Tecnis Eyhance ICBOO vs. Tecnis 1 Piece ZCBOO

That curve strikes me as extremely optimistic for the Eyhance. It shows an extension of the depth of focus at a LogMAR of 0.2 that exceeds 1.0 D! That is way beyond what is required to officially call the lens an EDOF. The curves I have seen show it gaining about 0.35 to 0.4 D over the monofocal. This falls just short of the 0.5 D required to call it an EDOF, and J&J appropriately do not call it an EDOF. I also have not seen the flat area to the left of of the 0.0 D on other curves. The curves shown in the 2021 IOL Newcomers article seem more realistic to me.

I have one Eyhance so far and got 20/20 at distance and J3 at near in the surgeon's office 12 days after surgery. At 3 weeks+, I have functional vision from 12" to infinity in that eye. I can drive unaided with that eye and read an electronic tablet/phone at 12". My other eye is -5D with additional astigmatism and not helping at all since I'm not correcting it (I quit contacts several years ago.) We targeted -1D and achieved -0.9D with < 0.25D astigmatism.

Perhaps these results won't hold up after I get an IOL in the other eye but right now if I close off the other eye, my IOL eye does pretty well in many (not all) real world conditions. In lower light or at dusk with a slightly larger pupil (~4mm) my experience is that the Eyhance vision will be worse than a monofocal because it's worse than my other corrected eye. At dark (5mm pupil), the Eyhance is outstanding with superb contrast sensitivity. The results you get with the Eyhance really depends on the conditions you test it under. Published defocus curves vary widely depending on the characteristics (astigmatism, age, pupil size, etc) of the eyes studied.

My result is consistent with the "extremely optimistic" curve from BMC Ophthalmology pictured above but would be considered nearly impossible with the curve in the IOL Newcomers article in the Review of Ophthalmology. There are several other Eyhance studies that show more favorable results for the Eyhance than the Review of Ophthalmology article. Here's another:

Kang, Korean Journal of Opthamology 2021: Visual Performance and Optical Quality after Implantation of a New Generation Monofocal Intraocular Lens

So...Ron brings up an interesting point - why wouldn't J&J advertise Eyhance as an EDOF if it qualifies? Consider the advantages of being the best monofocal on the planet and in a group known for having the least undesirable visual distrubances. Or place the product in a newer EDOF category that is trying to sell itself as having fewer visual issues than multifocals but perhaps weaker contrast sensitivity and more night driving issues than monofocals.

J&J probably made a great business decision to place the Eyhance into the monofocal category. Eyhance won't beat Vivity at EDOF unless they can convince people that Vivity's night driving / contrast sensitivity issues are dealbreakers. Eye surgeons don't seem too concerned about them so Eyhance as an EDOF was likely to be a losing proposition.

Anyone targeting intermediate vision should consider Eyhance. If you achieve a target between -1.5D and -1D with minimal astigmatism, there's a reasonable chance you'll get decent near and far vision that might be ok to drive with. My experience is that the area to the left of 0D defocus (+1.5D to 0) is fairly flat and in line with some (not all) published studies. I've listed two studies that support the flat defocus curve, consistent with what I'm experiencing. There are at least 10 studies that have been done on the Eyhance and I haven't reviewed all of them but most note improvements in contrast sensitivity, especially at night. I've noticed that as well.

Targeting anything near plano with Eyhance would essentially be trading away any near vision (less than 2 feet) for very little improvement in distance vision (perhaps 20/25 vs 20/20). Not a trade-off I'd make. Targeting between -1.5D and -1D ensures that flat portion of the defocus curve to the left of 0D (assuming it exists for most people) is brought back into your range of usable vision (less than infinity feet away). My experience is that the flat part of the curve exists and can be achieved if residual astigmatism and bad surgical outcomes can be avoided.

Plano targeting:

20/10 is double the distance visual acuity of 20/20 and three times the distance visual acuity of 20/30. 20/20 is 50% greater distance visual acuity than 20/30.

