of choice.
I have learnt that there appears to be two main choices of IOL lenses for those who wish to be glasses free and have relied on progressive/multifocal glasses.
The two are the trifocal IOL and the Extended Depth of Focus (EDOF) IOL.
From what I can understand the main Pros and Cons for each are (forgive me as I know there are several others that may be considered as main points):
Trifocal:
Pros - close-up reading possible. Strong mid distance and long distance focus.
Cons -
i) Distance in-between the close up to the set mid distance focused point is blurred. The distance in-between the mid distance point to the set far distance focus point is blurred. This would necessitate at times the need to move your body within the range of the focus points that the trifocal IOL three-focal point distance settings are are, so as to see clearly.
ii) Night time visual disturbances (as well as low light). Halos, starburst and increased glare effect.
iii) Out of focus vision other than for the one of three focal points that you are adjusted to.
EDOF:
Pros -
i) greater range of focus from near vision to distance, without gaps that are blurred like tri-focal IOLs. A smoother transition from near to far objects.
ii) Significantly reduced night vision anomalies such as the halos, starburst and glaze issues
Cons -
i) Close-up vision begins at a greater distance than trifocal lens. This may necessitate the need for reading glasses for close-up work.
ii) The points of focus ranges where the trifocal lenses cover are not as clear as the trifocal IOLs.
There are other things I have not included as I became overwhelmed. The trifocals and EDOF also seem to perhaps have varying advantages/disadvantages in regards to contrast, colours, haziness. These additional points were further muddled with different brands and models of IOLs having different advantage/disadvantages.
And each IOL is on the spectrum on or somewhere in-between the refractive and diffractive range too (Google search - Refractive Multi Focal Intraocular Lenses provide better intermediate vision and diffractive slightly better near vision and less haloes and glare).
Adding another layer of confusion is the definition of EDOF. The FDA has not apparently adopted a strict EDOF definition. So, certain IOL manufacturers appear to claim their lenses are EDOF IOLs when in fact they are really only trifocal IOLs with a closer stacked visual range to look like EDOF IOLs.
(I truly recommend the YouTube Channel titled 'Eye surgery explained' that is run by a guy that truly seems to have a very in depth knowledge of intraocular lenses and the IOL industry tricks. Downside is that I have suffered information overload.)
At the night's end (about 3am) I had a whopping headache and overwhelmed. From what I thought was a relatively straight forward thing ( mutlifocal IOL implant) has turned into a minefield. I am now unsure as to what to do.
I want it all - close up 'glasses free' vision and the progressive smooth focus from near to far, deep contrasts, vivid colours, true blacks, no haziness, no night time visual disturbances, and a focus that is constantly crisp and sharp through all depths of field. Reality is it seems, you cannot have it all and there is no free lunch. I just don't know what to compromise.
I was close to booking the first surgeon there and then after he showed me a view of how my lenses may look like. But after the second surgeon's consultation and his opinion, I am very indecisive.
I would love to hear from the IOL community and their experiences. Any help to assist me (and perhaps others) in this significant choice would be greatly appreciated.
1 like, 23 replies
RonAKA Peter81761
Edited
It sounds like you have thoroughly researched the issues with EDOF and MF IOLs. I am not familiar with the particular ones you have been offered, but others here may be, and hopefully will comment. I will leave that subject to those that have researched it further than I have. I have dismissed it due to the potential adverse optical effects. My personality is not tolerant of those kind of issues...
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Not wanting to confuse you, but there is another option that you may want to consider. That would be mini-monovision where one eye (ideally the dominant one) is corrected for full 20/20 distance vision with a standard aspheric monofocal lens. The other eye is under corrected by about -1.25 to -1.5 D to leave you slightly myopic and able to read to some degree. The brain does have to get used to using one eye for distance and the other for close up, and not everyone can adapt to that. It is best to simulate it with contacts before you jump in and consider doing it with IOLs. The advantage is that you can be 95% free of glasses, and really only need them for very fine print or reading in lower light levels. For that you need reading glasses. The advantage of monovision is that it uses standard monofocal lenses for both eyes and there are non of the associated effects of EDOF or MF lenses like halos or starbursts. I currently have one IOL for distance and am simulating the slight under correction of -1.25 with a contact in the other eye. I actually like it a lot and almost never wear glasses. But, for very close work, very fine print, or in lower light I do use some +1.25 off the shelf readers. Most days I never wear them.
