Monofocal or EDOF - Near vision after surgery vs before

Many thanks. I think we discussed mini-monovision on here last year. I have tried it with contacts in the past a couple of times but didn't really get on with it.

I'll have a look at the Vivity link, although we've ruled out that lens already because of the contrast issue (big thing for me as I ski a lot and you need contrast in the snow)

Thanks again.

PS. Your vivity link didn't work. I assume you meant this one?

https://www.accessdata.fda.gov/cdrh_docs/pdf/P930014S126C.pdf

Yes, that is it. It wasn't a link, just a title to search for with google. I have pretty much given up what links are allowed here and which ones are not. The arbitrary moderation of links is one of the most frustrating things about this site.

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On the contrast sensitivity loss with the Vivity I think it is most noticeable in low light conditions, not sunny snow conditions. And if you consider Vivity, I would only use it in your non dominant eye, while using a pure monofocal like the Clareon in the dominant eye set for distance. That way the monofocal can make up for lost contrast sensitivity.

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The other thing to consider is micro-monovision which is targeting the near eye with less myopia in the -0.5 to -0.75 range. This is going to help some with the intermediate distances, but not give you good reading vision with a monofocal, although a Vivity at -0.75 D might be starting to get close.

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If you go with straight monofocals set for distance there are some slight differences. Tecnis 1 provides the least depth of focus, while the B+L enVista provides the most. The Clareon or AcrySof IQ is about in the middle.

Thanks again. I won't be having Vivity because I want to ski in flat light as well as sunny conditions (skiing vison is particular as contrast on snow in flat light is difficult anyway, without being compromised by an iol or cataracts).

I've pretty much decided to have either (undetermined) monofocals or Lentis Mplus EDOFs which my prospective surgeon rates highly and which don't affect contrast (I understand)

As I say, I'm not that bothered about using readers but being relatively free of them would be a nice bonus.

If you really sit that far from the computer (3-4 feet) you should do fine with monofocals set for distance. You will almost certain,y need readers closer up though. I don't know anything about the Lentis IOL but I think JnJ Eyhance or Alcon Clareon Monofocal would be good choices.

Thanks. for that.

I measured it & it's 47 inches

You may want to look at the MTF and Defocus curves for the Lentis lens. Some manufacturers like Alcon with their Vivity publish the curves, and some do not. If they do not, then you don't really know what impact the EDOF technology has on contrast sensitivity and peak visual acuity. The "there is no free lunch theory" would suggest when you stretch the focal point of the lens there is loss of visual acuity and loss of contrast sensitivity. I am not familiar with the Lentis lens and the technology it uses.

Cheers, I had a look. This is the, claimed, defocus curve

I didn't know what MTF was and after a little research I'm still not clear. I can't find any numbers for it for this lens.

MTF basically means contrast. If you spread the available light out over a longer range, the amount of light (and therefore contrast) at any one point along that range of focus will be less than the amount of light at the one point of focus of a monofocal.

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The reason EDOF and MF lenses can get away with this is because in bright light (like daylight) your eye is already getting more light than it needs anyway for a crisp, clear, high contrast image. The trade off is that you will notice the difference in lower light or flat light (think fog, rain, overcast and snowy, etc.)

That defocus curve indicates that lens is a multifocal, not an EDOF. The clue is the bump up in visual acuity as the distance reduces. That suggests it is a bifocal version of a multifocal lens.

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In the Vivity package insert document you can see an MTF curve which is a measure of contrast sensitivity. They include the curve for a standard monofocal to compare to the Vivity. Assuming they are using the same units this would be a good reference.

Thanks again. The surgeon I saw did call these EDOF and stated that he does not use multifocal lenses at all (although that was in response to my asking about the concentric circle type MFs)

Looked a bit more but still can't find MTF stats for these lenses.

I did however find an article from 2010 which says

"Contrast perception with the Lentis Mplus is equivalent to that of a 20-year-old with healthy eyes" ..... which sounds pretty encouraging (usual caveats of course) I won't post the link because of the auto-moderation but anyone so minded could google "Lentis Mplus: An innovative multifocal lens technology"

I think for me it's going to come down to trusting the surgeon and his advice. I have met with this one once and left feeling confident. He doesn't have very many online reviews (50 or so) but what there are all good but I'll take my time before deciding, both about the surgeon and the lenses.

Thank you again for your input on the lenses. Very helpful.