Snellen 20/10 = LogMAR -0.30 = Meter 6/3 = Decimal 2.00

Snellen 20/12.5 = LogMAR -0.20 = Meter 6/3.8 = Decimal 1.60

Snellen 20/16 = LogMAR -0.10 = Meter 6/4.8 = Decimal 1.25

Snellen 20/20 = LogMAR 0.00 = Meter 6/6 = Decimal 1.00

Snellen 20/25 = LogMAR 0.10 = Meter 6/7.5 = Decimal 0.80

Snellen 20/32 = LogMAR 0.20 = Meter 6/9.5 = Decimal 0.63

Sounds to me like you've got a great base to proceed with a monovision solution when/if it comes time to do your other eye.

My eyes (bilateral Eyhance) handle being at -1D very differently than yours it seems. I have a variety of sphere & cylinder lenses and can simulate -1D sph, 0 cyl or -.25 cyl etc. On a 10' chart my left eye at -1D sph 0 cyl can claim a fuzzy 20/20 but only just. My right eye at -1D sph 0 cyl can't claim 20/20 though. Neither eye at -1D sph 0 cyl can claim 20/20 using an actual 20' chart monocularly but can binocularly. However, even the 20/100 letters are fuzzy. I would choose to correct that vision to drive or just enjoy the outdoors for example.

At -1D sph 0 cyl looking outdoors through a window seems OK-ish until I remove the Trial Frame. Huge difference in distance image quality at 20/15 vs -1D sph 0 cyl.

You can order -1 D single vision glasses online probably for less than $20 delivered. That would give you an idea of the difference and I'm sure it would benefit the decision making for your other eye. It might confirm your theory that -1 D near and intermediate gains out-way the distance losses for you.

Focal points:

300 feet = -0.01 D

200 feet = -0.02 D

100 feet = -0.03 D

50 feet = -0.07 D

20 feet = -0.16 D

10 feet = -0.33 D

6 feet = -0.55 D

3 feet = -1.09 D

2 feet = -1.64 D

18 inches = -2.19 D

12 inches = -3.28 D

10 inches = -3.94 D

8 inches = -4.92 D

6 inches = -6.56 D

With monofocals (excluding monovision), it kind of comes down to when would being glasses free be the most beneficial and how easy it is to have the corrections you need available when you need them when deciding on distance, intermediate or near targets. It's a very specific to the individual choice.

Greg,

I have seen three cornea/anterior segment specialists in Atlanta, GA. All three said the Eyhance is an excellent monofocal, but they all said it had been "over-hyped" as far as improving near/intemediate vision. Based on their experience, they said most patients will still need eyeglasses. Also, I understand that Dr. Ben LaHood, a renowned Australian cataract surgeon, told a member here that if a patient was not going to have a toric IOL implanted, the Eyhance, because it is an EDOF, would make it more difficult to correct astigmatism with eyeglasses. He recommended the Tecnis I instead.

Thanks billy111. I may need to delay getting the Eyhance in the 2nd eye if the expected residual astigmatism can't be corrected.

IMO, success with the Eyhance depends on targeting something close to intermediate vision -1D to -1.5D and being happy with drivable distance vision that is a bit short of 20/20 in the best conditions more like 20/40 in the worst. People who drive/work outside at night will really like the lens. I'm sure people who get Eyhance results close to plano will have no usable phone vision and mediocre intermediate vision. Surgeons going this route with Eyhance will have unhappy patients, especially so if they miss on the + side. I think they are leaving way too much good vision to the left of the defocus curve. Based on billy's comment, those with significant uncorrected astigmatism might be unhappy as well.

Thanks Myope_PSC.

It's been a very long time since I was corrected to 20/15 so I've forgotten what it was like. Frequently, one of my eyes wasn't correctable beyond 20/25 so seeing near 20/20 seems about as good as I'm likely to get. Plano probably also gives you better low light vision at distance than hitting a minus target. Still the risks of missing to the plus side seem to far outweigh the benefits, at least for me.

