Symfony already implanted (dominant eye). Which one to choose for the other eye, Synergy or Panoptix

When I look at the defocus curves of the Synergy and PanOptix I am not sure your conclusions about them are quite correct. See this article and in particular Figure 2.

.

Optometry Times guide to the latest presbyopia-correcting IOLs October 27, 2021 Tracy Schroeder Swartz, OD, MS, FAAO

.

I don't seem much difference in the vision acuity between the PanOptix and Synergy until you get to about 33 cm. It is at distances closer than this that the Synergy starts to improve. At more than 33 cm the PanOptix is superior. And even at the slight dips in both around 1 meter the Symfony will easily make up the deficiency. I also think the monofocal curve is a lowball. I would suggest a more accurate monofocal for the Tecnis 1 or Clareon would intersect the -0.2 visual acuity line at about -1.4 D, not at -1.0 D. An Eyhance would be somewhere between the real monofocal curve and the Vivity. I would also question where there is a significant difference in the halos and flare at night. Both are going to be much more than a monofocal or the Symfony. But yes the Synergy may be slightly worse.

.

I would question whether there is a real difference in the material used in these two lenses. I say that despite the fact I paid $300 more for a Clareon lens over an AcrySof. But, I really paid that fee to get into a private clinic and reduce the wait time to get my surgery. I now have one Clareon and one AcrySof lens in my eyes. You may want to read this article. I think the glistenings issue has been long solved.

.

David J Apple Laboratory Glistening through the years Timur Yildirim Feb 05, 2021

"Optometry Times guide to the latest presbyopia-correcting IOLs October 27, 2021 Tracy Schroeder Swartz, OD, MS, FAAO".

Excellent reading tip, I consider it a must-read for anyone who wants to understand a little. I confess that I had read it, but I didn't remember.

Is it correct to consider that, if the target is calculated for +0.5D or -0.5D, the curve would remain exactly the same, only shifting 0.5D to the right or to the left?!

One of the reasons I initially chose Symfony was because of the promise of less loss of focus and contrast in low light (this is where I feel the cataract hurt me the most...). It's mentioned in the article and I've read studies that prove that Synergy outperforms PanOptix in low light situations. Do you think this would be very relevant (as I have been considering)?

"David J Apple Laboratory Glistening through the years Timur Yildirim Feb 05, 2021".

Apparently the "Glistening" are no longer something to worry about (especially me at 63...).

good summary. but it would seem the panoptix distance is more than slightly better than synergy.

Thank you! But it was just a slightly different way of putting together what you had already listed...

"it would seem the panoptix distance is more than slightly better than synergy"

As far as I've learned, it depends on several factors. If we take into account only the refractive error. A Synergy lens that resulted in +0.5D, should behave at close range like a PanOptix in emmetropia. While a PanOptix that resulted in -0.5D should behave closely like a Synergy in emmetropia. However, refraction errors in Synergy will always result in worse vision. Apparently PanOptix is a little more tolerant of this error...

in my opinion even emmetropia with synergy results in lower quality vision. that is why I continue to ask if the distance qualitu could be improved with glasses but havent gotten a response.

also i dont want to sound like a panoptix supporter. i believe glistening is a serious issues and per Safran,who is the iol exchange expert, still not resolved. also at 46 it is a serious consideration.

I sent you a reply but it went to moderation. This is a very strange site....

The distance visual acuity is at the 0.0 D position. The red (PanOptix) curve is identical to the green (Synergy) curve at that point. The only curve significantly different is the monofocal one, and it is slightly higher at distance 0.0 position. Both dip to 0.1 (20/25) at 1 meter, but at that point the Symfony is just slightly below 0. I would expect based on the defocus curve that binocular vision at 1 meter with a Symfony in one eye and either the PanOptix or Synergy in the other eye would be 20/20.

Yes, I start to understand the blur curves better. That was the reason for my question. Whether a shift of + or - 0.5D would keep the curves exactly the same, just shifting them to the right or left. Following this reasoning, as the distance visual acuity is in the 0.0D position, in Synergy, a refraction error of -0.5D, will place it closer to 20/25 (0.10 LogMAR), while in PanOptix , this same error, would only be a little below 20/20 (0.00 LogMAR). I don't know if this would explain the poor quality at a distance reported to Synergy. This would also explain why, as I read some statements from some ophthalmologists, they always calculate Synergy pointing to a possible positive refractive error (farsightedness), contrary to what they usually do with other lenses, where they prefer to err on myopia...