On my read of the Lentis sales information, the Mplus lenses are hybrid EDOF plus multifocal technology. They are quite unusual in that they are like a bifocal with the bottom section providing an Add to get the nearer vision. The Add is what is responsible for the bump up in nearer visual acuity. They seem to come in three flavours with progressing Add power. It seems to me that they would provide vision similar to having a major irregular astigmatism effect. If purity of vision is a desire, they would not be my choice. Here is an article to read that is somewhat dated, but provides a review of choices. The Vivity is not included in the EDOF category, as I suspect it was not available at the time of the article. Also keep in mind that multifocal technology also impacts contrast sensitivity as it effectively splits the light coming to the eye. If it meets a minimum standard the manufacturer may not disclose that though. The Vivity just missed that minimum standard which is why they have published data disclosing it. Other styles may just make it over the minimum and be effectively the same.

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https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7299221/

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I will post an image in a separate post because it will get moderated that compares some of the monofocal lenses that provide some extra depth of field but fall short of the minimum 0.5 D addition to be called an EDOF.

Here is a graph of visual acuity vs depth of field (focus) with various monofocal lenses on it. It is published by Bausch & Lomb to promote their enVista monofocal as having an increased depth of focus. They and others do this with residual spherical aberration. The Tecnis 1 lens fully corrects the +0.27 um of SA in the average cornea by building in -0.27 um of negative SA. It has the highest visual acuity but least depth of focus. The Acrysof (Clareon will be the same) partially corrects SA and provides more depth of focus. The enVista lens provides zero SA correction (SA neutral) and provides the most depth of focus. It is also said to be tolerant of lens position be off center or tilted. The Eyhance lens does not admit to what SA correction they have used, but based on their claim for extra depth of focus I have added them to the curve. It provides less than the enVista but more than the AcrySof IQ or Clareon. The only issue with the Eyhance is that I believe they change the power of the lens quite quickly in the center area, so it becomes pupil dependent. There may be pros and cons to that. It may not be quite as insensitive to the lens position as the enVista. If your interest is in staying away from the side effects of EDOF and MF one of these lenses that provides some extra depth of focus may be a better choice than diving into a lens that is a hybrid EDOF and MF.

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I forgot to add this image to the post. It shows the defocus curve of the Eyhance compared to the Tecnis 1. It is hard to find an accurate defocus curve for this lens, but this one makes some sense. The is a small loss in peak visual acuity, and extension of the depth of focus. It is worth keeping in mind that they are comparing the Eyhance to the Tecnis 1 lens which has the least depth of focus of common monofocals. If they had compared it to the AcrySof IQ/Clareon it would not look so impressive. And if they had compared it to the enVista it would look worse instead of better...

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Yes, I agree-- on overcast days or when it's actively snowing, or if you are night skiing you are going to want that contrast! Not to mention on sunny days there are shadows on the snow from trees, and you'll want to see the snow clearly in the shadows.

Since you want the best possible vision and don't mind readers, you should get monofocals.

My friend is an airplane pilot and his doctor talked him into getting Vivity. Technically he can drive without glasses, but he still wears bifocals because he wants the clearest possible vision, near and far. On top of that he finds the EDOF annoying when driving because both the street in front of him and every bit of dirt on his windshield are simultaneously in focus!

Thank you for that article. Long read but enlightening .

Thank you too. I have the skiing into shadow issue. Sunny day, skiing with others in the sun, then we move onto a trail in shadow and suddenly I have to slow down a lot while everyone else keeps going. This was the first thing I noticed with my vision and started to happen a couple of years before cataracts were even mentioned.

Interesting about your pilot friend. I was under the impression that commercial pilots could only have monofocal iols (told to me by a different ophthalmologist)

Thanks, he is an older guy, Vietnam vet, who teaches flying. I don't know if teaching at a flight school is considered commercial as he doesn't fly for a commercial airline.

I think he would have been much happier with monofocals-- but our local go-to hospital for cataract surgery really pushes the "premium" lenses and the laser-assisted procedures. He trusted the recommendation of his care provider, which for him was the fellow working under the supervision of an extremely busy in-demand highly rated ophthalmologist.

One thing that really struck me about his experience was that when he went for his second eye surgery, after they sedated him, the surgeon asked him if he wanted his second eye to be a little more tuned for distance or for near vision. He had to choose right there in the operating room while under conscious sedation! The surgeon had on hand a selection of Vivity IOLs in different powers to choose from.

I just don't get how he wasn't given the opportunity to think that over and make that decision in advance.

