Journal of Refractive Surgery

Original Article Supplemental Data

A Comparative Evaluation of a New Generation of Diffractive Trifocal and Extended Depth of Focus Intraocular Lenses

Beatrice Cochener, MD, PhD; Guillaume Boutillier, MD; Mathieu Lamard, PhD; Claire Auberger-Zagnoli, MD

Abstract

PURPOSE:

To evaluate and compare the performance of two diffractive trifocal and one extended depth of focus (EDOF) intraocular lenses (IOLs).

METHODS:

In this 6-month, single-center, prospective, randomized, comparative study, patients undergoing routine cataract surgery were randomized to receive one of two trifocal IOLs (AcrySof IQ PanOptix; Alcon Laboratories, Inc., Fort Worth, TX, or FineVision Micro F; PhysIOL SA, Liège, Belgium) or an EDOF IOL (TECNIS Symfony; Abbott Medical Optics, Inc., Abbott Park, IL). There were 20 patients in each group. The primary outcome was binocular and monocular uncorrected distance (UDVA), intermediate (UIVA), and near (UNVA) visual acuity. The secondary outcomes were quality of vision and aberrometry.

RESULTS:

There was no statistically significant difference between groups in either monocular (P = .717) or binocular (P = .837) UDVA. Monocular and binocular UNVA were statistically and significantly better for both trifocal lenses than for the EDOF IOL (P = .002). The percentage of patients with J2 UNVA was 52.5% monocularly and 70% binocularly for the TECNIS Symfony IOL, 81.5% monocularly and 100% binocularly for the AcrySof IQ PanOptix IOL, and 82.5% monocularly and 95% binocularly for the FineVision Micro F IOL. There was no significant difference in binocular UIVA between groups; VA was better than 0.6 in 55%, 53%, and 35% of patients with the TECNIS Symfony, AcrySof IQ Pan-Optix, and FineVision Micro F IOLs, respectively. Overall, 90% patients achieved spectacle independence. There were no differences in visual symptoms and aberrometry among groups.

CONCLUSIONS:

All three IOLs provided good visual acuity at all distances, a high percentage of spectacle independence, and little or no impact of visual symptoms on the patients' daily functioning. Near vision was statistically better for both trifocal IOLs compared to the EDOF IOL.

[J Refract Surg. 2018;34(8):507–514.]

Abstract

PURPOSE:

To evaluate and compare the performance of two diffractive trifocal and one extended depth of focus (EDOF) intraocular lenses (IOLs).

METHODS:

In this 6-month, single-center, prospective, randomized, comparative study, patients undergoing routine cataract surgery were randomized to receive one of two trifocal IOLs (AcrySof IQ PanOptix; Alcon Laboratories, Inc., Fort Worth, TX, or FineVision Micro F; PhysIOL SA, Liège, Belgium) or an EDOF IOL (TECNIS Symfony; Abbott Medical Optics, Inc., Abbott Park, IL). There were 20 patients in each group. The primary outcome was binocular and monocular uncorrected distance (UDVA), intermediate (UIVA), and near (UNVA) visual acuity. The secondary outcomes were quality of vision and aberrometry.

RESULTS:

There was no statistically significant difference between groups in either monocular (P = .717) or binocular (P = .837) UDVA. Monocular and binocular UNVA were statistically and significantly better for both trifocal lenses than for the EDOF IOL (P = .002). The percentage of patients with J2 UNVA was 52.5% monocularly and 70% binocularly for the TECNIS Symfony IOL, 81.5% monocularly and 100% binocularly for the AcrySof IQ PanOptix IOL, and 82.5% monocularly and 95% binocularly for the FineVision Micro F IOL. There was no significant difference in binocular UIVA between groups; VA was better than 0.6 in 55%, 53%, and 35% of patients with the TECNIS Symfony, AcrySof IQ Pan-Optix, and FineVision Micro F IOLs, respectively. Overall, 90% patients achieved spectacle independence. There were no differences in visual symptoms and aberrometry among groups.

CONCLUSIONS:

All three IOLs provided good visual acuity at all distances, a high percentage of spectacle independence, and little or no impact of visual symptoms on the patients' daily functioning. Near vision was statistically better for both trifocal IOLs compared to the EDOF IOL.

[J Refract Surg. 2018;34(8):507–514.]

