Tecnis Eyhance ICBOO vs. Tecnis 1 Piece ZCBOO

That seems unusual for vision with your -1.75 D eye. Do you have uncorrected astigmatism? Even with astigmatism and a spherical equivalent of about -1.4 D in my near eye, I can read J1 in full sunlight, and J3 with indoor lighting. I believe the standard distance for the Jaeger chart is 14". I have to keep reminding myself that if I don't see well when trying to read, the solution is more distance, not less. Exactly opposite to the way I was before with higher myopia.

Actually I don't think it makes all that much difference. The standard practice is to do the near eye for closer vision. But you are not really doing a monovision solution, but an offset near/intermediate split. The -2 eye is going to give you good near vision, and a -0.75 Eyhance will do intermediate. I have crossed monovision with my dominant eye as my near eye, and it is not a big problem. With the high amount of astigmatism in the right eye, I think getting the Zeiss lens to fully correct it is a good idea. But you could correct it to about -1.0 D sphere, and then use either a Eyhance at -1.75 D or a monofocal at -2.0 D. I think to keep things simple, and clear from any optical side effects I would just do the monofocal in both eyes.

Correction:

"The standard practice is to do the non dominant eye for closer vision"

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The other issue to consider is that if you use the Eyhance lens it will compromise your ultimate vision with eyeglasses. Eyeglasses can make a correction when the diopter amount is off. However, the Eyhance lens has a progressive power change with the radius of the lens. That is how it gets the EDOF effect. It smears the focus point over a range. A good aspheric monofocal like the Tecnis 1 will bring all the light to a single focus point, and will be easier to correct with an eyeglass lens. The contrast sensitivity or MTF will also be higher with the true monofocal.

Ron, What you said about the Tecnis 1 making it easier to correct astigmatism with eyeglasses is correct per Dr. Ben LaHood, a renowned Australian opthalmologist. You can google his name and see his credentials. A friend of mine emailed him about that question and he recommended the Tecnis 1 for astigmatism correction with eyeglasses. However, he added that the preferred way to correct astigmatism was with a toric IOL, and he said the Eyhance toric was excellent for that. My friend forwarded Dr LaHood's email to me and I read it myself.

I would add that on Dr LaHood's website are some informative articles on refractive surgery that he has had published and can be read online

Clarifying question Ron: "The other issue to consider is that if you use the Eyhance lens it will compromise your ultimate vision with eyeglasses. "

Why say "with eyeglasses." Isn't the compromise you speak of with Eyhance extant equally with or without glasses?

Is your point when you say the monofocal will be "easier" to correct with eyeglasses do you mean less time spent in the optometrist's office to get the prescription right? Or do you mean the best corrected vision will be better with the monofocal?

My concern is with a monofocal you have to be at just the right distance for close or intermediate to be sharp. That's a pain. I would like a bigger landing zone.

You say contrast sensitivity is worse with the Eyhance.

I am confused. What am I missing? Can you please cite the source for both the "not as sharp" and "inferior contrast" assertions. I'm confused because I read studies that I interpret to say the opposite and find none with the warnings you are giving. For example:

"A total of 80 eyes of 40 patients were evaluated in this study. Although monocular and binocular uncorrected and corrected distance and near visual acuities were similar between groups, monocular and binocular UIVA were significantly higher in the Eyhance group. There were no statistically significant differences between the 2 groups in terms of photopic contrast sensitivity, OSI, MTF cutoff, Strehl ratio, and glare and halo perception. The ICB00 IOL provided better spectacle independence than the ZCB00 IOL for intermediate distance." https://pubmed.ncbi.nlm.nih.gov/32050218/

"Overall, 139 patients were bilaterally implanted with the enhanced monofocal IOL (n = 67) or standard monofocal IOL (n = 72) and available for the 6-month visit. The enhanced monofocal IOL significantly improved mean monocular and binocular DCIVA and UIVA by at least 1-line logarithm of the minimum angle of resolution vs the standard monofocal IOL (all P ≤ .0001). Distance vision for the enhanced monofocal IOL was 20/20 or better and comparable with that of the standard monofocal lens at 6 months. Contrast sensitivity, photic phenomena outcomes, and rates of adverse events were similar between the 2 groups." https://journals.lww.com/jcrs/Fulltext/2021/02000/Clinical_evaluation_of_a_new_monofocal_IOL_with.8.aspx

Dr. Mencucci said " the refractive IOL design in the Eyhance IOL enables intermediate vision while keeping distance image quality comparable to a standard monofocal aspheric IOL.”

https://www.reviewofophthalmology.com/article/dawn-of-the-monofocal-plus-era

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Jim - Do you read from one eye or both eyes now? I don't seem to use my left eye for close up reading for example. I'm sure it contributes but it's not the eye I see from when reading. I'm very right eye dominant and when I read something that is in close range it's always the image that the right eye sees. It has always been that way for me. Before cataracts, I could hardly read with anything with my left eye even though it had good vision. The focus was weird and my right eye just took over. After cataract surgery (both eyes set for distance) my left eye has the very best vision but it's still not my reading eye. I still read with my dominant right eye. Whenever I do monovision now with contacts or glasses I always make my dominant right eye the near vision eye as that is what is natural for me.

I think the use of the Eyhance mini EDOF is a separate issue from using a toric lens. I would have no issue with the toric part of the Eyhance. What I would have issue with is the impact of the stretched/smeared focal point that achieves the extra depth of field. You can't correct that effect with an eyeglass lens. You have locked it in when you select the Eyhance or Vivity for an IOL.

Ye s, You are correct on both accounts

You'll have to explain why you think one would want to correct the effect of the extended depth of focus of an EDOF or almost EDOF IOL.