Peter81761 RonAKA
Posted
Thanks for your reply. I have read about patients like you who have opted for similar opposing lenses. I read one who also opted for different multifocal IOLs (Carl Zeiss LISA and LARA IOLs) in a previous post in this site.
The issue I am concerned about is losing 3D vision ability and Virtual Reality headset issues. It is a small nerdy hobby where I use VR but I want to be able to keep that option. I am not sure entirely if different focused lenses could be corrected with glasses or contacts to enable 3D viewing?
I am actually already seeing glare and starburst at night with/without my glasses and have for quite some time.
I'd be okay with reading glasses if they were infrequent, such as a pair on the bedside table just for fine print and finicky things, but being out and about I want to be unshackled from them.
I also suffer from dry eye so contacts are something I am trying to avoid too.
But then again, you seem to have a good solution!
Cheers.
RonAKA Peter81761
Edited
The research I have seen shows that 3D vision and depth perception starts to get affected if you go for more than 1.5 D of anisometropia.
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With respect to the VR, but I would expect you are looking at a screen that is quite close to your eyes. For that you would need near vision in both eyes. The close eye would should be fine in monovision, but the distance eye would likely not be. You would have to wear correction glasses for that.
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I also have a pair of progressive glasses that I wear when I want the very best vision. I would expect they would work for VR, but I have no experience. I also have a pair of +1.25 off the shelf reading glasses that give me excellent close vision in both eyes. But, I rarely use them, except for very fine work.
Sue.An2 Peter81761
Edited
Hi - I have EOF lenses implanted in 2017 (Symfony)
There are many who really do not like the night vision drawbacks of EFOF or trifocals. So it is a trade off between more range of vision vs night vision. If you work in an environment at night or with lighting or like to drive a lot at night this may not be the compromise you want to make. And if the power calculation is off you can end up needing glasses some of the time anyways. IOLs come in .50 diopters vs .25 like glasses. During healing process the IOL shifts back and forth as it is much thinner thinner than your natural lenses do that too can give you a .25 either way as well.
As your cataracts ate not severe you could keep wearing glasses for some time as often they take years to develop to point of needing cataract surgery. A lot of these surgeons push this solution to off your glasses as it is very profitable to them as these premium lenses are pricey. Don't be mislead by premium meaning better than standard monofocal lenses.
As Ron suggested you can op for a mini monovision using monofocal lenses to keep you glasses free most of the time without much compromise to contrast and halos/glare.
While your vision is still decent I recommend experimenting monovision with contact lenses to see how well you tolerate it. My own were too advanced at time of diagnosis so could not do that.
Good luck to you
dreamer2020 Peter81761
Edited
I'm in absolutely the same situation. I even spoke with that Youtube guy you've mentioned. By the way he's not that big of a fan of mini-monovision and thinks it's "poor people solution". So, in my case I've spent almost a month to convince myself that trifocals are not for me even being the only option to have all 3 distances covered. I am about to make my final decision because my cataract cannot wait for some company's lab developing a perfect ( Accommodative) IOL. I'm thinking about two particular EDOFs: Tecnis Eyehance and Alcon Vivity with a slightly different characteristics. That Youtube Optic specialist mentioned by you told me that he likes Eyehance better than Vivity for several reasons including contrast sensitivity and chromatic aberration. But my ophthalmologist never had a chance to implant it... only Vivity saying it is showing pretty good results. By the way that Youtuber offers personal online consultation for 20 Euros. My wife is joking " if you can't choose between those two IOLs - implant them both!"
RonAKA dreamer2020
Edited
"By the way he's not that big of a fan of mini-monovision and thinks it's "poor people solution"."
Actually it makes for poor surgeons. Monovision just uses standard monofocal lenses and they don't get to charge a premium price for the lenses!
Sue.An2 RonAKA
Posted
Yes agree not a good comment for him to make. Makes it very hard for people needing the surgery to get unbiased consultation. Why I like Canada's medicare system as our surgeons don't get to charge $$$$ for implanting one lens vs another.
Peter81761 dreamer2020
Edited
Thanks for your feedback. I am still torn between the EDOF lenses and trifocals. Completely ditching the glasses is a motivating factor for having IOL implants. My eyes are struggling to see clearly with these glasses I have and it seems I need yet again a change of lenses. At the point my eyes are tired a lot.
The issues surrounding the tri focal IOL dysphotopsia side effects with haloes, glare and starburst is a concern. However, as was explained by the first surgeon, this phenomena reduces in intensity with neural adaptation.