I'm in the US and contacts / eyeglasses require prescriptions and optometrist visits that are expensive. A lot of doctors don't want to help "simulate" IOL vision and one claimed it wouldn't work anyway. I guess you can't simulate the lack of accommodation but I'd still like the idea of simulation.

I am interested in finding a way to get some -3D or -4D daily use contacts (or trial lenses) to work with but I'm not sure there's a legal way to do so in the US unless you find an optometrist willing to help. Then again, you appear to be resourceful and might even be in the US as well. I got out of contacts years ago because of dry eye issues and inability to wear them for long periods.

Right now, I'm much more afraid of losing my near vision than sharpening my distance. As you indicate, I could probably see 20/15 with a -0.75D or -1D lens in addition to my IOL. And what I have now might seem unacceptable in comparison. I'll probably get prescription sunglasses as some point for driving but only because I'll be using sunglasses anyway. I'm still correctable to 20/20 in my non-IOL eye and without correction can still read pill bottles and just about anything I can't read with the IOL.

I have the 2nd surgery scheduled for next week but am strongly considering waiting based on some comments made on this forum.

Myope_PSC,

Your results aren't all that much different than mine for distance (barely 20/20 in one eye). Distance vision seems to decline rapidly as light gets dimmer - faster than a natural lens with early cataract. My IOL distance vision is still a bit slow to focus and I'm hoping that goes away when I correct/fix the 2nd eye. That leaves large letters a bit fuzzy for a few seconds. That seems to be getting better over time though.

Maybe all IOLs are like this since accommodation is lost with nearly all of them. You might not experience the rapid dimming with a plano Eyhance. Night vision is still great.

It's possible that simulating -1D with a plano Eyhance and a corrective lens just isn't as good as an Eyhance (or EDOF) alone at -1D. Billy's comments suggest it might be harder to correct astigmatism with an Eyhance...maybe that also extends to sphere. Not knowing how the Eyhance IOL works makes it difficult to know if it could be expected to work as well with the smaller image projected from the corrective lens. From what little I understand, having the light coming directly to an EDOF or Eyhance lens probably gives better results than putting the light through a corrective lens before it hits the IOL.

I asked my surgeon if there would be any problem correcting residual astigmatism after toric Eyhance lenses and he said there would be no problem. From that, I assume that correcting residual astigmatism after non-toric Eyhance would be just as easy if not easier. I've been to an optometrist twice and there has never been any indication of any difficulty getting accurate cylinder axis and power numbers.

I ended up on the plus side indoors not plano. I mention indoors because it changes to plano when I'm out in daylight. One eye is an easy 20/20 indoors or out. The other is not as sharp indoors but becomes a crisp 20/20 outdoors. Despite being on the plus side, indoors in good lighting, using a purchased 20' distance eye chart, my RE is 20/15 calculated by reading the 20/20 line letters from 27 feet away & LE is 20/12 calculated from reading the 20/16 line letters from 28 feet away. Binocularly, outdoors in daylight, I get to 20/10 tested by being able to read the 20/20 letters of that same chart from 40' or the 20/16 letters from 37' away. Also in daylight, I can read the smallest text on a Jaeger reading test sheet no problem. It doesn't actually have to be outdoors as sunlight coming in through a window causes the same effect. I can hold the Jaeger test sheet at 14" or so and struggle reading the smallest print but if I swivel my chair around to face the window with sunlight coming in it becomes easy to read the smallest print. There's a lab study that compares the ICB00 and ZCB00 that predicts a myopic shift with 2mm pupil size and hyperopic shift with 4.5mm pupil size. I think I get both the myopic shift and a pinhole effect in daylight and that why I get both great distance vision good reading vision.

Being on the plus side does not normally help distance vision though because 0.00 or plano is as good as it gets. Keep in mind that 20' focal point (20/20) is -0.16D though. It needs to be confirmed if others experience a myopic shift with Eyhance and 2mm pupil size. Some doctors will target +0.25 when the patient needs really good distance vision or to overcome night myopia for example. Being on the plus side does impact near vision though as you've mentioned. Indoors and dim lighting, for me it's often +1.00 for computer, +1.50 for kitchen tasks etc. & phone reading when I don't want to make do without and +2.5 for reading in bed. I've ordered progressives for when I need help to see if they simplify things for me. Hopefully they'll be almost universal "readers" for me.