Multifocal intraocular lenses (IOLs) are an essential component of a refractive surgeon's treatment armamentarium affording patients with presbyopia the opportunity of spectacle independence. Multifocal IOLs are designed to distribute light to different foci dedicated to different distances and use either refractive or diffractive optics. For example, conventional bifocal diffractive optics work by splitting and bending light using steps on the optic surface to create two principal focal points, thus providing good functional vision at distance and near.1 Although multifocal IOLs can provide recipients with spectacle independence, they can reduce contrast sensitivity and may also be associated with unwanted photic phenomena, such as glare and halos, which occur due to loss of light through diffractive optics.1–4 Additionally, studies report insufficient intermediate vision with bifocal diffractive multifocal IOLs.5,6

A new generation of multifocal lenses (trifocal IOLs) has been commercially available since 2010. As their name suggests, trifocal IOLs incorporate a third focal point to help improve intermediate vision while maintaining performance at distance and near.7 More recently, a new technology known as extended depth of focus (EDOF) was introduced. IOLs with EDOF technology aim to improve intermediate vision without compromising quantitative and qualitative vision. This is achieved by harnessing a unique pattern of light diffraction that elongates the focus of the eye. This concept is supported by three main principles: focal points extended to focal zone, modulation of asphericity, and pinhole optics. In theory, eyes implanted with EDOF IOLs should also experience fewer photic phenomena and less loss of contrast sensitivity at distance than traditional multifocal diffractive IOLs.

There are several EDOF and trifocal IOLs on the market, each with numerous advantages and disadvantages that surgeons must carefully consider alongside their patient's needs and preferences when deciding whether to implant a trifocal or EDOF IOL versus a “traditional” multifocal IOL. In a study that compared the resolution and optical quality of multifocal and trifocal IOLs, resolution at 20/40 Snellen visual acuity equivalence was attained over nearly the entire viewing distance range with the trifocal AT LISA tri (Carl Zeiss Meditec AG, Jena, Germany) and FineVision Micro F (PhysIOL SA, Liège, Belgium) IOLs, but the authors reported that background shadows were more prominent with these lenses than with ReSTOR multifocal IOLs (Alcon Laboratories, Inc., Fort Worth, TX) with +2.50 and +3.00 diopters (D).8

According to their design features, the AcrySof IQ PanOptix (Alcon Laboratories, Inc.) and the FineVision Micro F trifocal lenses should, theoretically, offer gains in intermediate vision at 60 cm for the AcrySof IQ PanOptix and 70 to 80 cm with the FineVision Micro F with good distance and near vision. The EDOF lens known as the TECNIS Symfony (Abbott Medical Optics, Inc., Abbott Park, IL) should, in theory, offer better quality of vision (ie, an incidence of halos and glare similar to monofocal IOLs) than the AcrySof IQ PanOptix and the FineVision Micro F, but with poorer near vision.9 Sheppard et al.10 found trifocal diffractive-refractive IOLs provide improved intermediate visual restoration when compared to bifocal diffractive-refractive or apodized diffractive IOLs, noting the added intermediate focal point was not a detriment to far or near vision. Another recent prospective case series by Monaco et al.11 comparing the AcrySof IQ PanOptix and TECNIS Symfony IOLs supports the theoretical loss of near vision in EDOF IOLs, with the AcrySof IQ PanOptix trifocal IOL demonstrating significantly better near visual acuity compared to the TECNIS Symfony IOL.

We present findings from a 6-month, single-center study to evaluate and compare visual outcomes following implantation of this new generation of diffractive IOLs. The primary aim was to compare visual acuity at all distances. The secondary aim of this study was to compare the quality of vision between lenses.

Patients and Methods

Study Design and Patients

This 6-month, single-center, prospective, comparative study included patients scheduled to undergo routine cataract surgery at Brest University Hospital. Patients were randomly allocated to receive bilateral implantation of one of two trifocal IOLs (the AcrySof IQ PanOptix or the FineVision Micro F) or an EDOF IOL (the TECNIS Symfony).

