Vivity, LAL, & panoptix - Oh my!

First, my cataract was much worse than yours and I still drove, though it was a challenge at night.

Second I have a mix and match IOL, so I think it can be a great idea for the right person. In fact I would only recommend the Synergy IOL, which I have in one eye as a Mix and Match.

Whatever you do it comes with tradesoffs. The key is to understand those tradeoffs and choose which is best for you. Then after you have some idea we can then go into all the options such as monovision and so forth.

Also I mention LAL, but to address your comment, I have only heard of it being in Clinical trials for the EDOF configuration and not aware that configuration has been FDA approved.

Below is my list of refractive IOL option in order of risk:

Non Premium Monofocals:

These are the most common IOLs implanted. They will have the best contrast and the least issues of any lens (unless you consider close vision an issue). They have been around and tested for a long time. A Monofocal lens should provide great distance. In general close vision is reading your cell phone or a book, maybe 33cm-40cm. Intermediate is about 2 feet or so. A perfect example might be the dashboard on your car.

A monofocal you should get pretty good vision down to about 3' or so (again it depends on many factors). As you get in closer; vision quality drops off rapidly.

Premium Monofocals:

LAL – If considering a monofocal I would recommend giving this IOL serious consideration. I have had Top Ophthalmologist highly recommend this lens. Having said that it has been around for a while now, but not as long as the standard monofocal so there is the test of time issue.

What makes this lens great is no matter what equipment Ophthalmologist use they don’t always hit the refractive mark and in a few cases can be way off by more than 1D. And let’s say you decide to do monovision. You want to hit those marks.

From what I understand you can adjust the LAL more than once. So you decide on monovision, but not 100% sure how much monovison. So set 1 eye to plano and then try various settings with the 2nd eye to see which one works best for you. I would only consider micro-monovision like -0.75D, but if I had the option to adjust it you could try a different setting and see if you end up with a lack of stereopsis or other problems.

IQ Vivity and Tecnis Enhance - The newest hottest IOLs on the block. A refractive IOL that provides some EDOF. I think IQ Vivity is around .5D and Eyhance a little less. So not a lot but combined with micro-monovision you should get decent intermediate and some close up vision.

Vivity can have contrast sensitivity loss.

I tried mono-vision with contacts and was not a fan. I need good distance vision. That is why I say if doing mono-vison go with micro-monovision (<-1.0D). If you do that with Vivity (and use the -1. 0 D setting) you will be getting -1.5D of mono-vision, preferable in the non-dominate eye.

Enyhance from what I read has no CS lost, but you don't gain much EDOF.

Also there is the Ray One EMV, though I am a bit confused on this IOL, so you would need to do more research. Best I can figure it is designed to give superior monovision. So their claim (from the best I can tell) is with this IOL using monovision you would get a greater EDOF range than using the same amount of monovision with a monfocal. I have no idea if that is actual true, so make sure to research this IOL thoroughly if interested in it.

Diffractive IOLs

These IOL, which include Trifocal and EDOF IOLs, give you improved intermediate and close vision but they all come with tradeoffs (dysphotopsias & Contrast Sensitivity loss). This category is a paper in itself, so I will not go into details unless you are interested in a defractive IOL. I personally have a defractive len in each of my eyes. In the US the main defractive lens currently would be Panoptics, Symfony, and Synergy IOL.

There is another poster here, @john20510, that has been wrestling with different choices. Here were my thoughts as of today. He had dismissed the PanOptix due to concerns about optical side effects.

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"These would be your choices with my comments on using a Vivity lens:

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Both eyes set for distance using Vivity in both - This will give you very good but not excellent distance vision, and OK to Poor reading vision. Hard to predict how good it will be for reading, but for sure reading glasses would be needed for smaller print, especially in dimmer light. You would also have the issue of reduced contrast sensitivity in lower light.

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Vivity in both eyes with the right set for distance and the Left set for -0.5 D - Distance vision should still be pretty good, and you will be able to read better. Since the Vivity is good for about 0.5 D of extended vision this would be somewhat equivalent to micro-monovision of about -1.0 D total. It is a reasonable option but will still leave you short of very good reading vision. And the issue of reduced contrast sensitivity remains.

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Clareon monofocal set for distance in the right eye with a Vivity set for -1.0 D in the left eye - This will give you very good distance vision and very good reading vision. The Clareon in the right eye will make up for the loss of contrast sensitivity with the Vivity lens. This would be my choice if I was to use a Vivity. I was very close to choosing it but backed out at the last minute, and went with two monofocals."

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When you are considering a monovision solution (under correction of one eye to see closer) you ideally want to get a lens for full distance in the dominant eye (his right eye is dominant), and under correct the non dominant eye. Under correction is measured by what correction you would need in an eyeglass lens to see distance very well. A -1.5 D under correction would mean you are -1.5 D myopic, and would need a -1.5 D eyeglass lens to correct your vision. This amount is normally enough to get decent reading.

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In addition to these choices there is a pure mini-monovision solution with a monofocal lens like the Clareon in both eyes. The dominant eye would get full distance correction, and the non dominant would be left at -1.5 D. These are all something you could ask your surgeon about. You mentioned your "focal point is just off center in my eye". Another monofocal lens to consider is the B+L enVista. It has a neutral asphericity and is more tolerant to less than perfect eyes.

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Hope that helps some

I think the simplest answer is Vivity with or without a 0.5 non-dominant offset. I'm afraid you have to accept that there is no perfect solution. Every lens available today has trade-offs. The choice will be between quality (monofocal has amazing quality but only at one distance) and quantity (multifocal like panoptics doesn't have the best image quality but you can see at many different distances without glasses). A lot of Vivity patients (especially if they do a small offset) can still see their watch and check their phone but still use readers for prolonged reading… which doesn't sound so bad. I feel like if you can still get by without glasses for the day to day quick glances when out and about and just use glasses for prolonged activity like reading that's a pretty good outcome. It sucks that there's no perfect lens now but with 20/200 you really can't wait for something better I don't think. Anything that is "game changing" better is probably, realistically, still 5 years away.

I don't want to give up my near/intermediate vision -- and I'd really like to explore options that get me out of glasses.

1. You can do monofocals for near/intermediate. Although it's not a common choice, it works very well for those of us who prioritize close vision. Definitely something to discuss with your surgeon.

2. You will undoubtedly need glasses in some way, either drugstore readers if you target distance vision, or prescription (probably progressive) glasses if you target near/intermediate. There is no glasses-free lunch yet, although there are some people on this board who rarely have to wear them, like Ron.