Myope_PSC's nice explanation of an Eyhance defocus curve that shifts nearly 1D hyperopic as pupil size increases from 2mm to 5mm is consistent with what I'm seeing from one IOL eye at -0.9D. Great distance vision at night but the small print on the phone hard to read, even at 16 inches. In bright sunlight facing north (away from the sun in the US,) I can see 20/20 or better. Driving south, east or west during a bright day when my pupils are at their smallest, I'll struggle to read small faraway signs a bit, vision falls to maybe 20/30. Indoors with sun coming in a large bank of windows, I can see well at 16 inches and functionally at 12 inches and about 20/20 at distance. A cloudy day reduces the functional window vision to about 16 inches.

I struggle more than expected at work in dimly lit computer labs with lots of students working on screens asking for help. I figured that computer monitor vision would be strong but it’s not very good without excellent lighting. A hyperopic shift in the defocus curve would explain why intermediate vision falls off rapidly in dim light, despite focusing at -0.9D. Perhaps progressives would help.

It’s hard to distinguish the effects of dim light from a defocus curve shift. I’d be interested in how they design experiments to separate the effects. The unexpectedly superb night distance vision I experience with a -0.9D Eyhance would suggest a hyperopic-shifting defocus curve with increasing pupil size is real.

My distance vision is also slow to focus and that may be the pinhole effect Myope_PSC mentions. I’d hoped my slow-to-focus vision would clear up when I get the other IOL. If it is the pinhole effect, it may be difficult to adapt and utilize it for driving but perhaps it will be more useful for reading.

Anyway, the hyperopic shift as the light gets dim seems to mostly work for me., except in my work environment. I’ll use sunglasses when my pupils are small anyway so putting in an extra -1D helper lens won’t be a nuisance. I’d like to avoid carrying readers everywhere and putting them on / taking them off dozens of times each day when I’d like to see near/intermediate in mediocre light. Not sure if I’ll be able to read screens in lower light even if I target -1.25D to -1.4D in my other eye though.

While the cylinder and axis numbers might be easy for the optometrist to obtain, the sphere may depend on your pupil size and eliminating the pinhole effect. The sphere would seemingly change as the defocus curve shifts for dark sunglasses vs clear lenses and bright sun vs low light. Dark sunglasses and low-light indoor glasses might need a bit less minus power since the pupil is larger.

The way my manual lensometry refractions have been performed, the pinhole effect would be tough to eliminate. J&J recommends a "max-plus" refraction that starts fuzzy on the plus side then moves toward minus and stops when vision is good enough. This avoids over-correction on the minus side that would take away from near/intermediate vision. It might under-correct if pinhole vision is used.

I agree. For me, my "real world" prescription has less "plus" than what it is in the optometrists chair. I also think that my small amount residual astigmatism goes away when I'm out in daylight with a very small pupil size. I just need non prescription sunglasses. Fortunately my optometrist is willing to accommodate. It took me a while to figure all this out. I was so puzzled by my first Rx because it made my distance vision worse than no glasses at all. As a previous myope, new glasses used to always mean better distance vision. The final Rx for me is a compromise but still permits 20/15 vision.

People that end up very near plano might not notice the shifts as much if they turn out to be common. The study I looked was a simulation so it might not be what actually happens with people or with the majority of people. Another study mentioned the lab study and didn't get the same results. It's good to be aware of the possibility of it occurring though.

Keep in mind that with eyeglasses the minimum step in correction is 0.25 D. With an IOL at eyeglass plane the minimum is about 0.35 D. When you talk about differences less than this, you are kind of splitting hairs that can't be split...

I have some 0.12 D trial lenses and can see the effect they have. Some optometrists still prescribe in those 1/8 diopter increments but it's not common. That's about the limit of what's usable though.

I think the hyperopic shift from small pupil to large could easily be 0.75D. The pinhole is worth at least one line of vision as well.

