to be as close to 20/20 for distance, intermediate, and reading vision without
glasses, but this usually requires special implants, such as the Trifocal-PanOptix
intraocular lens (IOL) and Femtosecond Laser Assisted Cataract Surgery
which also helps decrease corneal astigmatism by making small microscopic cuts
in the cornea. While there is not a 100% guarantee a patient who chooses both
the Pan-Optix and Femtosecond Laser-Assisted Cataract surgery will be glasses
free, publications and our experience has shown over a 90% chance of being
glasses-free for distance and intermediate and over an 87% chance of being
glasses-free for reading. For patients who are jewelers or do very close work,
they have a higher chance of needing reading glasses even with the PanOptix. Some
patients who want to be completely glasses-free for reading would have to
choose intraocular implants in 1 or both eyes that are between -1.75-2.50D but
then would need glasses for intermediate and distance.
An issue arises when a patient has already had Refractive Surgery, such as LASIK or PRK. More than 40 million people have had LASIK or PRK around the world. Many of these patients will need cataract surgery in the future which can cause vision issues after cataract surgery. Many of these patients have enjoyed 20/20 vision for distance, intermediate, and reading, but after cataract surgery, the eye’s natural eye lens is removed and accommodation (ability to focus for intermediate and reading) will disappear completely if not already gone with aging.
We place an implant or intraocular lens IOLs so a patient can focus again for distance: the first type is called a Monofocal (for 1 visual plane: usually for distance).
New-Technology implants (multifocal implants, Extended Depth of Focus implants like Symfony, or Trifocal implants like PANOPTIX) give a non-refractive patient a high chance at being glasses-free for reading, intermediate, and distance (though not 100% guaranteed). These new implants have their positive and negatives but the majority of patients are thrilled with these implants but they can cause vision quality issues for patients who have had refractive surgery (ie LASIK, PRK) as well as a refractive surprise: where the IOL implant power is completely incorrect (which is rarer given we use ORA intraoperative interferometry to triple check the implant power for every post-refractive patient who has cataract surgery (but it can still happen as LASIK and PRK change the cornea’s shape significantly which interfere with our implant calculations.)
I and many surgeons spend a great deal of time trying to convince post-refractive patients to NOT have multifocal implants, Extended Depth of Focus implants like Symfony, or Trifocal implants like PANOPTIX given the risks and the newer implants are not FDA approved for post-refractive surgery patients. I often try to convince these patients to go with MONOFOCAL IOLS as they have the least risk of causing haloes and glare (though not 0% guaranteed either).
Still there are many patients who insist that these new technology implants (i.e., PanOptix, Symfony, Multifocals) are the only ones they want to try. This is a new category of patients that are being intently studied as some brains CAN tolerate the new images these new IOLs present. Some will likely hate these new IOLs but when a patient pushes to have the new implants inserted, they are highly motivated to make it work and ignore extra glare or haloes all these new implants can cause.
My team has now done about 10 patients who have had LASIK or PRK and have had PanOptix or Symfony implanted in one or both eyes. So far, patients have been very happy. We have not had to explant any yet. But that is a risk: we might need to change out the implant for a MONOFOCAL but patients know this. I suspect these patients are working with the images their eyes receive to train the brain to accept them and deal with the negative components of these implants.
There are some things we can do to help assess the risk the patient will not be happy with the new-technology implant. IOL power calculation is one of the most difficult parts for cataract operation after refractive surgery.
In every post-Lasik/PRK patient having cataract surgery, we use many IOL formulas, such as Haigis-L, SHammas, Barret True K, Pentacam, OCT. With non-refractive patients, we usually only use one formula.
We always use ORA intraoperative interferometry to triple check the implant we are putting in.
Different studies show different formulas to be the best. A recent one showed Haigis-L turned out to have the highest percentage of cases that achieved the refraction of targeted SE ±0.50 D and SE ±1.00 D . A meta-analysis by Chen et al. also concluded that the clinical inquiry was inaccurate in predicting postoperative refraction as compared to the Haigis-L formula . In this case, the Haigis-L formula again proved to be reliable to attain emmetropia.