I went skiing last month at Steamboat and Arapahoe. My cataracts are so bad that I had to have one of my kids babysit me on each run and lead me slowly down the mountain-- I just locked into them and followed them exactly so as to avoid bare patches and bumps. My kids didn't understand what I meant when I said, "everything is white" until one of them was up at the top of Arapahoe in heavy snowfall and wind blowing and he was like-- "I couldn't see the contrast-- I couldn't see the tracks in the snow." And I was like "duh, that's what I've been saying all along!"

Here is an interesting and quite detailed article on the enVista lens which kind of goes with the images I posted that are still in moderation. The advantage of the enVista is the increased depth of focus and tolerance to being off center. I think it is a good choice to get increased depth of focus without the side effects of a full EDOF MF hybrid.

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Bausch Surgical EU ENVISTA SIMPLIFEYE Brochure compressed PDF

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In comparison to the Eyhance which varies the power of the lens based on the radius, the enVista maintains the same fixed power over the whole radius of the lens. This is a fairly old lens but seems to have been updated in about 2017 with a change in material that lets it unfold in the eye much more quickly. The older lens was the MX60, and the newer one the MX60E. It is available in North America but is harder to find than the more common Alcon and J&J lenses. Not sure about the UK, but this is an EU publication.

"The surgeon had on hand a selection of Vivity IOLs in different powers to choose from. I just don't get how he wasn't given the opportunity to think that over and make that decision in advance."

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Not only should the patient have been given the chance to think it over, the surgeon should have thought it over in advance too! The Alcon ORA system measures the eye during surgery and an on the fly decision on lens power has to be made, but that also needs to be discussed well ahead of the surgery and the target, if not the IOL power, needs to be agreed on ahead of time.

I requested more near vision (first eye was targeted for distance) in a post-op with the surgeon's assistant before the second eye was done 12 days after the first eye. I asked for mini-monovision, the term I picked up from Ron. Recently, I have learned from reading studies that what I have is hybrid monovision with a 1.0 D differential between the two Vivity IOLs. I can't recommend decisions for others because of the differences among us. There are limitations with every aspect of the process, so it's a matter of evaluating the risks against the rewards as best we can.

Are you satisfied with the outcome that you got? I think -1.0 D in the near eye with a Vivity is a good target. With the EDOF built in that should be equivalent to about -1.5 to -1.6 D with a monofocal lens.

Yes, thanks...

"I had to have one of my kids babysit me on each run and lead me slowly down the mountain-- I just locked into them and followed them exactly so as to avoid bare patches and bumps. My kids didn't understand what I meant when I said, "everything is white"

Similar experience. I'm not that bad yet but my kids don't really get it. Think I'm getting old and can't keep up (painful truth!)

The "everything is white" thing is what I get in flat light and shadow. Just can't see the terrain or bumps. Skied off the edge of the piste a couple of times! I have a goggle lens for low light (Oakley Prism High Pink I think it is) and that gives me a little more contrast but it's still a problem

Thanks, those ski goggles look really nice! I'm hopefully getting cataract surgery in March or April. I'm heading to Europe for a consultation at the end of February to see about getting a German made HumanOptics IOL. Due to my extreme myopia I am not eligible for a lot of IOL options here in the US and I was only offered a 3-piece Acrysof IOL with a 30-year-old design. The HumanOptics IOL has much better optics and is available in my Rx, but it's not FDA approved.

My US insurance won't cover medical care in Europe but the surgery is only about 3000 euros per eye and my deductible is $6000 in the US so the cost will be roughly the same as it would be here. I'll have to pay for the travel expenses but I think it will be fun to visiting the Alps for my surgery.

I have been really surprised by the level of personal attention I received from the two different cataract surgeons I've spoken with in Europe. If you go to a private practice in Europe you are given so much time and attention. The surgeons I've consulted here are overbooked and always in a big hurry and I've had to do all my own research.

I believe there's a wider range of lenses available here in Europe than in the US.

Are you going to Prague? I understand that some of the best cataract clinics operate there and the prices are very low. I've considered it myself but my UK insurance will cover the bulk of it and I've found a surgeon I think I like.

I have pre-existing eye pathology that makes my surgery risky and limits my IOL options. So my priority has been finding a surgeon who has extensive experience with high risk cataract surgery and access to and knowledge of IOLs that will work in my unusual eyes.

