Dagny Zhu, MD, is a board-certified ophthalmologist specializing in cornea, cataract, and refractive surgery. She is Medical Director and Partner at NVISION Eye Centers in Rowland Heights, CA.

Shamik Bafna, MD, is a board-certified refractive and cataract specialist at the Cleveland Eye Clinic and Clear Choice Laser Eye Center. He has been in practice for nearly 25 years and specializes in laser-assisted cataract surgery with a focus on reducing a patient’s dependence on glasses.

SHAMIK BAFNA, MD, CALLS THE Alcon Vivity a game changer in the world of presbyopia-correcting intraocular lenses (PC-IOLs).

“Prior to this lens,” Dr. Bafna said, “all of the lenses that had extended depth of field (EDOF) were diffractive technology lenses. And even though that’s a fantastic technology, the downside is that because it splits light, it tends to cause visual dysphotopsias such as glare and halos.”

He explained that Vivity is the first non-diffractive EDOF lens, which for the first time offers patients a range of vision, but with the visual disturbance profile of a monofocal IOL. This means patients experience less of the blur and dysphotopsias that occur with most diffractive lenses.

“The previous lenses on the market, the ones we’re most familiar with, have diffractive rings, and are plagued by bothersome symptoms for a lot of patients, including decreased contrast, halos and glare,” Dagny Zhu, MD, added. “The fact that the Vivity is non-diffractive—it doesn’t have rings that split light—really mitigates a lot of the bothersome symptoms traditionally associated with diffractive presbyopia-correcting IOLs.” She noted that in her experience, visual disturbances with Vivity are very comparable to those encountered when using a monofocal lens.

“You’re basically offering the best of both worlds,” Dr. Zhu said. “The minimal visual disturbance profile and excellent quality of vision of a monofocal, plus the extended depth of focus that you would get similar to a low-add multifocal.”

She says her clinical experience matches or in some ways even exceeds the outcomes of the FDA trials, and that even though the near is not going to be as strong as a traditional multifocal, she’s obtained good outcomes with Vivity. She notes intermediate vision around 20/25 or 20/20, and often pretty good functional near vision as well, around 20/30, or even 20/25 or 20/20 in a handful of cases.

Real Life Experience

Drs. Zhu and Bafna both began implanting Vivity shortly after it became available, and each has implanted a few hundred of the lenses.

Dr. Zhu said she’s been “pleasantly surprised” at the great quality and range of vision that Vivity provides.

“I always tell my patients they may still need to use their readers for fine print,” she said, “but overall, for things like looking at their phone or their computer, they’ll be very happy with the Vivity. And sometimes I’m surprised to see that patients get even better near than I had promised them!”

Dr. Zhu has encountered problems with Vivity similar to those experienced with monofocal lenses. “There will always be a small handful of patients that still experience some halos and glare, some nighttime dysphotopsias, but you get that with monofocal lenses and even virgin eyes,” she said. “I haven’t had to explant any of these lenses for that reason. It’s just not as bothersome as it would be with a traditional diffractive lens.”

She noted that it’s important to keep in mind the Vivity is different than a monofocal lens, so care should be taken if considering it for use in eyes that are very irregular.

Dr. Bafna has found that his patients are very happy with their distance and intermediate vision, and they’ve got functional near vision. He pointed out one exception: “I think the only patients that may sometimes have concerns are my low myope patients where I employ Vivity,” he said. “They’re used to having very good near vision, and even though you may have a pre-operative discussion with them and explain that their near vision may not be as good as what they’re used to, patients tend to forget those conversations after surgery.”

Patient Populations

With any emerging medical technology, clinical experience allows doctors to explore different uses, and to identify what patients are the best candidates. Both doctors say the addition of Vivity has not reduced the number of patients they treat with other IOLs.

Dr. Zhu pointed out the downside of Vivity is it doesn’t give as strong of near vision as a traditional diffractive multifocal lens. “So I’m actually using it concurrently with the trifocal," she said. “And I decide between one or the other based on the patient’s exam, lifestyle, and personality.”

She explained that in terms of the patient exam, the Vivity is more forgiving. “If there is some ocular surface disease or a little irregularity of the ocular surface, I might be traditionally afraid to put in a diffractive lens,” she said. “But I feel pretty comfortable putting a Vivity lens in, again because it’s so similar to a monofocal in terms of the quality of vision.”