"Is it correct to consider that, if the target is calculated for +0.5D or -0.5D, the curve would remain exactly the same, only shifting 0.5D to the right or to the left?!"

.

Yes that is correct. A residual myopia of -0.5 D shifts the defocus curve 0.5 D to the right.

.

I gave you a much more detailed response, but it went into moderation. I also noted that a recent response to John went into moderation and then was deleted, so I am not sure you will see my response, and I am not inclined to do it over again. Not sure what is going on with the moderation at this site. Now that I have an IOL in both eyes, I am starting to lose patience with the site.

Yes, the slope of the curve is important when considering refraction error. And yes if they miss on the + side (to the left) the loss will be slightly greater at distance on the Synergy compared to the PanOptix. What is missing here is what the curve looks like to the left of the 0.0 position. That tells you what the loss of vision would be if there is error to the - side. Based on other curves I would expect the error to be the same on the - side, but you should google for some defocus curves to be sure. Aiming to miss on the + side is playing with fire in my opinion. If you really end up at +0.5 it is true that the PanOptix will suffer less loss than the Synergy. But consider the impact on the near vision. You are buying these lenses to get near vision. A +0.5 D error moves the whole curve over to the left, and you get much more significant loss of the near vision. This is why the normal target is -0.25 D. You get a slight loss at distance, but you can pick up much more at close distances, or avoid loss of vision at close distances.

.

My guess is that there is not a significant difference in the loss for error on the minus side between these two lenses. And for you, you already have the Symfony distance vision "in the bank". I small loss at distance is going to be compensated for by the Symfony eye. People with monovision have a relatively large loss of distance vision in the close eye, but it is compensated with very good vision in the distance eye.

"Aiming to miss on the + side is playing with fire in my opinion."

In "Study Mirrors Real World for Tecnis Synergy - mivision", the lead ophthalmologist on this study says: "The only potential issue to be aware of for synergy is the relatively steep fall off the minus side of the defocus curve. In planning refractive target it is essential to plan for a hyperopic refractive outcome – ie first plus in all cases, otherwise distance acuity might be compromised."

In this other article "The TECNIS Synergy IOL: Patient Consultation to Postsurgical Success", it caught my attention that one of the surgeons says: "When I first began implanting the TECNIS Synergy IOL, I used the recommended A-constant of 119.3, which I found in slight myopia. Now, I use the A-constant 119.1.", and another doctor says: "I use the Barrett formula and the recommended A-constant as well. I aim for emmetropia, or sometimes a bit toward hyperopia ."

There are others that I haven't found yet. I could be wrong, but it seems to me that with Synergy, pointing to the "-" side is playing with fire...

I am not a cataract surgeon, but I can't agree. Unless the IOL has some magic flat spot in the curve to the left of 0.0 you are going to lose distance acuity if you go to the plus side. If you google "synergy iol package insert" you should find a pdf document that give a lot of detail on the lens. Then look at figure 2 on page 11. There you will see the defocus curve of the Synergy compared to a Tecnis monofocal. There is no magic flat spot to the left of the 0.0 peak acuity point. Both lenses have a fairly steep peak at 0.0. In fact the drop off in acuity of the Synergy to the left is even steeper than the monofocal. If you go left of the peak, then you loose on distance and near. Going to the myopia or minus side is a lose-win. You lose a bit of distance but gain close up. Going to the plus side is lose-lose. You lose distance and lose close up.

.

This said I sense that what these surgeons you are quoting are doing is compensating for IOL power calculation error. If for example you use the factory A factor to get a 0.0 outcome but you get a -0.5 outcome then you may want to target 0.25 to 0.5 on the plus side to compensate for formula and factor error, or adjust the A factor. And, as I understand it, these factory A factors are just a starting point. Most surgeons alter them somewhat to compensate for their particular surgical technique. Different techniques can result in a different lens position in the eye and a different power outcome.

Wow!

