JUST HAD VIVITY LENS IMPLANTED 3 WEEKS

It's weird: I spent $8000 to be free from glasses/contacts using trifocal IOLs (similiar to the PanOptix) but instead I need several glasses now (had none before surgery, only contacts). In addition I suffer from severe dyshotopsia which means huge and bright rings/spiderwebs around every point light source (up to 12 rings due to the diffractive optic of the lenses). It's six months now after surgery and no reduction at all. I'm facing explantation now and thought of the Vivity as replacement because it doesn't use diffractive optics.

I'm sorry that you and the former writers are suffering. As already posted: The Vivity doesn't provide good near vision. If near vision is needed without glasses Vivity has to come with micro-monovision. That means - 0,5 or - 0,75 in the non-dominant eye. I suppose nobody writing here was told about these facts and you are all using Vivity without monovision.

Something I don't understand is why it doesn't work in the distance. Is there any residual astigmatism? That's why I have to put on glasses for far and readers on top for near vision. What was your refraction before the surgery? It's much easier if toric lenses are not needed and best if there is no astigmatism. I had rotation and only partly sucessful rerotation. Plus significant residual astigmatism in both eyes. In that case and with complex trifocals the whole thing is already spoilt. The PanOptix is not a forgiving lens either - the Vivity was supposed to be one. I remember surgeons speaking of "a soft landing spot" that will forgive residuale refractive errors.

jw38627 - if you are thinking of explantation and if you are sure about it (ask your surgeon first about your problems, they have to do refraction tests, find out about residual refraction errors, e.g. astigmatism, rotation of the lens, misplacement and other issues) - explantation is much easier within the first weeks after surgery. I was told to wait for neuroadaption but in your case that's rather not the cause of your problems. Think about the PanOptix twice - it's a trifocal lens which means it also uses a diffractive optic. There are several posts here in the forum about that IOL. You may read them.

Sure - you can be happy with the PanOptix but you can have problems with them as well. There is another post in the forum about Vivity and there are many people happy with them. I was supposed to be happy with my trifocals (Zeiss LISA) but it turned out to be the very opposite.

Let us know what they say April 13th. Best wishes. We are in the same boat - a quite uncomfortable one.

Note: I just spoke to someone using mini monovision with Vivity and was told that in their case, contrast sensitivity is impacted by that setup. Putting in a contact to get both eyes back to perfect distance improves this person's contrast sensitivity significantly. I suspect what's happening is that the Vivity has clinically significant contrast loss monocularly but it's ok binocularly... but binocularly means setting both eyes the same so they can both work together in sync to overcome that 0.25 MTF result on the bench. That makes sense. That's what the trial data shows and that's what Alcon recommends.

Thank you, davi! That's important. It means that micro monovision will cause significant contrast loss even if Vivity is implanted bilaterally. Can you ask the person how much this contrast loss affects her/his night driving? And how much this bothers in general?

I think one factor of people perception of cataract surgery is what their vision was before having the surgery. I think a young person that just barely has cataracts will have a completely different view of the outcome from someone like me that had a bad cataract and pretty poor vision before surgery.

You mentioned significant contrast loss, I have seen various charts like the one attached, but have not seen any Real World examples of just what that looks like. If you have any links to an article that compares a monofocal lens image to a vivity image under various circumstances I would be interested in seeing that.

I think one factor of people perception of cataract surgery is what their vision was before having the surgery.

Absolutely. As always your milage may vary. A lot. I mean Ron can see down to 18" with his Alcon mono-focal. Amazing. Outragous. Incedible result. And likely very rare. But in any case the person I was talking to is close to the same age as me so it was a useful anecdote for me.

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The chart we both attached (MTF) is a bench test (as you may know). That means it's a laboratory experiment. The human eye and brain is a much better image processor. But just about every IOL gets this same MTF 50 bench test so it's apples to apples in that sense at least. Eyhance scores 0.47 on that test. Tenics 1 is just over 0.5 I think. With a 3mm aperture. Vivity peak at 0.0 defocus is 0.25.

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But you're absolutely right that real world clinical evidence is more valuable. Numbers from experiments are theoretical. In that case the best test is the "cycles per degree" eye chart tests that are also often done in trials. It was done in both of the Vivity trials. This is an eye chart test done in a clinic with real patients trying to make out increasingly more dense contrast patterns. In the trials they compare Vivity to the Alcon Acrysof IQ mono-focal. And they consider a drop of 0.3 logs compared to the mono-focal as "clinically significant". Vivity did not pass this benchmark in monocular testing (hence the warning label). But it DID pass it in binocular (with both eyes presumable set the same and/or distance corrected to remove any bias due to residual refractive error)

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That said I understand this is all still very abstract and hard to understand in real terms! BELIEVE ME! I know. I wish surgeons had photos they could show us! But everyone's result varies so much so maybe showing photos would be a can of worms surgeons would not want to open.