The study was performed in accordance with the tenets of the Declaration of Helsinki and its amendments and all patients provided written informed consent before study enrollment. The study was reviewed and approved by the Brest University Hospital ethics board committee. Patients seeking spectacle independence with normal binocular vision and presenting with an early objective scatter index (> 2) as determined by double-pass aberrometry (Optical Quality Analysis System; Visiometrics SL, Barcelona, Spain) or true cataract (Lens Opacities Classification III > 2) or a corrected distance visual acuity (CDVA) better than 0.63 (decimal) with a cylindrical component of 0.75 D or better were eligible for inclusion. Exclusion criteria included the presence of amblyopia, ocular surface disease as defined by a score of greater than 6 on the Speed questionnaire or greater than 1+ Oxford score for fluorescein dye test, macular or retinal abnormality as determined by posterior optical coherence tomography (Heidelberg Engineering GmbH, Heidelberg, Germany), astigmatism of 1.00 D or worse, glaucoma, diabetes mellitus, inflammatory disease, and evolutive ocular or systemic disease. Patients were informed of the potential need for intermittent correction, loss of contrast at night, and light optimization for visual performance.

AcrySof IQ PanOptix

The AcrySof IQ PanOptix is a non-apodized diffractive trifocal IOL that distributes light to four focal points (near, intermediate, and distance) in both small and large pupils. The lens has an intermediate focal point of 60 cm, with a light transmission of 88%. The light is split into two: half on the distance focus and the other half on the near and intermediate focus. The lens incorporates an intermediary 4.5-mm diffractive zone; thus, its performance does not wholly depend on pupil size.12 Made from hydrophobic acrylic, the IOL has an optic body diameter of 6 mm with an overall diameter of 13 mm. The AcrySof IQ PanOptix IOL is available in powers from +6.00 to +34.00 D (in 0.50-D steps). Per the manufacturer, the energy percentage delivered with the Enlighten optical technology is 42% far, 24% near, and 22% intermediate with 12% loss.

TECNIS Symfony

The TECNIS Symfony IOL has a biconvex, wavefront-designed anterior aspheric surface and a posterior achromatic diffractive surface to correct chromatic aberration for enhanced contrast sensitivity. The lens incorporates a proprietary diffractive echelette design that introduces a novel pattern of light diffraction that elongates the focal zone resulting in an extended range of vision and features a 360° posterior square edge. Made from ultraviolet-blocking hydrophobic acrylic, the IOL has an optic body diameter of 6 mm and an overall diameter of 13 mm. The TECNIS Symfony IOL is available in powers from +5.00 to +34.00 D (in 0.50-D steps).9 Although still a diffractive optic, the range of foci allows for nearly all light to be transmitted to the retina, with the reduction of chromatic aberrations.

FineVision Micro F

The FineVision Micro F is a diffractive, aspheric, trifocal IOL with a 360° square edge inserted through a 1.8-mm or greater incision. The concept is based on the “Bi and Bi” principle, combining two bifocal optics with two different additions: one for near, one for intermediate, and a combination of the two foci for far vision to optimize the quality of vision and not increase the loss of light energy compared to bifocal diffractive IOLs. Composed from 25% hydrophilic acrylic, the lens has an optic body diameter of 6.15 mm and an overall diameter of 10.75 mm. The FineVision Micro F IOL is available in powers from +10.00 to +35.00 D (in 0.50-D steps). Per the manufacturer, the energy percentage delivered by the apodized optic is 42% far, 29% near, and 15% intermediate with 14% loss.

Preoperative and Postoperative Assessments

All patients underwent comprehensive preoperative and postoperative examination including slit-lamp/biomicroscope examination, pupillometry, and tonometry. Biometric IOL power calculations were performed with the SRK T formula between 21 and 26, the Hoffer Q formula below, and the Haigis formula above using the IOLMaster (Carl Zeiss Meditec AG, Jena, Germany). At 6 months postoperatively, manifest refraction and monocular and binocular UDVA and CDVA (decimal) at near (40 cm), intermediate (60 cm), and distance (4 m) were measured. Quality of vision was assessed using a quality of life questionnaire (functional symptoms), modulation transfer function (MTF) to describe contrast sensitivity (iTrace, Tracey Technologies, Houston, TX), and aberrometry (iTrace).

Surgical Procedure

All surgeries were performed under topical anesthesia by a single surgeon (BC) using an uncomplicated sutureless, phacoemulsification technique. A 2.2-mm superior corneal incision was used for the AcrySof IQ PanOptix and the TECNIS Symfony, and a 1.8-mm incision for the FineVision Micro F followed by in-the-bag IOL implantation. In all cases, the IOLs were injected at the incision edge. The postoperative care regimen combined tapered steroid anti-inflammatory treatment for 2 weeks, flash antibiotic therapy with azythromicin for 3 days, indomethacin non-steroidal anti-inflammatory drugs for 4 weeks, and two to six drops of lubricant per day if needed for 1 month. Both trifocal IOLs were targeted for emmetropia. The EDOF lens was targeted for micro-monovision (better near vision) or emmetropia (better intermediate vision).