It's not a clarity issue I'm certain as I can already read 6mm high letters at a distance of 37' with the Eyhance. Reading those tiny letters at 38' or 39' instead of 37" for example would be nice of course but the effect on day to life with a small gain like that would be unnoticeable as that might be around 20/8 vision. There's a limit to how good human vision can be. I think an eagle can see at a 20/4 level but humans can't for example.

If your concern is about fully utilizing the EDOF one paid for then I think most people wouldn't opt to rely on the 20/30 or worse type vision from an EDOF tail end when it is not necessary because you'll have better corrected vision readily available using your glasses that properly correct for the range you need.

That said, I do think that if the plan is to wear glasses after surgery then go with a great monofocal with a proven history like the ZCB00. That way you start with the best clarity and contrast available even if a fair part of it is above the level of what's needed for excellent vision.

I wanted to have good distance vision without glasses and for it to be usable from arm's length to infinity so that's why Eyhance torics were my first choice. Second choice for me would have been a toss up between the toric version of the ZCB00 or just the regular ZCB00 and continue using glasses. Fortunately, the Eyhance toric was available to me so I didn't have to decide between the other two. At the time, I probably would have chosen the regular ZCB00 and put some of the money saved toward really good progressive lenses. Now that I've gotten to enjoy not wearing glasses for lots of things and have the benefit of hindsight, my second choice would have been the toric version of the ZCB00.

There is a lot of hype surrounding the Eyhance lens about what it can do and what it does not do. The bottom line is that the refractive power of the lens is being adjusted from the periphery of the lens to the center. Instead of a single power lens it is a combination of powers. That is how it achieves the extension of the depth of focus. However when you do this, you lose the asphericity of the lens that brings all light to the same single focal point. It in effect smears the focus point over a range of distances. This is an effect that you cannot correct with an eyeglass lens as the eyeglass lens is a single power. It is like trying to put the toothpaste back into the tube.

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It seems to me that the benefit of an EDOF is when you are trying to be eyeglasses free. Then you make a compromise in image quality to get that convenience. But due to your prism and likely significant residual astigmatism you are unlikely to get a great image without glasses. So, then if you are going to wear glasses it will be easier, in my opinion, to get a good correction when they only have to deal with a pure monofocal lens.

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Is this effect major? No, not likely as the EDOF properties of the Eyhance are quite minimal. But, my point is that if the objective is the best corrected vision with eyeglasses you are more likely to get better vision when the IOL is a pure monofocal. Without glasses and all the other stuff going on, the effect is likely to be negligible.

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As far as the landing area being wider for the Eyhance this is a pretty minor effect. If you choose correction to -1.0 D in one eye and -2.0 D in the other area that is going to give you a really wide landing area already. That is much more close and intermediate than someone is going to get with one eye plano and the other eye at -1.5 D. You are giving up your distance vision to do that of course, but given that, I don't see any further benefit from an EDOF once you have chosen to under correct by those amounts.

My only point is that if you are correcting with an eyeglass lens you are going to get a more precise effect with the combination of a pure monofocal aspheric lens and the eyeglass lens, than you will get with the eyeglass combined with a non aspheric variable power IOL lens.

But I can't get EDOF eyeglasses. I don't want my vision to be specific to one exact distance.

I think it is a bit of a misunderstanding/myth that a monofocal is specific to one exact distance. Yes, it will peak in visual acuity at some point, but acuity does not drop off a cliff when you go away from that point. My distance eye tests at 0.00 D sphere and -0.5 D Cylinder. I can see 20/20+ for distance and read a computer screen at 18". I have no problem at all seeing my dash instruments in my car, truck, and motorcycle.

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And, it appears you have pretty much decided not to try for the full range of vision from close to distance and have chosen to focus on the intermediate and near. Two monofocals with one set to -1.0 D and the other at -2.0 D will give you a very wide range. Yes your vision at distance will be down to about 20/32, but as you get closer you are likely to have near 20/20 down to about 1 foot or closer.

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If you look at the defocus curves in that IOL Review: 2021 Newcomers you will see that the plain Jane Tecnis 1 has a 20/32 (LogMAR 0.2) range of +1 to -1 D, for a total range of 2 D. The Eyhance only extends that on the minus side by about 0.35 D. It is not a big difference. With two monofocals at -1 and -2 you will have a total range of 3 D, and that will easily cover your intermediate and close distance of interest. You will need EDOF glasses (progressives) to see 20/20 at distance though!

I'll agree on the basic point Ron is making: an aspheric monofocal lens with the highest peak on the defocus curve that focuses all light onto one point on the retina should in theory give the best corrected distance vision with high quality eyeglasses. You get more light around the focal point where you are trying to see. In theory, you could move that defocus peak to whatever distance you wanted with eyeglasses if they were perfectly clear and added no distortions. In practice, progressives add distortions and lower the overall defocus curve. While likely better at the targeted distance, an ideal aspheric monofocal with progressives might not give better corrected vision at other distances than an EDOF alone.

I'd like to see studies comparing monofocals corrected with progressives to EDOF's without, especially under lower light, less than optimal conditons with the lenses targeted to different distances.

The higher defocus curve peak, clearer lens material, and promises of better contrast and night driving are among the reasons I chose the Eyhance over Vivity. I want best correctable vision at all distances and wouldn't mind wearing eyeglasses, if they improve vision. But I'm not convinced progressive eyeglasses with distance-targeted monofocals can beat EDOFs alone at intermediate distances.

However, if you know you'll need eyeglasses after an IOL, a monofocal may well be the best choice. That seems to be what most surgeons recommend if they know they can't fully correct vision with an IOL. If I ended up in glasses full-time, I'd probably regret choosing Eyhance over a monofocal. Fortunately, I think I'll only need glasses in limited situations.