Regarding patient lifestyle, she said that for a patient who is Type A, or OCD, or the type that pays a lot of attention to the detail and quality of vision, or who does a lot of nighttime activities like driving, she feels the Vivity lens is superior to the traditional diffractive lens because of the reduction of dysphotopsias and increased overall quality of vision.

Dr. Bafna said when Vivity was launched he wasn’t sure where it would fall into his spectrum, especially because he loves using the PanOptix trifocal. “I found that Vivity allows me to take care of patients that I would not have been able to take care of with PanOptix. By employing this lens, I’ve almost doubled my utilization of presbyopic lenses,” he explained. “I still use the PanOptix with the patients I normally would, but now there’s a new subset of patients that I can offer Vivity to, whereas in the past I would have deferred to more of a monofocal lens.”

He also believes patients with a Type A personality, or with very high expectations, are potentially good candidates for this lens.

Dr. Bafna has identified several patient groups that may benefit from Vivity.

1. Patients expressing a desire to have a greater range of vision—some distance, some intermediate, and some functional near vision—who cannot tolerate any night vision disturbances. This may be someone like a truck driver or an airline pilot. In the past, this group would have faced the tradeoff of tolerating some degree of dysphotopsias. Now, Vivity is a choice that won’t result in quite as much range of vision as a diffractive technology, but has a dysphotopsia profile very similar to that of a monofocal lens.
2. Prior refractive surgery patients. Dr. Bafna points out the biometry in a prior LASIK patient is not predictable, and therefore you may not want to employ diffractive technology in those patients. He said the Vivity is very forgiving since the defocus curve is fairly flat around emmetropia, so even if the biometry is a bit off, the procedure can still be a success.
3. Patients who don’t have a pristine eye. If diffractive technology is used in these patients, the optics will be off from that perspective. So for an eye with a mild epiretinal membrane, or a little bit of dry eye disease, or that has some drusen that isn’t yet AMD but has the potential of eventually developing further pathology, Dr. Bafna will employ Vivity. “Even if the patient with drusen has further degradation toward macular degeneration, because I do not split light, all I’m doing is stretching it and shifting it through the X-Wave technology within this lens,” he said. “I’m able to get all of the light energy to the retina, so I’m not worried if there’s some loss of vision or similar.”
4. Dry eye patients. Even after optimizing the ocular surface prior to cataract surgery, some patients just have an inherent degree of dryness. Dr. Bafna says in the past, with diffractive technology, you end up where you feel their vision quality is not as good as you’d like it to be. But with Vivity, again because it’s not splitting light, he is confident he can provide that extended range of vision.

Individualized Use

Because the compromise with Vivity is with near vision, Dr. Zhu believes the upcoming pharmaceutical presbyopia treatments may be a useful adjunct to Vivity.

“The great thing about these presbyopia-correcting drops,” she said, “is when they come to market—depending on the label and study data—we may be able to adapt them to different situations. Not necessarily just the early presbyopic virgin eyes, but potentially for patients who have had surgery already: LASIK patients or pseudophakic patients with multifocal or EDOF lenses who just want a little more near."

Dr. Bafna uses Vivity for blended vision, which he says is very different from monovision. He said many patients are averse to monovision because they feel like their near eye doesn’t see distance and their distance eye doesn’t see near. But when you have a very small defocus of -.50 to -.75, patients still feel like they’ve got very good distance vision, along with near vision and good stereopsis.

“With Vivity,” he said, “I feel it’s the closest thing to your natural phakic monovision because you do have that range of vision. So all you’re doing is moving that range of vision down a little bit from where it normally would be.”

Increased Access

Dr. Zhu ended by saying that no one wants to over promise and under deliver, which was the situation eye care professionals could find themselves in with some existing IOLs. “I think that the Vivity lens is a great gateway lens to presbyopia correction, because the upside is so high with very little downside, as long as you set appropriate expectations from the start,” she explained. “So I think it really increases the market, in terms of the percentage of surgeons who can start using presbyopia-correcting lenses and also the number of patients to whom we can offer presbyopia-correcting technology. I think the Vivity lens has really increased the number of surgeons and patients who can access that market.” ■

Disclosures: Dr. Zhu is a consultant for, and recipient of, a research grant from Alcon. Dr. Bafna is a consultant to Alcon.