Statistical Analysis

Summary descriptive statistics were produced for all key variables of the study, including the mean and standard deviation. For each IOL, changes in outcome measures at 6 months postoperatively versus preoperatively were compared and analyzed for statistical significance using the one-way analysis of variance (except in case of variance problems, in which case the Kruskal–Wallis test was employed). All tests were performed with MedCalc statistical software (version 17.1; MedCalc Software bvba, Ostend, Belgium; https://www.medcalc.org; 2017). A P value of less than .05 was considered statistically significant. Figures were generated in accordance with Journal of Refractive Surgery recommendations.13

Results

A total of 60 patients underwent bilateral IOL implantation, with 20 patients in each IOL group. The mean age in the TECNIS Symfony, AcrySof IQ PanOptix, and FineVision Micro F groups was 69.2 ± 8.4, 62.5 ± 4.6, and 62.5 ± 4.6 years, respectively.

Refraction

Figure 1 shows the distribution of the postoperative spherical equivalent (SEQ) for all eyes implanted with the FineVision Micro F, AcrySof IQ PanOptix, and TECNIS Symfony IOLs. The FineVision Micro F and AcrySof IQ PanOptix eyes achieved similar results, with 73% of FineVision Micro F eyes and 76% of AcrySof IQ PanOptix eyes within 0.50 D. In the TECNIS Symfony eyes, 18% of eyes were within 0.50 D. It should be noted that the refractive distribution in patients with the TECNIS Symfony IOL was skewed toward myopic values because these patients were targeted for micro-monovision. Figure 2 shows postoperative refractive cylinder for each subgroup, with comparable results between the three groups: 87% of the FineVision Micro F group had less than 1.00 D of residual astigmatism, whereas 89% of the AcrySof IQ PanOptix and TECNIS Symfony eyes had less than 1.00 D of residual cylinder.

Distribution of postoperative spherical equivalent (SEQ) for the FineVision Micro F (PhysIOL SA, Liège, Belgium), AcrySof IQ PanOptix (Alcon Laboratories, Inc., Fort Worth, TX), and TECNIS Symfony (Abbott Medical Optics, Inc., Abbott Park, IL) groups. D = diopters

Figure 1.

Distribution of postoperative spherical equivalent (SEQ) for the FineVision Micro F (PhysIOL SA, Liège, Belgium), AcrySof IQ PanOptix (Alcon Laboratories, Inc., Fort Worth, TX), and TECNIS Symfony (Abbott Medical Optics, Inc., Abbott Park, IL) groups. D = diopters

Distribution of postoperative refractive cylinder (diopters) for the FineVision Micro F (PhysIOL SA, Liège, Belgium), AcrySof IQ PanOptix (Alcon Laboratories, Inc., Fort Worth, TX), and TECNIS Symfony (Abbott Medical Optics, Inc., Abbott Park, IL) groups.

Figure 2.

Distribution of postoperative refractive cylinder (diopters) for the FineVision Micro F (PhysIOL SA, Liège, Belgium), AcrySof IQ PanOptix (Alcon Laboratories, Inc., Fort Worth, TX), and TECNIS Symfony (Abbott Medical Optics, Inc., Abbott Park, IL) groups.

Postoperatively, the mean sphere in the FineVision Micro F, AcrySof IQ PanOptix, and TECNIS Symfony groups was −0.31 ± 0.56 (range: −1.25 to +1.25), −0.56 ± 0.55 (range: −0.75 to +1.75), and −0.75 ± 0.60 (range: −2.00 to −0.50) D, respectively, versus 0.48 ± 4.90 (range: −12.00 to +8.50), 0.50 ± 2.84 (range: −8.00 to +4.75), and −1.74 ± 1.89 (range: −3.00 to +6.75) D preoperatively. Postoperative cylinder was −0.68 ± 0.71 (range: −3.15 to 0.00), −0.69 ± 0.41 (range: −2.00 to −0.00), and −0.71 ± 0.43 (−2.25 to 0.00) D in the FineVision Micro F, AcrySof IQ PanOptix, and TECNIS Symfony groups, respectively, versus −0.71 ± 0.76 (range: −3.25 to 0.00), −0.76 ± 0.43 (range: −2.00 to −0.25), and −0.57 ± 0.31 (0.57 ± 0.31) D preoperatively, respectively. Postoperative differences in mean sphere and cylinder between groups was statistically significant (P = .05).