The FDA approval process is something of a barrier to innovation in medical devices in the US. Europe and the rest of the world have a lot more options for IOLs. Even so there are plenty of IOL choices for normal eyes in the US. I just have unusual eyes and they tend to get ignored by profit driven manufacturers who are focused on developing premium lenses for typical eyes.

I'm not going to Prague because I think the clinics there primarily do routine surgeries. I'm actually heading to the area near Kitzbühel and Dolomites. I was thinking it might be fun to combine the visit with some skiing because our Ikon passes will cover the lift tickets. But I got too overwhelmed trying to find hotels near the slopes and trying to plan everything. I've only ever skied in the US so I felt like it was too much to learn from scratch and my focus should really be on planning my surgeries.

If you are in London I have a few names of surgeons that were recommended there. I consulted with one and she was wonderful but unfortunately she didn't have enough experience with extreme myopia and long eyes like mine. She loved the Zeiss lenses-- her go-to monofocal was the Zeiss Asphina 404P. She also said there was a really promising new EDOF in trials that was going to be available soon but I don't know which IOL she was referring to.

Skied Kitzbühel 20 years ago after an 18 year break from skiing. It's a great resort.

I am near London. There are lots of excellent ophthalmologists here largely because of Moorfields eye hospital (world renowned postgraduate training hospital). Some of their prices match their reputations though, the high end can be up to US$7000 per eye.

One thing to think about getting surgery away from home is the aftercare, but I'm sure you've considered that.

Thank you, I found a really good anterior segment specialist who agreed to provide local follow-up care for me on an as needed basis after my surgery. I wish I could do the surgery with him but he simply doesn't have access to the same selection of IOLs that doctors in Europe have.

Worst case scenario would be to get a retinal detachment as a complication of surgery and have to get corrective surgery in Europe, which usually means they inject gas bubbles into the eye, and then I wouldn't be able to fly home for many weeks while I wait for the gas bubbles to be absorbed.

But I'm just going to have to hope that I don't get so terribly unlucky.

I think I was quoted a cost of £4000 for surgery at St Thomas' but I don't remember exactly-- it you don't let them talk you into the premium lenses the cost is much lower. Truth is most eye surgeons would choose monofocals over premium lenses for themselves but they make a lot of money on the premium lenses so they are happy to sell them. I definitely would go private if you can afford it because with NHS I don't think you can't choose your surgeon.

"Truth is most eye surgeons would choose monofocals over premium lenses for themselves..."

Is that true? It would be interesting to know. What evidence have you seen?

Yes, it is true. If you google surgeon preferences for their own cataract surgery you will find articles and videos indicating that the majority would choose monofocals. Not all surgeons would of course, but most would. There is a YouTuber who made a video about it that you can easily find by googling. Just now, a quick Google search led me to this quote from a 2019 publication, "Monofocal options were the most popular surgeon preference whether or not astigmatism was present, suggesting that quality of vision is more important to the respondents than glasses independence."

When I went to my initial consultation for cataract surgery my surgeon told me that he had a hard time recommending multifocals like the PanOptix as he would not put them in his own eyes. But, 2.5 years later when going for the consult on my second eye he suggested a PanOptix for me! In the 2.5 years that had elapsed his father who was an ophthalmologist too had passed away, and he inherited his practice and clinic. He was handing out fancy brochures on the PanOptix and Vivity. I suspect the financial reality of operating his own clinic with at least 3 staff had set in. Prior to having his own clinic he was operating out of the local hospital that had a large ophthalmology department. He had none of those overheads as the staff, instruments, and clinic space were provided by the hospital.

Thanks, ka76787. As I thought, the info from the article you referenced is very interesting. Couple of observations:

1. The survey data in that 2019 publication is from early 2017, so it's over seven years old now. At that time, about 61% of surveyed ophthalmologists said they would choose monofocal lenses. I wonder what a 2024 survey would show. The use of premium lenses has increased in recent years. Perhaps the 61% has by now dropped below 50%?
2. The same survey data suggests that the doctors are actually more conservative with patient eyes than their own. That is, they are more likely to choose monofocal lenses for patients than for themselves. Compare Figure 3 with Figure 2, for example.
3. A lot of the docs who would choose monofocal lenses for themselves also would choose monovision. Nearly half of them. I suspect they are also likely more conservative with patient eyes in this respect. Perhaps to the detriment of the patients...
4. My impression is that the RxSight Light Adjustable Lens LAL is becoming increasingly popular among ophthalmologists for their own cataracts. LAL is a monofocal lens, but may need a different response category if such a survey is done again in the future.

