On August 27th of this year Alcon announced the FDA approval of their new trifocal intraocular lens for use at the time of cataract surgery or refractive lens exchange. Since this launch my Instagram has been flooded with doctors all over the country announcing that they have been the first to implant it in their city. As a result of this I have found patients have a lot of questions about this lens during consultations at my office. I thought it might be best to get some good data out there from a doctor who has implanted multiple IOL designs from multiple manufacturers over the years, to get the pros and cons of many of the intraocular lens designs currently on the market.
What is a trifocal intraocular lens?
A trifocal intraocular lens is different from a trifocal pair of glasses. In a trifocal pair of glasses you can see the distance through the top portion, your computer through the middle portion (intermediate vision), and a book (near vision) through the bottom.
This is different from a trifocal IOL because in a trifocal IOL you can see distance, intermediate, and near vision all at the same time. The reason is that this lens technology is splitting light for all of those distances and having them all reach your retina at once. This is the same technology we have been using in multifocal lenses for years, but bifocal multifocal lens just had light from distance and near reaching the retina at once and they left out an intermediate focal point.
The following video does a great job showing how multifocal lenses work and what you can expect the haloes look like when driving. The halo effect will be similar with the Alcon Panoptix.
Harbor View at Night with a multifocal Intraocular lens, showing glare around lights.
If we are splitting light in multifocal lenses does that affect image quality?
This splitting of light is great because it allows you to see distance and near objects at the same time. However, because light is essentially a form of energy it can be neither created nor destroyed (1st law of thermodynamics.) This means that a multifocal lens is simply transforming this light energy. So, the distance image is at a lower light intensity in a multifocal lens than it is in a monofocal lens. For most people this is not an issue, but lower contrast images can be issues for people who have had altered optics from prior LASIK or RK (we can test for this at Las Vegas Eye Institute), for patients with retinal diseases like macular degeneration or diabetic retinopathy, and patients with moderate to severe glaucoma (mild glaucoma this is not an issue.) So, you can probably guess that the trifocal lens is taking light energy away from distance and near vision to provide you with this third intermediate vision level. In physics, and life, it seems that nothing is ever for free!
Is the Alcon PanOptix new technology?
No. The Alcon PanOptix is a multifocal intraocular lens that has been used in Europe for about 4 years. It received the EU CE mark approval in October of 2015. In Europe, they have had access to other trifocal intraocular lenses including the Zeiss AT LISA and the Finevision Trifocal. In the United Stats we don’t have access to these other lenses and the Alcon Panoptix is the first and currently “only” trifocal available here.
What is an extended depth of focus lens and how is it different from a multifocal lens?
An extended depth of focus (EDOF) lens is a lens that allows for patients to see both distance and intermediate vision at the same time. Some patients will even find they have adequate near vision with this lens once it has been implanted in both eyes. In the United States we have one lens in this class and it is called the Symfony lens and is made by Johnson and Johnson. It uses technology that essentially blends the image from distance and intermediate. This lens was designed to give better optical quality than the multifocal lenses that came before it, however it’s biggest downfall in my practice has been that patients are sometimes disappointed that they need to use reading glasses more often than they had hoped. Although their computer (intermediate) vision is usually quite good.
The following video discusses the EDOF lens but it has what I consider to be a few important errors in the video. First, most of my patients do get a form of halo with this lens that is often described as a “fuzz” and is usually not overly problematic for driving at night. However, it is definitely present and nearly never seen with a monofocal lens. The next problem with this video is that is shows that patients have good “near” vision. I find this to only be the case for about half of my patients with this lens implanted in both eyes. The other half feel they need reading glasses for extended periods of reading and for looking at finer levels of print. Regardless the video does at least give an idea of what the engineers were aiming for with this technology.
Have there been clinical trials of Trifocal Intraocular lenses post European approval?
An article came out in the Journal of Refractive surgery in August of 2018 comparing the Alcon Panoptix, the Finevision, and the Symfony extended depth of focus lens. They found the distance vision was equivalent in all three groups. The near vision was found to be very good for both the Alcon Panoptix and Finevision trifocal but not nearly as good in the Symfony group. Binocular vision was excellent at near (J2 vision on our eye cards) in 100% of patients with the Symfony and 95% of patients with the Finevision lens but this was only seen in 70% of Symfony patients. The intermediate vision was good and essentially equal in all three groups. In this particular study they reported that less than 1% of patients had complaints of night vision issues such as haloes or glare.
A newer article was published in the Journal of Refractive surgery this year in September of 2019. This new article was comparing implantation of the trifocal PanOptix in both eyes, to the implantation of two multifocal IOLS with one IOL set for distance and intermediate while the other eye was set for distance and near. This implantation of bifocal IOLs with a mixture of intermediate and near has been common in the United States over the last few years to essentially provide distance, intermediate, and near vision similar to trifocal technology. I have performed it on many of my patients with great outcomes. Hence the aim of this study was to try to determine if we are truly gaining anything with this new technology or perhaps even losing something. The article essentially found that there was a slight improvement in the quality of intermediate and near vision in the PanOptix group but overall, they had similar outcomes. The one downfall to this article was that it was performed using a combination of the Alcon Activefocus 2.5D bifocal lens combined with the Alcon Restor +3.0D bifocal lens. Most surgeons I know that perform this, use a combination of lenses from Johnson, specifically the ZKB00 +2.75D and ZLB00 +3.25D lensed which tends to provide a bit better near and intermediate vision in my experience.
What other advantages does the Alcon PanOptix lens have?
The Alcon PanOptix lens is also approved to treat astigmatism. This is helpful because many patients have corneal astigmatism that needs to be addressed at the time of cataract surgery to make a multifocal lens work properly. In comparison, the previously mentioned lenses the ZKB00 and ZLB00 by Johnson and Johnson cannot correct astigmatism so they have a smaller pool of patients that they can be effectively placed into.
This all sounds very complicated. How can I learn more about whether a Symfony (EDOF), Multifocal, or PanOptix Trifocal may be right for me?
You are right. This is complex. I will be the first to admit that a consultation for cataract surgery with me can get complex. We perform a lot of testing and we will ask you questions about what activities you do most often to try to determine what is the best lens for you. If you go see a doctor and he tells you that the PanOptix is the best lens for ALL of his patients then you know you need to find a new doctor. Many patients will not like any type of multifocal lens whether it is an EDOF Symfony, Bifocal Johnson and Johnson, or an Alcon PanOptix trifocal. For many people the very best lens for them is a standard monofocal lens that costs them zero dollars out of pocket. Other patients may be best served by a standard toric lens to just correct their astigmatism. The best thing you can do is try to get educated on different lens options and since you’ve read this article, we know you are on the right track!
You can also take our cataract surgery self test or contact us to schedule an appointment for an evaluation.
By Matthew Swanic, M.D.
UCLA Fellowship Trained Refractive Surgeon
Las Vegas Eye Institute