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"Great video on YouTube about IOL options where he shows side-by-side simulated images of mono-focal vs. tri-focal but who knows how accurate and representative those are! I bet not accurate at all. Some of the tri-focal images look really bad. Especially the night time city shot. Search "Patient Guide for Cataract Surgery Lens Implant Options" on YouTube.

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But since we're talking about this conversation I had with a Vivity recipient I can tell you what he told me. Some direct quotes in the bullet list below (lightly edited for clarity). Take it for what it's worth. Since this is just one person's experience it is of course not AT ALL scientific. But interesting nonetheless.

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Note: He did mini-monovision with one eye at 0.0D and the other at -0.5D. So when he's talking about adding the -0.5D back he's talking about using a contact lens to reset both eyes to the same peak focus point of plano.

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• You will see perfect in daylight
• Night driving is only tricky if it’s also foggy / hazy
• Distance vision in dim light is not crystal clear
• If you go bilateral Plano you will have no contrast issues
• Indoor soccer game w/ poor lighting things fall apart but put a -0.5D contact in the "near" monovision eye and it's back to amazing
• It’s so weird I add the 0.5D back and I was mind blown at the difference in dim rooms. I could see like a laser beam
• The contrast isn’t as bad as you think

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  This conversation actually happened in public on Twitter. If you search "Vivity" you'll probably find it. But the threading is a disaster because we were replying to a number of each others various out of order tweets. It probably should have been a DM conversation but it wasn't. That said since it is public I guess it's ok to reveal it.

Can you ask the person how much this contrast loss affects her/his night driving?

I posted some of his comments in a reply to rwbil above. He said night driving is fine unless it is ALSO hazy / foggy / poor vis.

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Mainly he said that distance in dim light isn't great and the specific example he gave was watching indoor soccer. Vision is not good / poor contrast / hard to follow game but put in a contact to set both eyes to the same focus point and it's "amazing" again. He didn't use the word "significant" contrast loss. That was me editorializing.

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I get the sense that by and large he's very happy and the contrast loss is noticeable in certain scenarios (no need to sugar coat it) but only in certain scenarios. He mentioned night driving being hard when it's ALSO foggy or hazy. But night driving is fine otherwise. There's no question that there will be somewhat of a trade-off in certain specific conditions (low visibility where the environment itself is low contrast... like fog / haze / snow... and low light in general).

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But the really interesting thing is that he seems to think that the 0.50D offset makes contrast worst. And he feels that going with plano in both eyes is the way to go and he notices a big difference when he simulates this with a contact lens. That makes sense since the the peak contrast of the Vivity IOL is a little low compared to other IOLs (even multifocal IOLs). So it's monocular contrast is borderline. But with TWO eyes working together at the same peak focus it's fine. This is EXACTLY what both the US and Global trials found as well. They did not test monovision.

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My personal unprofessional opinion based on the conversation I had with this guy is that monovision... even micro monovision... should only be done with mono-focal IOLs (or maybe Eyhance which is basically a mono-focal)

So many factors, such as was your friend a statistical anomaly or the norm. You mention his results match to the studies.

My biggest beef, which I have mentioned before and you also have mentioned, is Lab testing and Real-World results are not necessarily the same. I mean in the office everything is perfect from lighting to sharp black against white objects. Until they create a 4D simulated lab with lights coming at you in all direction, rain pouring on you, snow and its reflections and on and on results will always be different.

And I would just like Opthmalogist to stop over selling and promising. I just want patients to be able to see an accurate representation of what to expect and then they can make an intelligent decision on what tradeoffs are acceptable. And worse many Opthamalogists seem to be affiliated with a company and only push their brands. I know that from personal experience when I had my cataract done many years ago when almost every Opthamalogist in my area was pushing Restor and I was interested in Tecnis.

Then as an informed patient, some will decide Contrast loss at an indoor soccer game is worth getting "functional" close vision (I have described what I call functional close vision in previous posts).

Maybe one day someone will invent a simulator and you can see what your vision will look like with each IOL under an array of different conditions. This assumes the surgery went well with no issues like bad placement and way off the mark. And I would like that simulator not only show the mean results but a standard deviation or 2 out.

But that is just my pipe dream and I don't I will ever see that.

I 100% agree with everything you said rwbil. The only point I would add is about terminology.

