IF YOU’RE A SURGEON WHO HESITATES TO USE 2 DIFFERENT lenses bilaterally for your cataract patients, you may want to rethink that strategy.
Mixing and matching lenses provides an excellent way to give your cataract patients clear vision at all distances, especially with the advanced presbyopia-correcting lenses coming on the market. It’s not too much to say that this is becoming the new normal.
In fact, you’re probably already mixing and matching lenses. For instance, if you place monofocal lenses, you’re likely not putting the same power lens in each eye. If you put a 19D monofocal lens in the left eye and a 20D monofocal lens in the right eye, the lenses are of different powers.
In this article, I’ll share the success I’ve had in mixing and matching intraocular lenses (IOLs), specifically using the TECNIS Symfony OptiBlue IOL from Johnson & Johnson Vision. I’ll discuss why this lens works so well, as well as patient selection.
Best of Both Worlds
Several years ago, when the first-generation presbyopia IOLs became available, surgeons didn’t mix and match lenses. Surgeons implanted the same lens in both eyes, and patients had to accept the vision that those lenses provided.
Now, surgeons have a wealth of options available, including multifocals, trifocals, bifocals, and extended-depth-of-focus (EDOF) lenses. In my practice, my happiest patients are those for whom I’ve mixed and matched different lens technologies. Doing so provides them the best of both worlds in both vision quantity and quality.
Higher-add multifocals or multifocals mixed with EDOF technology, such as the TECNIS Synergy IOL, provide excellent quantity of vision. For near vision especially, the TECNIS Synergy can provide a “best-in-class” result, with patients routinely J one plus.
However, the patient might not have quality vision at every single focal point. When I have implanted the Synergy bilaterally, patients loved their intermediate and near vision, and most were pleased with their distance vision as well. However, some patients were less pleased with the quality of their distance vision, specifically with contrast and sharpness.
I’d had experience using the TECNIS Monofocal 1-Piece IOL (ZLB00), which is the previous-generation TECNIS multifocal +3.25D in the nondominant eye and the first-generation Symfony in the dominant eye, with good results. I had not had much luck with other brands of multifocals or trifocals on the market.
With the launch of the Symfony OptiBlue presbyopia-correcting IOL in September 2022, which is the next-generation EDOF lens, my ability to mix and match lenses increased further. Like the Synergy, the Symfony OptiBlue IOL uses InteliLight, which combines three J&J proprietary technologies (See Trio of Technologies).
By mixing and matching these two lenses, I give my patients the benefit of the overall quality of vision and the quality of distance vision of the Symfony OptiBlue, combined with the excellent near vision that the Synergy provides.
I also find the wider landing zone and wider sweet spot of the Symfony OptiBlue helpful. The Symfony OptiBlue, which also comes in a toric version, seems more tolerant of residual refractive error compared to the Synergy. With the Synergy, I find patients need to be very close to plano to experience the maximum benefit (See Symfony Specs).
Having implanted several hundred lenses using the Symfony OptiBlue in the dominant eye and the Synergy in the nondominant eye, I have seen remarkable results. I have not explanted any lenses, indicating high patient satisfaction.
Using the Symfony OptiBlue in the dominant eye and the Synergy in the nondominant eye suits the needs of just about all of my patients and has become my go-to solution. That’s the case especially for any patients who say they don’t want to wear reading glasses. By and large, most patients who are paying a premium for presbyopia-correcting IOLs don’t want to wear readers any of the time, so we try to reduce that as much as possible.
For example, imagine a myopic patient who is accustomed to excellent near vision without glasses. When time comes for cataract surgery, that patient may want really excellent near vision, say in the J one range. In that patient, mixing and matching the Symfony OptiBlue in the dominant eye and the Synergy in the nondominant eye can provide excellent results. This combination provides excellent distance and intermediate vision and very functional near vision.
- Optic diameter: 6.0 mm
- Overall diameter: 13.0 mm
- Center thickness: 0.7 mm (20.0 D)
- Powers: +5.0 D to +34.0 D in 0.5-D increments
- Material: UV-absorbing hydrophobic acrylic with violet-light filter
Source: Johnson & Johnson Vision
In contrast, some patients may want excellent distance vision and are willing to wear reading glasses some of the time. In that case, I may implant the Symfony OptiBlue in both eyes.
Patients who need excellent near vision for up-close tasks are also happy with this mix-and-match strategy. That includes patients who are voracious readers, needlepoint makers, and sewers and knitters.
Conversely, I tend to avoid using this solution with patients who need excellent night vision, such as those who earn a living driving at night. Even though patients can become accustomed to halo and glare after a few months, I avoid using a multifocal IOL for them. In these patients, I might consider using nondiffractive designs that provide minimal nighttime halo and glare.
Custom Lens Replacement
Besides cataract patients, I mix and match the Symfony OptiBlue and Synergy in my custom lens replacement patients. Specifically, the strategy works well in patients who want freedom from glasses but aren’t suitable candidates for laser vision correction. These are hyperopic patients who are in their 40s or 50s and have decent distance vision but notice that it’s starting to fade, and they have very poor near vision without reading glasses. These patients have been very happy with this solution.
TRIO OF TECHNOLOGIES
The TECNIS Symfony OptiBlue IOL is powered by InteliLight, a combination of 3 Johnson & Johnson Vision technologies: violet-light filter, echelette design, and achromatic technology. The technology was first introduced in the TECNIS Synergy IOL.
- Violet-light Filter: Blocks the shortest wavelengths of light that produce the most light scatter, helping to mitigate halo, glare, and starbursts, and minimizing visual disturbances when driving at night
- Echelette Design: Helps to reduce light scattering and halo intensity, making it easier to see digital devices
- Achromatic Technology: Corrects chromatic aberration for better contrast day and night and superior performance across every distance
Source: Johnson & Johnson Vision
Steps for Success
Prior to implanting lenses, my practice will perform a full tear film analysis with inflammatory markers. To ensure the patient has a clean macula, we perform a macular scan and a widefield Zeiss Clarus (Carl Zeiss Meditec) image on every workup.
Also, we perform topography and tomography to ensure that the astigmatism is regular. We use 2 different diagnostic devices to accurately determine the magnitude and meridian of the astigmatism. We avoid a mix-and-match solution with patients who do not have a regular astigmatism.
Finally, we strive to ensure that the patient will be happy with our solution from a psychological perspective. If a new patient is complaining bitterly about his or her first eye that was done by another doctor, yet it looks fine, and the complaints are out of proportion to what we see in the clinical exam, we expect this may not be a suitable patient for a multifocal lens.
Today, patients live in a near-vision world, relying constantly on digital devices, such as phones, tablets, and computers. As we care for cataract patients, we can restore their near vision, as well as provide excellent intermediate and distance vision. Combining the latest lens technologies provides a sound strategy for our cataract patients. ■