My suspicion is that everyone even with a natural lens or any IOL gains something from more light and the pinhole effect it creates. It is not so needed with the natural eye, but it really helps with an IOL when you have no accommodation. I think that is why you see so many comments from people new to an IOL that they have trouble seeing in lower light. The pupil opens up and they lose the pinhole effect boost. The other thing that I have discovered is about the old saying you need to turn a light on in the room when you are watching TV. Before cataracts and IOLs I found no benefit from having a light on in a dark room and actually preferred a dark room for watching TV. Now what I notice is that having a light on in the room improves the sharpness of the TV image. My suspicion is that the extra light in the room in addition to the light of the TV causes my pupil to close down, and I see a sharper image.

The pinhole I'm talking about seems to be a feature/bug of the Eyhance IOL. If I stare (without squinting) at a sign outside with my IOL and the other eye closed, it focuses much more sharply after several seconds have passed, maybe the difference between 20/30 and 20/20. I've never experienced that much of an effect with any glasses, contacts or my natural lenses. I think it takes my mind a few seconds to find an optical pinhole in the lens and the letters noticeably sharpen. Perhaps it will go away when I get another IOL and my eyes work better together but I'm thinking not. It's been a month since the first IOL was installed and the vision seems to have settled long ago. When getting refracted, I probably use the pinhole when reading the letters. When driving, the pinhole couldn't be used because my eyes move too quickly. If refracted to 20/20 using the pinhole, I probably wouldn't need glasses but would only see 20/30 when driving in bright sun. That's why I think it might be tough to get a useful refraction - the exam room is dark, pupils are large and eyes refract when the lens defocus curve is shifted in the hyperopic direction. Drive in bright sunshine. The curve shifts in the myopic direction leaving one under-corrected.

I don't think there are any "pinholes" in an IOL other than in the IC-8 IOL. Your pupil however can effectively create one to some degree though. The Eyhance lens has been overhyped in my opinion. It is a lens that varies in effective power over the radius of the lens. For that reason it does not have the advantages of a full aspheric lens that brings all light to a single focus point. But, it does "smear" the focus image over a range that allows a modest degree of EDOF. It is not unlike the old spherical lens which also does not have the advantages of an aspheric lens by bringing all light to a single point. The EDOF effect of the original spherical lens is about 0.25 D. The Eyhance increases that a bit to about 0.35 D.

Greg59,

I am confused by your post. You seem to say at one point that the darkened room produces a hyperopic shift, which I take to mean reduced myopic correction (better near vision, worse distance) then say driving in bright sun produces a myopic shift, which I take to mean increased myopic correction, but you call that "under corrected." Doesn't bright sun constrict your pupils, masking out the lower power periphery of the Eyhance (the part for near vision) and thereby improving your distance vision due to the central part of the Eyhance having stronger myopia correction (more negative lens power) in addition to smaller pupils having better focus inherently?

i think what is happening when you experience what you call "finding the pinhole" is pupil constriction, due to bright light and needing to see detail.

my bad -- the central part is better for near and the periphery for distance. I have to read everything again with that in mind.

One thing to keep in mind is that there is no "better" power, but only the "right" power. The power that will give the best vision is the one that offsets the error in your cornea, and eye dimensions. The right power will depend on where the basic power setting of the lens has been left. It could be myopic, hyperopic, or plano.

jimluck,

The central part of the lens has less power than the periphery. If I'm outside looking straight at a printed target in the distance that is somewhat out of focus, I can turn my head about 30 degrees and more of the light from that target will enter through the periphery of the lens to bring it into focus. That's because I'm undercorrected by roughly 1D through the center of the lens, still somewhat myopic. Turning my head reduces the undercorrection to maybe -0.5D because more of the light from the target enters through the more powerful off-center part of the lens.

Are you sure the center is less, rather than more, powerful? This letter

"Mencucci, Rita MD; Favuzza, Eleonora MD

Author Information

Journal of Cataract & Refractive Surgery: September 2020 - Volume 46 - Issue 9 - p 1326-1327"

says the opposite. It says power increase from the periphery to the center.