Distance VA

Monocular UDVA and CDVA at 6 months postoperatively are shown in Figure 3. Overall, 80% of patients in all IOL groups achieved monocular and binocular VA of better than 0.8 (decimal). All patients in the FineVision Micro F and TECNIS Symfony groups achieved a binocular VA of better than 0.8 versus 94.7% of patients in the AcrySof IQ PanOptix group.

Culmulative distribution of uncorrected (UDVA) and corrected (CDVA) distance visual acuity for the three intraocular lenses: (A) FineVision Micro F (PhysIOL SA, Liège, Belgium), (B) AcrySof IQ PanOptix (Alcon Laboratories, Inc., Fort Worth, TX), and (C) TECNIS Symfony (Abbott Medical Optics, Inc., Abbott Park, IL).

Figure 3.

Culmulative distribution of uncorrected (UDVA) and corrected (CDVA) distance visual acuity for the three intraocular lenses: (A) FineVision Micro F (PhysIOL SA, Liège, Belgium), (B) AcrySof IQ PanOptix (Alcon Laboratories, Inc., Fort Worth, TX), and (C) TECNIS Symfony (Abbott Medical Optics, Inc., Abbott Park, IL).

The mean monocular distance VA (decimal) was 0.844 ± 0.210 in the FineVision Micro F group, 0.868 ± 0.163 in the AcrySof IQ PanOptix group, and 0.833 ± 0.205 in the TECNIS Symfony group. The mean binocular VA (decimal) was 0.961 ± 0.100 in the FineVision Micro F group, 0.976 ± 0.139 in the AcrySof IQ PanOptix group, and 0.979 ± 0.06 in the TECNIS Symfony group. There was no statistically significant difference between groups in either monocular or binocular distance VA (P = .717 and .837, respectively).

UDVA was within one line of CDVA in 88%, 92%, and 80% of eyes in the FineVision Micro F, AcrySof IQ PanOptix, and TECNIS Symfony eyes, respectively (Figure 4).

Comparison between uncorrected (UDVA) and corrected (CDVA) distance visual acuity for the three intraocular lenses: FineVision Micro F (PhysIOL SA, Liège, Belgium), AcrySof IQ PanOptix (Alcon Laboratories, Inc., Fort Worth, TX), and TECNIS Symfony (Abbott Medical Optics, Inc., Abbott Park, IL).

Figure 4.

Comparison between uncorrected (UDVA) and corrected (CDVA) distance visual acuity for the three intraocular lenses: FineVision Micro F (PhysIOL SA, Liège, Belgium), AcrySof IQ PanOptix (Alcon Laboratories, Inc., Fort Worth, TX), and TECNIS Symfony (Abbott Medical Optics, Inc., Abbott Park, IL).

Near VA

Figure 5 shows uncorrected monocular and binocular near VA at 6 months postoperatively. Overall, 52.5% patients in the TECNIS Symfony group versus 81.5% and 82.5% in the AcrySof IQ PanOptix and FineVision Micro F groups achieved a monocular VA of J2 (> 20/32). Binocularly, 100% of the AcrySof IQ PanOptix and 95% of FineVision Micro F groups had a VA of J2 (> 20/32) versus 70% of patients in the TECNIS Symfony group.

Distribution of uncorrected (A) monocular and (B) binocular near visual acuity for the three intraocular lenses: FineVision Micro F (PhysIOL SA, Liège, Belgium), AcrySof IQ PanOptix (Alcon Laboratories, Inc., Fort Worth, TX), and TECNIS Symfony (Abbott Medical Optics, Inc., Abbott Park, IL).

Figure 5.

Distribution of uncorrected (A) monocular and (B) binocular near visual acuity for the three intraocular lenses: FineVision Micro F (PhysIOL SA, Liège, Belgium), AcrySof IQ PanOptix (Alcon Laboratories, Inc., Fort Worth, TX), and TECNIS Symfony (Abbott Medical Optics, Inc., Abbott Park, IL).

The mean monocular near VA (decimal) was 0.60 ± 0.13 in the FineVision Micro F group, 0.61 ± 0.11 in the AcrySof IQ PanOptix group, and 0.51 ± 0.17 in the TECNIS Symfony group. The mean binocular VA (decimal) was 0.64 ± 0.07 in the FineVision Micro F group, 0.66 ± 0.00 in the AcrySof IQ PanOptix group, and 0.57 ± 0.15 in the TECNIS Symfony group.

For both monocular and binocular near VA, there was a statistically significant difference between the TECNIS Symfony group and the FineVision Micro F group and between the TECNIS Symfony group and the AcrySof IQ PanOptix group (P = .002). However, there was no significant difference between the FineVision Micro F eyes and AcrySof IQ PanOptix eyes (P > .05).

Intermediate VA

Figure 6 shows uncorrected binocular intermediate VA (60 cm). The mean monocular distance VA (decimal) was 0.574 ± 0.203 in the FineVision Micro F group, 0.549 ± 0.123 in the AcrySof IQ PanOptix group, and 0.610 ± 0.174 in the TECNIS Symfony group. There was no statistical significance between groups.

Distribution of uncorrected binocular intermediate visual acuity for the three intraocular lenses: FineVision Micro F (PhysIOL SA, Liège, Belgium), AcrySof IQ PanOptix (Alcon Laboratories, Inc., Fort Worth, TX), and TECNIS Symfony (Abbott Medical Optics, Inc., Abbott Park, IL).

Figure 6.

Distribution of uncorrected binocular intermediate visual acuity for the three intraocular lenses: FineVision Micro F (PhysIOL SA, Liège, Belgium), AcrySof IQ PanOptix (Alcon Laboratories, Inc., Fort Worth, TX), and TECNIS Symfony (Abbott Medical Optics, Inc., Abbott Park, IL).

In the FineVision Micro F group, 35% achieved a VA of better than 0.625 (20/32), 40% had a VA of 0.4 (20/50) to 0.625 (20/32), and 25% had a VA worse than 0.4 (20/50). In the TECNIS Symfony group, 55%, 30%, and 15% of patients achieved a VA of better than 0.625 (20/32), 0.4 to 0.625, and worse than 0.4 (20/50), respectively. In the AcrySof IQ PanOptix group, 52.6%, 42.1%, and 5.3% of patients achieved a VA of better than 0.625 (20/32), 0.4 to 0.625, and worse than 0.4 (20/50), respectively.

MTF (Contrast Sensitivity)

MTF curves with and without correction at 6 months postoperatively are shown in Figure A (available in the online version of this article). The data are comparable for all three IOLs with a decrease in contrast sensitivity for all IOLs without correction versus with correction, and an acceptable decrease under mesopic conditions.

Modulation transfer function (MTF) with correction. y axis = MTF factor (0.4 correspond to % of contrast perceived); x axis = spatial frequency (cycles/mn) for the three intraocular lenses: FineVision Micro F (PhysIOL SA, Liège, Belgium), AcrySof IQ PanOptix (Alcon Laboratories, Inc., Fort Worth, TX), and TECNIS Symfony (Abbott Medical Optics, Inc., Abbott Park, IL).

Figure A.

Modulation transfer function (MTF) with correction. y axis = MTF factor (0.4 correspond to % of contrast perceived); x axis = spatial frequency (cycles/mn) for the three intraocular lenses: FineVision Micro F (PhysIOL SA, Liège, Belgium), AcrySof IQ PanOptix (Alcon Laboratories, Inc., Fort Worth, TX), and TECNIS Symfony (Abbott Medical Optics, Inc., Abbott Park, IL).

Mean defocus curves for each IOL are shown in Figure 7. For each IOL, the profile was smooth from far to near. However, with trifocal lenses, slight humps at the principal foci could be identified, whereas the curve achieved with the EDOF TECNIS Symfony IOL was smoother in the shape of a dome.

Defocus curves. y axis = visual acuity in decimal; x axis = diopters (blur test) for the three intraocular lenses: FineVision Micro F (PhysIOL SA, Liège, Belgium), AcrySof IQ PanOptix (Alcon Laboratories, Inc., Fort Worth, TX), and TECNIS Symfony (Abbott Medical Optics, Inc., Abbott Park, IL).

Figure 7.

Defocus curves. y axis = visual acuity in decimal; x axis = diopters (blur test) for the three intraocular lenses: FineVision Micro F (PhysIOL SA, Liège, Belgium), AcrySof IQ PanOptix (Alcon Laboratories, Inc., Fort Worth, TX), and TECNIS Symfony (Abbott Medical Optics, Inc., Abbott Park, IL).

Functional Symptoms

Figure 8 shows functional symptoms reported in the patient questionnaire. Fewer than 1% of patients in each IOL group experienced night-time visual disturbances, dry eye, halos, and glare. Patients reported that visual symptoms had little or no impact on their daily functioning.

Mean score for all functional symptoms reported in the questionnaire for the three intraocular lenses: FineVision Micro F (PhysIOL SA, Liège, Belgium), AcrySof IQ PanOptix (Alcon Laboratories, Inc., Fort Worth, TX), and TECNIS Symfony (Abbott Medical Optics, Inc., Abbott Park, IL).

Figure 8.

Mean score for all functional symptoms reported in the questionnaire for the three intraocular lenses: FineVision Micro F (PhysIOL SA, Liège, Belgium), AcrySof IQ PanOptix (Alcon Laboratories, Inc., Fort Worth, TX), and TECNIS Symfony (Abbott Medical Optics, Inc., Abbott Park, IL).

Aberrometry

Mean higher order aberrations (HOAs), coma, tilt, and spherical aberrations are shown in Table A (available in the online version of this article). For each IOL, none of the mean values were greater than 0.30 microns with a pupil of 4 mm. For all IOLs, coma, tilt, and spherical aberrations measured less than 0.16 microns; mean HOAs were highest in the TECNIS Symfony group (0.28 ± 0.51; range: 0.04 to 2.73). However, there was no significant difference between groups (P > .05).

Mean Aberrometry (iTrace) Data (RMS Values in μm) for a 4-mm Diametera

Table A:

Mean Aberrometry (iTrace) Data (RMS Values in μm) for a 4-mm Diameter

Patient Satisfaction

Overall, 90% of patients achieved spectacle independence. There was no need for refractive lens exchange in any patient and all patients stated that they would be willing to repeat surgery with the same IOL.

Discussion

Multifocal IOLs facilitate good near and distance visual acuity and produce satisfactory outcomes in the majority of patients.14 However, some patients implanted with bifocal IOLs report difficulties with activities performed at intermediate distance, such as using a computer or seeing a car dashboard. Some patients have also reported visual disturbances at night (eg, glare and halos).15,16

Trifocal lenses overcome several limitations associated with traditional multifocal (bifocal) lenses because they incorporate a third focal point to help improve intermediate vision while maintaining performance at distance and near. An even newer class of IOLs known as EDOF lenses also aims to improve intermediate vision without compromising distance vision.

Clinical findings showed that the visual acuity was comparable between lenses, except for near vision. There was no significant difference in monocular or binocular UDVA between groups with good vision for each lens. For near VA, there was no statistical difference between the two trifocal groups, but the mean VA was statistically better for both the AcrySof IQ PanOptix and FineVision Micro F trifocal lenses as compared to the TECNIS Symfony IOL. Nevertheless, near vision with the TECNIS Symfony was good; however, we suggest this is only the case if targeting slight monovision (<−0.25 D). If greater than −0.25 D, we would anticipate an increase in the incidence of halos. Regardless, the EDOF lenses worked less efficiently for near vision when compared to both trifocal IOLs.

In terms of intermediate visual acuity, there was no statistical difference between groups with a tendency for better performance with the EDOF lens when targeted for emmetropia. Of note, the AcrySof IQ PanOptix lens performed better than the FineVision Micro F IOLs (albeit not statistically). This is not surprising because both lenses were tested at 60 cm yet the FineVision Micro F may perform better at 70 to 80 cm. Vryghem and Heireman17 evaluated uncorrected intermediate VA at 70 cm in 50 eyes of 25 patients under photopic conditions; 98% of eyes achieving worse than 0.3 logMAR and 58% achieving worse than 0.3 logMAR. In a study by Jonker et al.18 that compared the FineVision Micro F with a +3.00 D add bifocal IOL, the mean uncorrected intermediate VA was 0.32 ± 0.15 logMAR.

A major issue associated with traditional multifocal IOLs as compared with monofocal lenses is the incidence of photic phenomena, which can have a negative impact on patient satisfaction with postoperative outcomes.18 Although many surgeons believe that diffractive lens technology is superior to refractive lens technology, the former has a somewhat poor reputation because they may be associated with reduced quality of vision under certain conditions. Indeed, it has been suggested that diffractive IOLs are associated with 18% to 20% loss in light transmission and reduced contrast sensitivity.19