I have watched a series of YouTube videos from a Belgian fellow who had 'PhysIOL Finevision Micro F' trifocal IOLs. The videos span over a year.
He described the halo/glare issues being quite an issue initially, but with neural adaptation he describes barely noticing it and believes it has reduced significantly. He is able to read very fine print without glasses, has good mid range and excellent distance vision. He explained he would do the surgery again as he is very happy with the results. (His Channel is called Kurt V. He has other videos about his pet silkie chicken!)
I have read reviews on EDOF lenses too and they also have dysphotopic issues, albeit less severe. But if neural adaptation eventually takes care of it, then I am not sure it is such a big deal.
I have read of patients wanting trifocal IOLs removed due to the distress from dysphotopsia. But, when their opthalmologists have insisted on persevering and giving it several months more, they are usually happy. One story I read where the patient, having only a single trifocal implant, came back and wanted the second eye done after initially demanding the explantation.
But, there are also of course satisfied EDOF IOL patients. Watching candid reviews on EDOF lenses, there appears to be the need to use low strength reading glasses. But, some lucky patients manage to not require them.
The first surgeon I saw has completed over 5000 IOL implants, so is very experienced. He recommends the Carl Zeiss LISA trifocals as explained before, but when talking with him he did implant other IOLs if the patient requested a different brand.
The problem with Google searches for patient reviews, is that other than scholarly articles of chosen cataract patients, it seems that Google actively scrubs out personal reviews being listed in search results. This would be done at a cost by companies and others with interests to control feedback sites and instead only post positive ones that are skewed with their own confirmation biases.
dreamer2020 Peter81761
Edited
I've watched Kurt V's videos including the last one with 3 years post-op experience. Unfortunately here in California Zeiss is not FDA approved if I'm not mistaken. Also it is really hard to make a decision based on only one patient's experience. Both J&J and Alcon are trying to present their trifocals as IOLs with 3-5% patient unsatisfactory rate where in real life I believe it close to 15-20% which is alarming to me. Another aspect for concideration is geographic location. I'm in California and it gets dark here pretty early all year around. Plus in US, especially in California, driving is essential (and I'm not that old to be able to avoid night driving). Here, on this forum, I've seen quite a lot of posts from people regretting their choice of trifocals. By they way, for those who is saying that Eyehance and Vivity are the same - it is not true. They use completely different system to achieve good mid range. Compare to Vivity, Eyehance doesn't have any concentric rings which helps to reduce disphotopsias. My doctor told me she can implant any FDA-approved trifocal IOLs but when I ask which one is her favorite, she said that she recently switched from Tecnis Symphony to Alcon PanOptix adding the fact that she doesn't have any experience with the latest EDOFs. I suspect that the majority of her patients are elderly, low-income people who most likely never heard of things like defocus curve, contrast sensitivity, chromatic aberration, etc. that are playing main role in the quality of vision. These category of patients main concern is mostly spectacle independence and price. I'm different... I still work in office and I like things like traveling and photography. Quality of vision is as important for me as spectacle independence. That's why I'm afraid I'll have to ditch my insurance doctor and seek more professional and more experienced private clinic to help me to avoid making mistake that can make my post-op life miserable.
P.S. I just came back from my consultation with one of the Top 10 ophthalmologists in LA and was shocked when he said he would not put any multifocal in his own eyes. Gosh, I hate doctors (my apology to all doctors on this forum)
Sue.An2 dreamer2020
Edited
There are no doctors as far as I know on these forums. We are patients like yourself.
Most would agree monofocals will provide least amount of halos/glare - night vision issues. Best contrast sensitivity and sharpest of vision. Oy way to get a eider range of vision is through monovision. If one does not go for anything greater than 1.25 diopters there shouldn't be issues with things like depth perception.
EDOF and Trifocals are becoming more popular - personally think this is being driven by profitability factor by private clinics.
I live in Canada so surgery is covered by our medicare system regardless of lens we choose. Bo additional money in it for our surgeons. If I had not inquired about premium lenses my surgeon would not have discussed them.
I think if one of your top surgeons told you he would not recommend a trifocal you should give it serious thought. He would have more to gain by encouraging it.
In reading your posts and seeing your desire for glasses free you have some high expectations for the outcome. I do have EDOF lenses but I did not have your expectations . I am pleased with outcome but would have been OK needing glasses. I will say I am not so confident in neuro adaptation. The concentric circles I had in the early weeks of implantation are still just as visible today. Yes you get used to them and become accepting (if not you drive yourself crazy). The most improvement I saw was within first few months.
