New presbyopia-correcting IOL offers glasses independence – Tips & Results

special to times of ophthalmology®

In a recent prospective case series, my colleagues and I evaluated the 3-month outcomes in 27 patients who underwent bilateral implantation of the ZFR00V lens (Tecnis Synergy; Johnson & Johnson Vision).1

This new intraocular lens (IOL) (figure) combines the advantages of diffractive multifocal and extended depth of field (EDOF) IOLs.

As with other EDOF lenses, the extended focus provides a more natural field of view while minimizing dysphotopsia symptoms.

However, since it also has diffractive optics such as multifocal IOLs, there was hope that this lens would improve near vision over EDOF lenses. Our study suggests that these goals have indeed been achieved.

The patients were followed up 1 day, 1 month and 3 months after the operation. Uncorrected and distance-corrected visual acuity were measured at far, medium (66 cm) and near (40 cm) distances under different lighting conditions.

Visual quality, visual symptoms, satisfaction and independence from glasses were indicated by the patients via questionnaires after 3 months.

Related: Improving the depth of field makes it easier to hit the target

Defocus curves were also made at the 3 month visit. The study was conducted before the availability of the toric version of this lens, so all patients had a preoperative astigmatism of less than or equal to 0.75 D.

visual acuity

At 3 months, under photopic conditions, mean monocular uncorrected distance acuity was 0.04 logMAR; the mean uncorrected intermediate value was 0.04 and the mean uncorrected near value was 0.05. Distance-corrected visual acuity was 0.03 and 0.00 for intermediate and near, respectively.

Under mesopic conditions, distance-corrected visual acuity was −0.01 for distance and 0.07 for near (table). An uncorrected distance acuity of 20/32 (0.20 logMAR) or better was achieved by 96% of patients.

These distance results are better than those reported for multifocal IOLs in several published articles.2.3

Our results were better than FineVision trifocals in intermediate and near vision4 and better at close range than the PanOptix trifocal lens or the combination of Tecnis Symfony/ZMB00 lenses.5

Near vision is significantly better than reported with Tecnis Symfony, with similar intermediate and distance results.6

It was exciting to see that patients did not lose distance vision in mesopic lighting conditions, which has historically been a weak point for multifocal IOLs.

Related: Presbyopia-correcting IOL improves vision for patients

The defocus curve was broad and smooth, showing that the IOL had a vision of 20/40 (0.30 logMAR) or better from +1.00 to -4.00 D and 20/25 (0.10 logMAR) or better from +0.05 to -3.00 D.

Results reported by patients

At 3 months, none of the patients reported wearing glasses for distance and 96% were completely glasses independent at all distances. One patient (3.7%) reported using glasses for near and occasionally for intermediate.

Although some patients experienced glare, halo, or starbursts, as we would expect with diffractive optics, no patient rated their night vision symptoms as “severe” or “very bothersome.” 89% of patients were fairly or very satisfied with their vision.

We now expect an inverse relationship between near vision and night vision quality.

Typically, with multifocal IOLs, better near vision is associated with higher rates of dysphotopsia, but we have found that this is not the case with this lens.

See Also: Posterior Corneal Elevation: Is There a Role for Premium IOLs?

personal impressions
In my practice, this new lens has expanded the pool of candidates for presbyopia correction IOLs to include those with very high close-up requirements.

In the past, mild to moderately myopic people who remove their glasses to read and hyperopic people who are accustomed to high magnification for near vision have found it very difficult to please with presbyopia-correcting IOLs.

Those who are short in stature or have short arms also demand very close-up vision, which we’ve struggled to provide.

Due to its near to intermediate EDOF range, this lens can satisfy both these patients and those who prefer a more traditional near point.

In fact, the lens’ large area for near vision means patients don’t have to experiment to find the best distance to hold their phone or newspaper – they can just read at their normal distance.

Related: Advances in Preloaded IOL Injectors

This has reduced the time I spend on patient education and holding hands after surgery and increased the proportion of happy faces I see at follow-up visits.

Good visual acuity and the quality of intermediate vision are also very important to me. Intermediate vision is more of an afterthought for clinicians as it is not a standard part of our exam like distance and near acuity are.

However, the reality is that much of our patient’s life takes place at medium distance.

exclude patients

As with any lens using diffractive technology, we should exclude patients as candidates for this lens if they have other eye conditions such as glaucoma or macular problems.

Surgeons implanting the new IOL should aim for emmetropia rather than mini- or micro-monovision, as some have done with other presbyopia-correcting IOLs to ensure good near vision.

See also: IOL dilemma: replacement or rescue

In fact, a myopic result risks compromising distance acuity, so I generally aim for the lowest positive predicted refraction (closest to plano).

Also, my personal preference for this and all presbyopia-correcting IOLs is bilateral implantation.

With neuroadaptation and binocular summation, we continue to see improvements in vision and satisfaction with these advanced IOLs at 3 and 6 months compared to largely unchanged vision at this point after implantation of the monofocal IOL.

This is a welcome new addition to the growing portfolio of presbyopia correction IOLs.

About the author
Filomena J. Ribeiro, MD, PhD, FEBO
Ribeiro is Head of the Department of Ophthalmology at the Hospital da Luz in Lisbon, Portugal. This study was funded by a research grant from Johnson & Johnson Vision; She has no other financial relationships to disclose.

1. Ribeiro FJ, Ferreira TB, Silva D, Matos AC, Gaspar S. Visual outcomes and patient satisfaction after implantation of a presbyopia-correcting intraocular lens combining extended depth of field and multifocal profiles. J Cataract refractive surgery. 2021;47(11):1448-1453. doi:10.1097/j.jcrs.0000000000000659

2. Rosen E, Alió JL, Dick HB, Dell S, Slade S. Efficacy and safety of multifocal intraocular lenses after cataract and refractive lens exchange: meta-analysis of peer-reviewed publications. J Cataract refractive surgery. 2016;42(2):310-328. doi:10.1016/j.jcrs.2016.01.014

3. Kohnen T, Herzog M, Hemkeppler E, et al. Visual performance of a quadrifocal (trifocal) intraocular lens after removal of the crystalline lens. Am J. Ophthalmol. 2017;184:52-62. doi:10.1016/j.ajo.2017.09.016

4. Nagy ZZ, Popper-Sachetti A, Kiss HJ. Comparison of visual and refractive results between hydrophilic and hydrophobic trifocal intraocular lenses with the same optical design. J Cataract refractive surgery. 2019;45(5):553-561. doi:10.1016/j.jcrs.2018.11.034

5. de Medeiros AL, de Araújo Rolim AG, Motta AFP, et al. Comparison of visual outcomes after bilateral implantation of a diffractive trifocal intraocular lens and mixed implantation of an extended depth of field intraocular lens and a diffractive bifocal intraocular lens. Clin Ophthalmol. 2017;11:1911-1916. doi:10.2147/OPTH.S145945

6. Ang RE, Picache GCS, Rivera MCR, Lopez LRL, Cruz EM. A comparative evaluation of the visual, refractive, and patient-reported outcomes of three extended depth of field (EDOF) intraocular lenses. Clin Ophthalmol. 2020;14:2339-2351. doi:10.2147/OPTH.S255285

Leave a Comment