For sure things like that happen, RonAKA, and I can easily believe that in some cases a surgeon's view changes due to his own financial considerations, rather than because of additional experience with the lenses or the patient's best interest.

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FWIW, my experience was very different. My surgeon has two premium lenses in his own eyes, and recommended Symfony OptiBlue for me. I had to advocate firmly for the monofocal lens I eventually received. Despite the fact that my premium monofocal was even more expensive than the Symfony.

I suspect that the LAL is not likely to become a major contender in the IOL market due to cost. I recall from that Mayo Clinic video that it was less than 1% or so. I also suspect for ophthalmologists that cost is not an issue.

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To give my surgeon some credit, after I dismissed the PanOptix option and we discussed the Vivity, in the end he discouraged me from going with the Vivity. So essentially he did recommend a monofocal when it came down to the crunch.

What I do is I read every article I can and watch every video I can to find what the general consensus is rather than relying on one particular source. As this forum moderates links and also names of doctors it's just too time consuming to try to post all of that. So I was using that particular article as an example of the many sources I have found that state that more than half of ophthalmologists would choose monofocals for their own eyes. I think now with the advent of monofocal plus IOLs those are becoming quite popular as well with surgeons.

One interesting thing I read was a panel of surgeons describing what they would choose for themselves. Of course all of the ones who disclosed their relationship with a particular IOL chose the one they were affiliated with. But one surgeon said something very valuable-- and that is that he would choose his surgeon first, and then he would choose an IOL that the surgeon was comfortable with. And the reason for that is that you don't want a surgeon implanting something they are unfamiliar with. You want your surgery to be as routine as can be, something they do every day, not a special or new procedure where they are learning something new.

The interesting article I mentioned is from Feb 2022 published in CRST and can be found by googling:

The Surgeons’ Desires

Panelists discuss what IOL technology they either have selected for their own eyes or would select if they were to require cataract surgery soon.

From the 2019 article:

" Surgeons who implanted at least 50 accommodative IOLs are two times more likely to select a presbyopia-correcting IOL option (odds ratio = 2.0 [1.02–4.15]). Of the surgeons who value glasses independence, 55.0% would select a presbyopia-correcting IOL for themselves. Of the respondents who did not find glasses independence valuable, 72.3% would choose a monofocal set for distance or monovision. Surgeons who value glasses independence are two times more likely to select a presbyopia-correcting IOL (odds ratio 2.1 [1.13–4.00])."

I read the Feb 2022 article and noted that cataract surgeons generally liked EDOF lens. They seemed to be elderly. Some were no longer in practice, and many reported a complicated vision history.

One thing that's important to consider is the financial disclosures listed for each panelist at the end of the article. For example the panelist who chose a Zeiss IOL works for Zeiss. LOL

I would have to disagree with that surgeon's advice. In a perfect world, I would pick the IOL first, and then find a surgeon that is competent in using that IOL. I don't think may people realize that when they pick a surgeon they have most likely also chosen what IOL manufacturer, and perhaps even the specific IOL they are going to get from that surgeon.

Yes, there are very few starving ophthalmologists...

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Cost factors would also affect the results of surveys like the one discussed above. If surgeons are less likely to choose premium lenses for patient eyes than for their own eyes, it is not necessarily because they are more cautious about patient results (although lawyers no doubt motivate them to be cautious with patients). They may also be choosing less expensive lenses for patients because many patients can't easily afford the premium lens costs. Still, the data is informative.

I can't remember which thread now, but I recall we were trying to clarify the low power ranges that the B+L enVista was available in. I noticed in this more recent brochure on the lens that the new enhanced (MX60E) is available from 0.0 D to 10 D in 1.0 D steps.

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Bosch Surgical EU ENVISTA SIMPLIFEYE Brochure compressed pdf

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Edit: And to your point about lenses being available sooner in Europe due to the FDA, that may be the case here. This appears to be an EU publication, and may not apply to the US.

Thank you! I contacted Bausch & Lomb in January and received the following information back regarding availability of the enVista:

Aspire diopter range is as low as +6.00D

enVista begins at 0.00D and is in +1.00D steps till 10.00D

Hi Phil,

I think you would find this video interesting. Go to 12:14 in the video, it is fairly long and I think you'll find the part from 12:14 -13:30

to be informative

google:

"limitations with the Vivity IOL (extended depth of focus)"

and then look for the first video that pops up and fast forward to 12:14