It also says the Eyhance maintains distance vision independent of pupil size where as a spherical monofocal loses distance vision and gains depth of focus with larger pupil size due to spherical aberration, which increases in proportion to the square of the radius of the pupil.

I don't have an opinion. Just deeply confused and looking for clarity..

I find it confusing too. And if you are not confused enough, consider that lower the power of an IOL the more correction it provides for myopia. High powers correct hyperopia..... 5 D is about the lowest IOL power made to correct myopia. 30 D is about the highest power to correct hyperopia. Somewhere around 18.5 D is a neutral no correction power.

The plot thickens. Here is a quote from a technical paper:

"The TECNIS Eyhance™

IOL uses an aspheric anterior surface that creates a small continuous increase

in central lens power within the 1 mm diameter. The TECNIS Eyhance™ IOL

is designed to slightly extend the dept of focus compared to the TECNIS®

1-Piece IOL, Model ZCB00 as measured in bench testing (see Figure 1). The

power profile decreases towards the periphery outside the central 1 mm

diameter" Isn't higher power for distance vision?

I guess "powerful" isn't a good term to describe IOLs. An ideal natural lens with a perfect cornea and ideal eyeball shape has a "power" of about +24.7 diopters. When surgeons replace lenses, they use positive numbers to denote how powerful the lens would be. Optometrists use negative powers in eyeglasses to correct myopia. In my case, I had myopia (longer eyeball, less than ideal cornea) with roughly -6 Diopters in my corrective lenses. When my lenses were replaced, the surgeon used a +12D lens in one eye and a +13D lens in the other. From the surgeon's perspective, that's a less powerful lens than my original. From my perspective, using these "less powerful" IOLs reduces my need for "powerful" corrective lenses in glasses. So I think of them as "powerful" because they reduce my need for glasses while the surgeon thinks of them more appropriately as less powerful.

So, you are correct that the less powerful portion of the Eyhance is on the periphery while the more powerful is on the inside. However, the more powerful inside is closer to the +24.7D power of the natural lens while the periphery is further away from +24.7D. If myopic corrective lenses are needed when seeing out of the center of the Eyhance those lenses will need to be stronger (say -2D rather than -1.5D) than the lenses that would be required when seeing out of the periphery.

Most of my life, I've always thought of "powerful" lenses from the perspective of what it took to correct my now disposed of natural +24.7D lens with eyeglasses. If I get glasses to help me in bright sunlight when my pupil is small, I'll need a more powerful corrective lens than I would in situations where my pupil is large enough to take advantage of the "less powerful" lens periphery.

So that explains it. The center of the Eyhance is higher power for better intermediate vision (less myopia correction). The periphery is lower power for better distance vision (more myopia correction). All we have to do is bear in mind that "power" works in reverse for IOLs, as compared to how we use "power" when talking about myopia-correcting glasses or contacts.

Isn't higher power for distance vision?

No. Higher power is for near. A few ways to remember this are, readers come in positive powers (positive = power) and a "fatter" lens (like a magnifying glass or the squeezing of your natural lens to focus close up) is more powerful. If you are myopic your problem is actually that at rest, your eyes are TOO powerful. So you need to make your eyes less powerful (negative power prescription) to see in the distance (i.e. with your eye in its natural rested state / no accommodative effort)

That is the question. Not sure what power is defined as. When you are myopic you need a lens which essentially straightens the light out so it comes to a focus on the retina, instead of coming up short (short sighted). If you are hyperopic the lens has to cause the light to focus closer, or thus bend the light more. More power means bending the light more? That kind of fits with the idea that myopic eye has too much power and you need a lower power (less than 18 D) to get the light back to the retina, while the hyperopic eye needs more power to bend the light more (power higher than 18)?

When I reported your observations to my doctor (i.e, bright light=> better near vision; dim light => better distance) he replied "It makes sense logically. In bright light, the pupil constricts and more light is going through the central optic which on Eyhance is a bit steeper and a little less distance focused."