I have been implanting “multifocal” lenses for almost 20 years. Often, patients would be frustrated by having to make compromises in either intermediate or near vision. Our technology could deliver distance (often with significant dysphotopsia) and excellent near or excellent intermediate, but not both.

However, the Alcon Clareon PanOptix intraocular lens (IOL) has addressed that conundrum. This trifocal IOL provides full depth of focus for near, intermediate, and distance vision. With minimal side effects, the PanOptix has become my go-to lens for cataract patients with healthy eyes. I don’t tell them it is an “upgraded” lens, but rather, I tell them that, except for their cataracts, their eyes are healthy. Consequently, they qualify for the lens that will provide them vision at all distances without correction.

In this article, I’ll share the success I’ve had with the PanOptix IOL. I’ll discuss selecting the appropriate patients and setting patient expectations.

First, let’s take a look at the lens itself.

Lens Structure

The PanOptix is part of the Alcon Clareon family of IOLs, which includes Vivity and PanOptix, as well as monofocal and toric lenses. All family members feature a 1-piece hydrophobic acrylic, and are available in both clear or natural.

I actually started using the precursor AcrySof IQ PanOptix Trifocal IOL before I used the Clareon. In late 2019, the AcrySof IQ PanOptix Trifocal became the first such lens available for U.S. patients undergoing cataract surgery.

I often tell patients that, with any kind of optical system using rings to bend light, there will always be some loss of contrast sensitivity and perhaps even central resolution, which is why these lenses historically have had many detractors. However, with the PanOptix IOL, many of those issues have been significantly diminished.

In addressing patient satisfaction, one study reported that 99% of patients said they would choose the same lens again (Clareon PanOptix Trifocal Hydrophobic Acrylic IOL Model CNWTT0 2021 Directions for Use).

Patient Selection

Critical to success is selecting patients who have healthy eyes. Specifically, I won’t implant the PanOptix IOL in a patient with macular disease, moderate to severe glaucoma, chronic inflammation, or any other significant ocular disease.

If a patient has ocular surface disease, I won’t implant the lens until I’ve treated the disease aggressively. I stress to the patient that we are in no rush to implant the lens until we improve the ocular surface, as this will be the quality of vision for the rest of their lives, and we need to get it right the first time. If it takes 2-3 months to control the patient’s ocular surface disease, so be it.

Universally, patients appreciate this thoughtful, measured approach to aggressively managing their ocular surface disease. I understand that, during a busy clinic day, clinicians focus on conditions that will steal patients’ vision, often causing ocular surface disease to fall by the wayside. However, scolding your patients by telling them to just do a better job using their artificial tears is both unkind and irresponsible.

Before performing any cataract surgery, let alone implanting the PanOptix lens, we must aggressively use all the tools in our arsenal to treat a patient’s ocular surface disease, depending on its cause. These tools include anti-inflammatory medications, punctal plugs, lid hygiene, any number of meibomian gland heating/expression tools (BlephEx, TearCare, etc.), or even intense pulsed light therapy, which I purchased for my practice more than a year ago.

As a fellowship-trained glaucoma surgeon with a busy refractive cataract practice, I’ve learned where I can push the envelope in patients with glaucoma. If my glaucoma patients have some visual field loss, I’ll use other IOL options, such as the Alcon Clareon Vivity IOL or the RxSight Light Adjustable Lens.

 Happiest Patients 

Among the patients in whom I implant the PanOptix lens, the group that tends to be happiest after surgery consists of those who had to wear glasses to see everything, or to read, prior to surgery. That includes hyperopes, as well as emmetropes who are presbyopic. They are overjoyed when I can resolve their presbyopia.

In addition, I encourage myopes who need to remove their glasses to read to have the PanOptix IOL. If they don’t use the PanOptix, then I tell them I will need to keep them nearsighted after surgery, which is what their brains are accustomed to, or they will have to suffer through reading glasses, which they’ve never had to do before. I stress to them that the PanOptix lens gives them an opportunity to have what they’ve never had before: distance, intermediate, and near vision.

Early in my career, I assumed that any myopic patient who needed to remove their glasses to read wanted to be plano for distance. However, I had a patient in whom I used that approach, only to discover later that she would spend most of her day working at her desk reading. As a result, she sent me a letter saying that I had taken her world away. I will never forget that letter.

With this experience in my past, I never fail to emphasize what patients’ expectations are, especially if they are myopic. I ask what they really want out of their surgery. Cataract surgery is always a refractive procedure, period.

My patients also have a very fast rate of neuroadaptation to the PanOptix, compared to previous presbyopia-mitigating IOLs. With bilateral PanOptix IOLs, most patients neuroadapt almost immediately. They simply don’t use glasses any longer.

Every Quarter Diopter Matters

In my practice, cataract surgery is all about precision. Preoperatively, I perform my lens calculations using 2 different devices—the Alcon Argos Biometer and Zeiss IOLMaster—and I perform topography with the Cassini.

Intraoperatively, when I implant a PanOptix lens, I always use a femtosecond laser and perform intraoperative aberrometry with the Alcon ORA or laser guidance with the Alcon Digital Marker Microscope.

Although some feel that lens calculations have become so precise that intraoperative aberrometry has less relevance, if intraoperative aberrometry causes me to change the lens selection by 0.25 D, that can make all the difference for some patients. Every quarter diopter matters.

For my patients with astigmatism, if they have <0.75 D of astigmatism, I will typically make arcuate incisions, either with limbal relaxing incisions or with laser. With higher astigmatism, I use the PanOptix toric lens.

If patients have a history of refractive surgery, I expect them to demand the same level of reliability in their refractive result as they did when they were younger and invested in LASIK, photorefractive keratotomy, or radial keratotomy. Like many surgeons, I tend to shy away from the PanOptix lens in these patients because of their increased dysphotopsias and the variability in my results in this situation. Instead, I prefer the Light Adjustable Lens to allow the patients to have the final say in their refractive outcomes, given their irregular astigmatism and often worsened ocular surface issues.

High-quality Tech

In my practice, more than 60% of the lenses I implant are “premium” lenses. Today’s cataract patients want to see as well as they can and are less willing to tolerate worsening vision as a consequence of growing older.

The high quality of the technology means that we can now offer patients a dramatically better result using the PanOptix lens for presbyopia correction. 

Disclosures

Dr. Sarkisian is a consultant/advisor for Alcon, and receives lecture fees and grant support from them.

Dr. Sarkisian is the founder and CEO of Oklahoma Eye Surgeons, PLLC. He specializes in cataract surgery and is fellowship trained in glaucoma and advanced anterior-segment surgery. In 2019, he was the first clinician in the state of Oklahoma to implant the PanOptix IOL.