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In trials they often do lab testing and clinical testing. The former is a lens installed in laboratory equipment on a bench. So that's purely theoretical. That would be the MTF graphs. But they do the same "bench test" with all lenses so you that is an apples to apples comparison. For what it's worth

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Trials will also always do clinical testing. That's a human in a room looking at a chart or answering survey questions. This of course is more "real world" but as you point out it's done under ideal conditions with black and white charts in controlled lighting with patients that probably have perfect eye (in terms of ocular pathology) etc. The contrast tests they do in this setting (cycles per degree charts) are probably quite similar from one study to another. But I hear you.

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So I agree it would be nice to get better simulations but really you're just adding more and more variables which will make it even hard to compare one IOL to the other. But I know 100% what you mean. And it makes the choice very difficult. And very abstract. You don't REALLY know how an IOL will work until it's done. And then it's (essentially) too late. Unless they really screwed up the power. Then they're willing to exchange. But if you just don't like it they will (rightfully) try to find other solutions first.

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What we REALLY really need is a modular system with a permanently implanted lens holder and easily snap-in / snap-out lens exchanges. If you don't like an lens (or maybe even if better lenses come out years later) you could do a simple low risk 5 min procedure to have the lens swapped out. Alcon is in fact working on this. They recently bought a startup with a modular IOL design. It's not like Juvene. The holder has standard C-loop haptics.

Thank you, David! That gives me a very good picture how contrast loss is experienced with -0.5D and the Vivity - in that person. It's a real world experience but sure we can't generalize it.

Unfortunately we don't have studies on micro-monovision with Vivity although it is already used world-wide to give patients as much spectacle independence as possible. Therefore I don't think that micro-monovision results in severe contrast loss. If so, the eye surgeons would cease to apply it in their clinics.

Monovision with monofocal Eyhance seems not to be that easy either. I came across a paper on Eyhance: In Europe 18 leading opthalmologists from different countries met in January 2019 to discuss the Eyhance and their clinical outcome while using the new IOL. At the end of the meeting one of them raised the question of using monovision with the Eyhance. I quote: "Finally, Scipione Rossi initiated a debate on the idea of low-diopter monovision (within 0.5-0.75D), thanks to the larger landing zone, in order to gain additional visual aquity in intermediate or even near. However, while there is some debate among surgeons on the concept of monovision in general, the approach will not likely seem favorable with the TECNIS Eyhance IOL as patients may see significant comprise on their distance visual aquity which is known to be the most important outcome parameter. Moreover, monovision may cause photic phenomena, is not tolerated by every patient and may demand for additional chair time."

"Increasing photic phenomena", "comprised far vision", obviously other problems caused by monovision otherwise there woudn't be a debate among the surgeons on the concept in general .... - well, I would very much like to read serious studies on the use of monovision with certain IOLs (Eyhance, Vivity, LAL). What other problems are caused with monovision? Balance, spatial vision ...? If you can't try it with contacts before surgery like me with trifocal implants (my multifocal rgp-contacts worked well, there was no reason to try monovison) you have to think twice about it. But even if you tolerate it with contacts: an IOL surgery and implants are still a box of surprise.

I think 0.5D is so tiny an offset that it wouldn't bother anyone. I tried a 1.25D offset this weekend with contact lenses and noticed no issues at all with stereo vision or contrast. Distance was a little fuzzy but not much. And 0.5D would be almost unnoticeable I think.

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The important point is Vivity does show clinically significant monocular contrast loss (i.e. enough for the patient to notice / lose a line on a pelli-robson chart). It's fine with both eyes (and presumably most of us walk around with both eyes open… LOL… so no problem). But the monocular result says to me it doesn't has a lot of contrast to spare. So I can see where someone might have issues if the surgeon uses offset targets.

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As for surgeons doing Vivity micro-mono anyway, they warn patients about contrast loss so if they get complaints they can fall back on that. And I've watched enough webinars to know that they experiment ALL THE TIME and go "off label" so to speak (use setups that there is no trial data on like mix and match etc.). And Alcon themselves don't endorse it. I'm sure that's just a "cover you a**" thing because it wasn't tested in micro-mono but still.

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Also I think we need to differentiate between monovision, mini-monovision, and micro-monovision. Micro (0.5-0.75) is such a slight offset that it should be well tolerated by anyone. Full monovision seems much more risky to me.

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Finally he didn't characterize the CS loss as "severe". I used the word "significant" but that was my word not his. I was just borrowing Alcon's language from their patient information insert. I actually tried to edit it late but it seems like this forum only allows edits within a limited time of posting. Anyway I think what he was saying is that the loss in a few very specific low light scenarios is enough to be noticeable. And that it (surprisingly) seems to be improved by using a 0.5D contact to reverse his mini-monovision. Take that for what it's worth. But I found it very interesting.

Just had another follow up visit 5/4/21. Up close vision still horrible and far away is not clear unless it's a bright sunny day. night vision is horrible as well. Doctor said the thin membrane is what's causing my cloudy vision and an easy laser surgery to pop a hole in it, but if he does that I'm pretty much stuck with these Vivity lenses.

We decided to do the lens removal on left first and then the right 2 weeks after that. I will still need that laser to clear the cloudiness down the road, but the Panoptix lenses should take care of my up close vision needs.

Doctor scheduled my left eye for 5/17/21 to remove the Vivty lens and replace it with a Panoptix. I will keep you updated.

I do have astigmatism and they fixed that. I have had prior Lasik in 2003. He used the ORA machine to properly match the lens prescription to my eye too.

I haven't found any positive reviews for these Vivity lenses.

Going from Vivity to PanOptix may be jumping from the frying pan into the fire. I believe PanOptix is associated with far more issues than the Vivity. You may want to read about the issues reported in other posts here.

JW please look into the Panoptix more. Was going to sat something similar to RonAKA. Most people wanting an exchange do not opt for another premium lens. Your prior lasik surgeries could be complicating the procedure and it mat be hard to calculate power you'll need. Monofocals offer less or no night time glare and halos too. You may end up having to wear glasses anyways so glasses free may not happen. Please research this well before deciding.

i am that guy..... here is the situation … it is a 100 percenr the contrast that is the issue with micro monovision becasue durimg the day at a soccer game for my son i barely notice the .5 offset ….. like david said you shouldmt notice it … however around dusk, night , being in a dim lit room everything falls apart … but i dont wear glasses is the pro ….. when i through in the contact to simulate plano in both eyes i see pefect in all lighting situatuons … i can tell you the test they did are spot on think about it … tecnically im mostly seeing distance monocular since im offset so i get that extreme comtrast drop off in low light when i put that contact in though i see like a champ … but now i cant read well …. another real world example for the reading portion …. mini monovision i can see my phone clear at about 15 inches … with the contact in 20 inches so you gain about 5 inches ..thats comfortable clear not like straining …so i feel as time goes on they will not do as many mini monovision with this lens or they might go distance with the vivity and then other eye panoptix to get the close range …. the contrast is really bad with mini monovision trust me im 42 and had great vision 10 months ago before this cataract formed so quick.. the pro is there are zero otehr side effects … no glare , halos , spider webs on lights nothing … its just the monovision contrast and by way i had no clue about the study before david wrote that… let me be clear the lens is awesome if you think you will hate positve dysphotopsia that you will get with panoptixs or more range then standard iol.. but the doctor will push mini monovision because they did with the symfony lens because they are used to it and i think with this lens its not a good idea

i have the vivity lens ask any questions

mini monovision - .5 near in non dominant eye , plano in dominant

currently using contact to improve contrast and bring non dominant eye to plano

might receive touch up lasik

What happens when you under correct the lens for monovision the MTF at distance goes down significantly. It is down already due to the extended focus range of the Vivity. Here is a comparison of the monofocal and Vivity lenses both set for plano.

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Now this is when the Vivity is under corrected by 0.75 D. The MTF curve shifts to the right and while it is improved at closer focusing distance, it is reduced at distance. So what you must be seeing is a loss in binocular contrast sensitivity at distance. It should be improved somewhat at closer distances.

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I think perhaps the best way to use the Vivity for monovision may be to use a standard monofocal lens set for distance in the dominant eye, and the Vivity in the close eye. That way the monofocal can make up for some of the lost contrast sensitivity more than another Vivity would.

its just crazy i see 20/20 according to the chart its clear as can be in daylight but the minute it gets dim or even overcast the vision (yes at distance not close) starts to get washed out.. i know this is a new lens but i think surgeons need to make people aware of the contrast loss if they go mini monovision because it is there ..... but im telling you with the plano the vision is awesome at distance ..... now the reading issue

Be wary of Panoptix - I got one implanted in December and it has been a nightmare. Good distance, but have to wear reading glasses for intermediate and near. Horrible night vision and halos. I'm currently trying to decide which lens to switch to in order to get a better result.

How is your vision at night? Any halos?

oops, I was trying to reply to Ryan who got the Vivity lens.

Hallo Ryan, your experience with Vivity is helping me to understand better about what it may happen with Vivity in my case.

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I would like to ask you something, to be sure I am getting the right conclusion from your experience.

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I have one lazy eye, so this means one of my eyes seea maximun 70%, and also I dont have binocular vision, this is, with both eyes opened, I get the image of the dominant eye, because my brain disregard the image of the lazy eye.

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I wonder if my kind of monocular vision is similar to what you experience with the -0,5D monovision. My question here is; If you close one of your eyes (I think this is similar to my case), do you experience loss of contrast? only in dim lit or also during day time? your answer would really help me.

thanks,