The younger you are the more this is about trade offs. In your 70s vision has diminished so
you gain something in cataract surgery.
dreamer2020 Sue.An2
Posted
thank you for your reply. I'm aware about the needs of reading glasses with EDOF lenses and I'm ready to pay this price for getting glasses-free mid range that would make my everyday tasks (including my full time job working on computer) glasses-free. EDOF lenses "marketing pitch" is that if you are in your 50s and have no other eye problems except Cataract , you will ONLY need reading glasses for up-close distance excluding Computer screen, car's dashboard and other similar things. And I'm still really afraid of funding myself not getting that very important mid range as promised by IOL makers. Plus since I never had any vision problem except minor presbyopia that appeared 6-8 months before being diagnosed with Cataract I never had a needs to see optometrist and have almost zero knowledge about lens powers, etc. And this fact makes it even more difficult for me to understand things like mini-monovision, blended vision, etc. American healthcare system is sucks and I'm about to become another proof of it.
RonAKA dreamer2020
Edited
" By they way, for those who is saying that Eyehance and Vivity are the same - it is not true. They use completely different system to achieve good mid range. Compare to Vivity, Eyehance doesn't have any concentric rings which helps to reduce disphotopsias."
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Eyhance and Vivity are similar in that they are both very mild EDOF lenses. Vivity is just strong enough to possibly allow some reading, but they never claim to be free of needing reading glasses. Eyhance on the other hand does not have enough depth of focus to be technically called an EDOF. There is some standard that specifies the minimum D required, and it comes up short. Vivity just makes it. I recall that there is only about 0.25 D difference between the two lenses. But, they are both stretching the focus point. You are not getting an optical perfect single point focus. There is no free lunch and when you do that there are consequences. Since the Eyhance has less depth of focus it should have fewer optical impacts, but it will not be free of them like a pure monofocal lens. I think both the Eyhance and Vivity need some monovision help if the expectation is to read normal sized print.
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My surgeon told me that he could do a MF lens (likely the PanOptix as he consults for Alcon) but he had a hard time recommending them to patients because he also would not put them in his own eyes. He is quite willing to do toric if necessary, and is also quite willing to do monovision, and even recommends it.
RonAKA dreamer2020
Edited
"mid range" - That term always raises a red flag for me. When I went into this IOL thing I would have put the car dashboard into that category. However, I believe in the real world the car dashboard for a properly done monofocal IOL set for plano distance is well within reach of a monofocal lens. When you get down to 10-18" I think that is a true mid range. Under 12" is close vision and at 4" really close vision. People that are myopic get used to taking their glasses off and seeing great down to 4".
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A couple of things to consider regardless of the lens you choose. First is that they only come in 0.5 D increments. You cannot get as precise a correction as with eyeglasses or contacts that step up in 0.25 increments for both spherical and cylinder for astigmatism. In IOLs the cylinder increments are even more course. The lowest power is 1.5 D.
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The point is that there will always be some residual astigmatism and spherical error. It is really important from a reading perspective that the surgeon does not leave you far sighted in the + correction needed zone. If you compare being left with -0.5 D to +0.5 D your distance vision is going to be the same. Not perfect but most will find it quite acceptable. However being +0.5 instead of -0.5 D is going to make a huge 1.0 D difference in your close vision reading. So, this is always a discussion you should have with the surgeon. They will have a choice in lens power to give you. The usual target is to be -0.25 D, not 0.0 D. This is to allow for the surgery error or measurement of your cornea error.
dreamer2020 RonAKA
Posted
thanks a lot for taking your time educating me! God bless you!
author11 Peter81761
Posted
I have PanOptix trifocals in both eyes... Based on what you have reported, I think you may be happiest getting the trifocals. That's the best way to be reliably "glasses free". The lenses DO produce halos around bright lights at night... but I have found this effect to be unremarkable, not the sort of thing that bothers me. Tho... perhaps it may bother you. I don't know
An EDOF by definition (and ironically) will have a shorter depth of field compared to a trifocal, and you will probably need glasses for close reading. Some people choose to under-correct one eye so that one eye sees closer than the other... and the blended vision helps them avoid glasses. I haven't done that, so I can't comment... except to say that I considered and rejected that option, and chose PanOptix trifocals.