In the current study, fewer than 1% of patients in each IOL group experienced night-time visual disturbances, dry eye, halos, and glare. Patients reported that visual symptoms had little or no impact on their daily functioning. Additionally, contrast sensitivity was comparable for all three IOLs with an expected decrease in contrast sensitivity for all IOLs without correction versus with correction, and an acceptable decrease under mesopic conditions. These findings echo those of Carballo-Alvarez et al.,20 who bilaterally implanted FineVision Micro F lenses in 22 patients. Their findings showed that patients achieved a full range of adequate vision, satisfactory contrast sensitivity, and a lack of significant adverse photic phenomena. Additionally, Sheppard et al.10 reported that, in patients bilaterally implanted with a diffractive trifocal IOL (FineVision Micro F), halometry showed a glare scotoma of a mean size similar to that in previous studies of multifocal and accommodating IOLs and there were no subjective complaints of dysphotopsia.

Overall, 86% to 90% of patients included in the current study achieved spectacle independence. Furthermore, there was no need for refractive lens exchange in any patient and all patients stated that they would be willing to repeat surgery with the same IOL. There was a subset of patients considering excimer enhancement at the end of the analysis period. This subgroup consisted of 5 patients with the FineVision Micro F, 4 with the AcrySof IQ PanOptix, and 2 with the TECNIS Symfony IOL. The primary reasons for considering enhancement included residual refractive error causing them to be unsatisfied with one eye compared to the other or, alternatively, discomfort with binocular vision primarily related to a cylindrical component of 0.75 D or greater. Interestingly enough, the TECNIS Symfony group had the fewest patients contemplating augmentation, despite a certain level of micromonovision purposively targeted. This signifies a tolerance of refractive error with this EDOF compared to the diffractive multifocal IOLs, which are more sensitive to achieving emmetropia.

The study has several notable limitations. First, intermediate vision was only tested at 60 cm. As noted previously, the AcrySof IQ PanOptix and the FineVision Micro F IOLs should offer gains in intermediate vision at 60 cm for the AcrySof IQ PanOptix and 70 to 80 cm for the FineVision Micro F. Additionally, the EDOF lens was targeted for micromonovision (better near vision) or emmetropia (better intermediate vision), which may confound near vision results. Ideally, each subgroup would have included a full complement of patients to minimize confounders. Future studies should address these limitations. Further studies with longer follow-up times are also needed to assess the stability of outcomes and occurrence of posterior capsule opacification.

Overall, findings from this study indicate good visual outcomes following implantation of this new generation of diffractive lenses. Vision at distance and intermediate was comparable between lenses, although the trifocal lenses performed better at near. Quality of vision, spectacle independence, and patient satisfaction were also comparable between groups.

References

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Mean Aberrometry (iTrace) Data (RMS Values in μm) for a 4-mm Diametera

IOLHOAsComaTrefoilSpherical Aberrations
FineVision Micro F0.16 ± 0.09 (0.06 to 0.53)0.10 ± 0.09 (0.01 to 0.50)0.08 ± 0.04 (0.00 to 0.20)0.02 ± 0.002 (0.00 to 0.09)
TECNIS Symfony0.28 ± 0.51 (0.04 to 2.73)0.13 ± 0.27 (0.01 to 1.72)0.12 ± 0.21 (0.01 to 1.03)0.05 ± 0.13 (0.00 to 0.80)
AcrySof IQ PanOptix0.16 ± 0.07 (0.05 to 0.31)0.07 ± 0.04 (0.02 to 0.20)0.08 ± 0.05 (0.01 to 0.18)0.03 ± 0.02 (0.00 to 0.01)
Authors

From University Hospital, Ophthalmology Department, Brest, France (BC, GB, CA-Z); and Inserm UM1101 LaTIM, Brest University, Brest, France (BC, ML).

Dr. Cochener is a clinical investigator for PhysIOL SA and AMO Lab (Johnson & Johnson). The remaining authors have no financial or proprietary interest in the materials presented herein.

AUTHOR CONTRIBUTIONS

Study concept and design (BC, GB, ML, CA-Z); data collection (BC, GB, ML, CA-Z); analysis and interpretation of data (BC); writing the manuscript (BC); critical revision of the manuscript (BC, GB, ML, CA-Z); statistical expertise (BC); administrative, technical, or material support (BC); supervision (BC)

Correspondence: Beatrice Cochener, MD, PhD, CHU Morvan, Department of Ophthalmology, 2 Avenue Finistère, 29200 Bretagne, France. E-mail: beatrice. cochener@ophtalmologie-chu29.fr

Received: September 15, 2017
Accepted: May 25, 2018

10.3928/1081597X-20180530-02

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