You are absolutely right! I saw figure 2 on page 11. And the curve is equally downward on the "+" side. So I was wrong in my assumption and I can't explain why some surgeons prefer to err on the "+" side.

Well, I'm not a surgeon either, and I've been at it a lot less time than you, not having even a fraction of your knowledge. I'm just getting as much information as possible so I can discuss it with my doctor on 07/03. I need to understand if he's going the right way.

Reading the latest comments I really can not add much more than I and others have already stated.

I just wanted to say if You are Happy with your Symfony IOL, as long as your doctor nails the refractive mark, you will more than likely be happy whether you get the Synergy or PanOptics.

I think the Synergy in daylight will provide similar distance vision quality as the Symfony as it basically uses the same EDOF technique.

You can go insane going back and forth and trying to determine the absolute best between those 2 IOLs. And the sad fact is one never knows until the IOL is implanted. I have seen Dr. Wong vidoes where he extracts a PanOptics to put in a Symfony and vice versa.

One of the reasons I went with Synergy is I already had a Tecnis diffractive IOL in one eye and was relatively happy with it, no PCO or anything else. But that was my Sample of 1 result and not a statistic. This is why I said if you are Happy with your Symfony, then the Synergy would probably be a good mix and match for you. And your are prepared about the Dysphtopsias as I have warned you about the Synergy dysphtopsias being large. Again I am just a sample of 1, but the clinical trials for Synergy low dysphotopsias IMHO are garbage. Again IMHO the dysphotopsias you will get from Synergy will be much larger than you experience with Symfony.

I waited anxiously for your replay, but it ended up being deleted, as you suspected...

I have to confess that I had already chosen to take the risks by going with Synergy, but, talking to my doctor at the last appointment, we decided to postpone the surgery, because he confessed to me that he still hasn't implanted any lens of this type (this has worried me a lot ). He was sincere in saying that he has already made hundreds of implants with Zeiss (AT Liza/Lara), Alcon (including PanOptix) and J&J (Tecnis 1, MF, Symfony) lenses, but the Synergy lens specifically would be his first. He himself asked me to postpone the surgery, because he would do research and advice with colleagues who have already implanted several lenses of this type and, only if he was fully convinced of being able to have the surgery, would he go ahead. If tomorrow he confirms to me that he can continue with Synergy, I feel that I need to be prepared to ask him some questions that can reassure me about the risk I will be taking...

It seems like the moderators do not like a specific cataract surgeon in the US. As many surgeons are mentioned here, I don't understand why they don't like this one. Newsweek rated him as #3 in the US in 2021.

"i believe glistening is a serious issues and per Safran, who is the iol exchange expert, still not resolved"

I did my research and now I understand what you want to warn me about. If it depends on his opinion, PanOptix is ruled out. I found it interesting that Safran, prefers EDOF lenses, like Symfony and Eyhance, as he responded to 2 weeks in a video of his...

One of the things I have noticed is that many of these "experts" have a pretty strong bias toward either the Alcon lenses or the J&J lenses. I think you have to take their opinions with a grain of salt. All of these lenses have strong points and compromises. It needs to be kept in mind that these experts are often "in bed" with a specific manufacturer. The surgeon I went to has an obvious strong preference for Alcon lenses, but he is willing to use J&J lenses if you insist. His story is that some of these specialist surgeons get outfitted with their expensive special equipment by one manufacturer, and it comes with an obligation to use their lenses only.

.

I still think the PanOptix vs Synergy choice is a Coke and Pepsi choice. They are more similar than different. And their biggest similarity is the significant flare and halo effect at night. They both have it, but perhaps the Synergy slightly worse. And the reward for that is slightly better close vision with the Synergy. It is kind of what you want to trade off. For me, alarm bells go off when one of these "experts" say Coke is better than Pepsi, or vice versa.... I become suspicious of their neutrality in looking at the facts.

why dont you get the LISA?

I did very little research on AT Lisa, because the Hospital specialized in eyes where I am doing all the consultations, exams and the first surgery, does not work with Zeiss (it only works with Alcon and J&J).

It is the same with most North American ophthalmologists. I don't know of anyone getting anything other than Alcon or J&J. They seem to have the lion's share of the market.