Furthermore, a thorough preoperative evaluation is fundamental for the success of the surgery. The recommended criteria for new-Technology IOLs (PANOPTIX, Symfony, multifocal IOL implantation in post-refractive patients is noted here below but there are patients who know they do not meet all these criteria and still proceed with the surgery and are happy with the results. Long term studies are needed to see why some patients will fail the below criteria and still be happy with results while as others will not.
Recommended: Do not use soft Contact Lens for at least 1wk before A-scan and before surgery if ORA will be used in the operative eye. Do not use a Hard Contact lens for 3wks before A-Scan and before surgery if ORA will be used in the operative eye.
1. corneal astigmatism of no more than 1.25D,
2. root mean square (RMS) of corneal HOAs within 6.0 mm zone no more than 0.50 mm, and
3. kappa angle no more than 0.29.
4. post-LASIK eye necessitates a uniform, well-centered and closely-attached corneal flap for multifocal IOL implantation.
5. treat dry eye conditions: patient again needs to know the quality of vision is also dependent on the tear film. Meibography should be done before surgery to give prognosis about dry eye symptoms, such as foreign body sensation, irritation, dryness, blurry vision, itching, redness, pain. I recommend Lipiflow or IPL if meibomian glands have scar tissue or the patient has signs of dryness on corneal exam. We also prescribe Xiidra, Restasis, Autologous Serum, PRP drops to help prevent issues after surgery from dryness.
Here is more information by Dr. Degan about what each patient can see based on age and eye’s status:
1. Top line=young 25yo
2. Dark green line: 50 yo healthy patient who can’t see to read or computer much but good for distance
3. Yellow Line: what you can see if we implant a MONOFOCAL implant: your distance vision will be better than computer or reading (which is minimal unless we purposely use mini-monovision).
4. Orange: a patient with a Multifocal Restor which we do not use much anymore given risk of halos & glare.
5. Teal colored: this is the vision one can get with a PanOptix Trifocal implant which most patients love. As you can see, the risk of still needing reading glasses for close-up is not 0% bu its better than the other options.
6. Pink line: Cataracts usually really decrease vision for distance, intermediate, reading and cause a lot of halos and glare. This is why surgery is needed.
More information about PanOptix which is becoming a surgeon-favorite as patients are really happy with this implant.
AcrySof IQ PanOptix Model TFNT00 (Alcon Laboratories, Fort Worth, TX) is a
a.1-piece aspheric hydrophobic presbyopia-correcting intraocular lens (IOL) launched in 2015 in Europe and approved in the US August, 2019.
b. Unlike traditional trifocal IOLs that usually have an intermediate focal point of 80 cm, the PanOptix IOL is designed to have an intermediate focal point of 60 cm (arms-length), a more natural and comfortable working distance to perform functional tasks on computers, laptops, mobiles, among others & provides a more comfortable near-to-intermediate range of vision than traditional trifocal IOLs
c. The non-apodized PanOptix IOL uses the ENhanced LIGHT ENergy (ENLIGHTEN; Alcon Laboratories, Fort Worth, TX) optical technology that provides high (88%) utilization of light energy,
d. low dependence on pupil size in all lighting conditions,
e. is an ultraviolet (UV) and blue light filtering, non-apodized, foldable presbyopia-correcting IOL.
f. it is a single-piece IOL has a central biconvex optic, with an inner diffractive and an outer refractive zone, and is made of a hydrophobic material acrylate/methacrylate copolymer and has 2 open-loop haptics
i. other commercially available trifocal IOLs:
A. Not approved in US: FineVision Micro F (PhysIOL, Liege, Belgium), the AT LISA tri 839MP (Carl Zeiss Meditec AG, Jena, Germany)
B. Approved in US but not as good for reading compared to PANOPTIX: the extended depth of focus IOL, TECNIS Symfony (Abbott Medical Optics, Santa Ana, CA).
Femtosecond laser-assisted cataract surgery with implantation of a diffractive trifocal intraocular lens after laser in situ keratomileusis: a case report
Availability of data and materials
|Anterior segment optical coherence tomography
|Corrected distance visual acuity
|Femtosecond laser-assisted cataract surgery
|Laser in situ keratomileusis
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6. Photo & Dangers of LASIK: