September 11, 2024 • 25 mins
Extended depth of focus (EDOF) lenses have transofmed the intraocular lens (IOL) landscape. As opposed to the binary choice of a monofocal or a multifocal IOL, there is an 'in-between' option that allows for more intermediate vision than monofocal lenses but less dysphotopsias than the mutifocal lenses. How do these lenses work, how should we explain them to patients, and what are the factors that guide our decisions on lens selection? Dr. Eric Donnenfeld joins the podcast.
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This episode is sponsored by SunPharma Canada - https://sunpharma.com/canada/
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:11):
Hey everybody, I'm zaoh Mednick and welcome to another episode
of blind Spot. If you're enjoying this podcast, please rate
and review it on Apple Podcasts or Spotify. We really
appreciate it when you do that and it helps spread
the word of the podcast. This episode is sponsored by
Sun Pharma Canada and we appreciate their support for helping
in the production of this podcast. With so many intraocular
(00:33):
lenses on the market, it can be tough to guide
a patient through cataract surgery and what decision they should
make for their particular eye. As newer lenses continue to
emerge on the market to treat presby opia, there is
so much to counsel patients on. One of the newer
players on the market, so to speak, are Eatoff's extended
depth of focused lenses. They're not quite monofocal lenses that
(00:54):
let you see at one distance, but they're also not
quite multifocal lenses, which let you see distance intermediate in near.
It's somewhat of a hybrid. Edoffs can kind of be
looked at as an in between lens for patients who
don't want him on afocal but who aren't necessarily candidates
for a multifocal or who don't want multifocals for whatever reason.
So what do we need to know about this new
(01:15):
set of lenses, How well do they work? And how
should we be advising patients about them. I'm joined today
by doctor Eric Donnenfeld, who joined me on a previous
episode discussing femtosecond laser assistant cataract surgery. Doctor Donnenfeld is
a clinical professor of optomology at New York University. He's
an internationally recognized expert with over two hundred and twenty
five peer reviewed papers, forty five book chapters, and three books,
(01:37):
as well as many named lectures around the world. He's
past president of ASCARS and OMG, trustee of Dartmouth Medical School,
editor in chief of iWorld, and the president of the
International Intraocular Implant Club. He was an initial FDA investigator
of Ristasis zydra, laser vision correction, corneal cross linking, the
femtosecond laser, and many refractive IOLs. Doctor Donnefeld was named
(01:57):
America's Best eye doctor in twenty twenty one, twenty twenty two,
and twenty twenty three by Newsweek, and The Ophthalmologist named
him one of the fifty most Influential People in oph
Theomology for twenty twenty to twenty twenty three. He's a
Fellow of the American Academy of Ophthalmology and has received
its Honor Award, Senior Honor Award, Life Achievement Honor Award,
and Secretariat Award. All Right, doctor Eric Donisfeld, welcome back
(02:18):
to the podcast. Thanks for joining me again.
Speaker 2 (02:20):
That's the pleasure. It's gonna be fun tonight.
Speaker 1 (02:23):
All right, good, you're you're enthusiastic about this topic, and
I'm curious to hear your thoughts on these lenses, the idofs.
I don't know if you'd say they're newer to me.
They feel like a newer player on the market, so
to speak, over the last several years, something that we're
implanting more impatience. And how would you describe an edof lens,
if that's even the right umbrella term, because I know
there's a lot of different lenses that some people might
(02:45):
categorize under that umbrella. Some people call some of these
lenses monofocal, plus some of them call them adopt.
Speaker 2 (02:51):
Yeah, so that's a great, great segue. But before we begin,
you know, I think the edof lens stands for extended
depth of focus are kind of a segue between our
conventional monofocal where you saw a distance and nothing in between,
and the multifocal, which gives you full range of vision
but has disphutopsy at Glarren halo. And the Edolph lens
(03:12):
is a lens that's kind of been adopted to kind
of fit in that middle ground where it gives you
a little bit of reading, but it doesn't take away
a lock in the distance. So you ask for a definition,
and the government has really come up with a definition
of what an Adolph lens is. To be an official
Adolph lens, it has to have non significant difference in
(03:33):
distance quality of vision to a monopocle lens, so it
can't be worse than a monopocle lens. It has to
be about the same disphotopsia profile, and it has to
have about a half a diopter or more of added
mid range and near vision. So it has to meet
that criteria if a half adopter of reading without losing distance.
(03:54):
And right now in the United States, there are two
lenses that meet those criteria and they're considered premium lenses.
The first one was the Symphony, which is a difractive
lens from Johnson Johnson, and then came the Vivity from Alkhon.
Both them meet the criteria of giving you a half
a docter more of reading. At the same time, you
(04:14):
don't lose distance visual quids significantly compared to a regular lens.
Now you mentioned another category which is kind of in between,
and that is the monofocal plus. Some people call these
edoph lenses as well, but they're not officially ados, but
they function like them. And these are lenses that give
you a little bit of additional reading, a little bit
(04:36):
more mid range. They don't sacrifice distance, but they're not
considered a premium lens, so you can't build for them,
but they do give you a little extra And there
are a couple lenses out there that do this. There
is the Eye Hands which kind of invented this from
Johnson Johnson. There's the Rainer EMV and Bauschem Loom has
(04:57):
the Investor Aspire LEEDS and then finally there are two
of the lenses that meet the criteria of extended depth
of focus, and those are the new lens from our Excite,
the light adjustable lens, which is a lot of adjustable
lens plus, which gives you about a half adopter more
of additional reading, and that is a premium lens. And
then there's the ephthero lens, which is a pinhole lens
(05:20):
that does give you additional reading and it doesn't sacrifice distance.
So there are a lot of choices that are out there.
Speaker 1 (05:26):
Those are really really thorough and clear summary. And I'm surprised,
maybe because I'm in Canada near in the States, the
billing model is a bit different, so I'm not as
acutely aware of some of that definition. And because you
said it obviously influences what you're allowed to charge for
as a premium lens, So that's helpful that there actually
is a definition out there that really is quite clear.
(05:47):
You mentioned that the symphony, for example, is diffractive. How
do these lenses work differently? And I guess we can
talk about whichever lenses you like, because I'm sure they
all work differently. But vivid, I know, is probably the
more common one that I see and can other people
are using. And for the monofocal plus the ihands is
a very common one. How do those lenses actually work
(06:07):
compared to some of the multifocals, And in a sense
that's not a fair question because multifocals don't all work
the same. You have difractive and you have non difractive multifocals.
But how do they generally work for someone trying to
understand that?
Speaker 2 (06:19):
Well, most of the etof lenses other than the symphony
which is a diffractive iol, are refractive IOLs, and they
give additional reading by stretching the zone of vision. Essentially,
they provide a little larger and they can do that
by providing negative fherre collaboration or positivephere collaboration, which is
the rain of MV, which is the only one that
(06:39):
does it that way, or it can just have a
little increased steepness in the centrable lens that gives you
just a little bit extra reading in that in that area.
But these are refractive lenses. They don't split light for
the most part, other than the symphony lens, and for
that reason there's a better quality of vision. There isn't
(06:59):
this footage your profile you have from a multifocal lens.
But on the other hand, you don't get nearly as
much reading. You get definitely a little bit less reading.
But they lend themselves very nicely to a mini monovision
or someone who just says, you know, I have specific
visual needs. I want to be able to see the
dashboard of the car. I want to see the food
(07:20):
on my plate. I want to put on makeup. And
if I had to put glasses on to thread a
needle or to look at, you know, a small font
very close, I'll put glasses on for that. But today's age,
most of our time near is not really that close.
It's really at arm's length, and that's where these edof
(07:40):
lenses really shine.
Speaker 1 (07:42):
So reading a book, your phone, those are kind of
the examples I can think of where really are up
close near. But laptops, dashboard that's more common, but phone
basically in books, reading or iPads. Is it accurate to
tell people that those are the things you'd be more
dependent on if you get need off on where more
(08:04):
dependent on wearing reading glasses?
Speaker 2 (08:06):
I think that's a very good summary of exactly what
to expect. However, a lot of patients who have the
ethof lenses will just increase the fonts on their smartphone
or on their kindle and they'll be able to, you know,
to read just holding a little bit further away. It's
a matter of just holding it six to ten inches,
a little further away than you might normally, and you'd
(08:29):
be amazed at how much time you spend at that distance.
It's a new world than there was before. You're not
reading small fonts from sixteen inches away. Twenty four inches
is kind of the new norm. So almost anything you
can do at twenty four inches you can do with
these eat off lenses.
Speaker 1 (08:46):
The side effect profile really helps determine how you're going
to advise a patient here, because if somebody says, yeah,
I really want all levels of vision, you'll say, okay,
so sure go with the multifocal. Obviously, there's personality factors,
and there's a lot of other factors too, if they're
a candidate, if they have that dry eye, if they've
gotten epi retinal membrane stuff like that. Which my understanding
and we'll talk a bit about that afterwards, is that
(09:07):
the eatoffs are more forgiving for but ultimately one of
the big factors is going to be how many side
effects is this patient willing to endure or are you
willing to risk with this patient. So I've seen patients
with a vividy for example, who they still have. I
don't know exactly what I would call it, if it's
(09:27):
a halo or but they've got some dispotopsias, so they're
not devoid of dyspotopsias. Is that correct? You know?
Speaker 2 (09:35):
The one thing about optics is you don't get something
for nothing. Yeah, anytime you gain something, you have to
give something up. And it's just a question of how
much you're willing to sacrifice to get that extra reading.
And the vivity is a great lens. It gives you
a good amount of mid range vision. But if you say,
is a quality of vision with a vivity the same
(09:55):
as it is with a monophople and the answer is
to no, it really is not the same. You do
sacrifice a little bit of quality of vision. And I
do have some patients who have not been happy with
eatof lenses where I've actually had to explain them to
put monofocal lenses. But for the most part, I think
you said it perfectly. The ead off lenses are more
forgiving than the multifocals. They tend to be much better tolerated.
(10:17):
There's much less just photoposy, and patients very rarely complain
of problems with these lenses. We just actually are doing
an FDA trial now with a new etof lenses, which
will be a premium lens that you have up in Canada,
and that's the Piracy lens from Johnson and Johnson. And
of all the eatof lenses that I've used so far,
(10:38):
this one has to me the best mix of great
quality vision at distance and a good intermediate vision without
much sacrifice. These have been very very happy patients and
the lenses doing very well in Canada and in Europe,
and we're looking forward to having it here in the
United States.
Speaker 1 (10:56):
When we talk about the quality of vision, you're referring
to this photopsias and then maybe I'm wrong to separate
into two categories, but I think of in my mind
at least as photopsis thinks they're going to actively complain about,
and then just the quality of how clear the vision is.
I already, based on what you've said, I'm going to
adjust how I speak to a patient because what I've
typically said might not actually be true. I kind of
(11:19):
lump multifocals and eat offs together and I say, listen,
you're going to give up something. The quality of the
vision might not be as sharp, and what I say,
is we take some of the light from the distance
in order to help you see it near. But it
sounds like that's not actually optically true based on your
explanation of that it's more of a refractive lens than
a diffractive lens. But I guess it doesn't really matter.
(11:41):
The point does stand that the actual clarity of the vision,
it is fair to say to a patient. And I'm
reiterating this even though I think you already said this,
because I think it's important. The fact does still stand
that it is reasonable to say to a patient, Listen,
you do still get your clearest, best distance vision if
you go with the monofocal. Is that still something people
can and feel confident saying to their patients.
Speaker 2 (12:02):
You know, I would be a little bit broader on
that and say that for the majority of patients, there's
no significant difference in distance vision between a monofocal lens
and the ethof lenses. Not a significant difference other than
maybe the symphony, which is a diffractive lens. I think
for the refractive lenses, no significant difference. But there is
(12:23):
a small subset of patients who will say that the
vision with the eat off lens is not as good
as it is with a monofocal lens, but for the
majority of patients, it's just not true. For the majority
of patients, they see no significant difference. And that's what's
made this lens so exciting for patients is that most
patients really enjoy the extra intermediate and they don't feel
(12:44):
like they're sacrificing anything. But having said that, there are
some patients where they will notice the difference, and those
tend to be patients who have underlying pathologies that put
them at risk. And just like with a multifocal lens,
when I examined a patient and you brought this up before,
and I think you hit the nail on the head
when you mentioned it, is that there are certain risk
(13:05):
factors that are going to give patients more risk of
having this photopsis. You mentioned dry eye, We can mention homa,
epiretinal membranes, cornial refractive surgery, krataconas, certainly mild mild octasia.
These are all patients who are going to have a
(13:25):
greater risk profile with a multifocal, less risk factor with
an eatoff, and the least risk factor with a monophoble lens.
Speaker 1 (13:35):
And typically would you still feel comfortable in a mild
ati retinal membrane, let's say, or somebody with mild dry eye.
Would you still feel comfortable where you'd say, yeah, the
eatoff is actually a pretty reasonable option. I'll tell them,
like you said, the risk profile is a little bit higher,
but this is a reasonable lens for somebody who who
does have some of these conditions you just mentioned.
Speaker 2 (13:57):
Yeah, And that's really the art of medicine and where
you know, you still need to have that doctor patient
conversation where we talk about different issues, and that's a
very important issue to discuss, and it's an informed consent decision.
And I will say to the patient there's a small
increased risk in your case with this lens, but the
(14:20):
risk is small and most patients don't notice it. But
the risk is not zero. And as long as the
pasal understands that and they're willing to compromise, I think
that it's a very reasonable lens to put in for
most patients who have mild risk factors. Now, when you
have a severe risk factor active careticonus and stage glow coma,
(14:41):
these are patients where I just would go with a
straight monofocal every single.
Speaker 1 (14:45):
Time for the monofocal plus versus the eatoff. How do
you make that decision? Again, it's an art, it's a conversation.
But what's typically the threshold where you'll say to somebody,
you know what, I think you're probably better for the
eyeants than the vividy for example.
Speaker 2 (15:03):
Well, it's very interesting. There's really very little difference when
it comes down to actual refractive difference between an eye
hands and aavivity. It might be a tenth or two
tenths of a diopter. Additional, the I hands in the
monofocal non toric version is a considered a government issue
lens where insurance would cover it here in the United States,
(15:26):
whereas a vivity we would be charging the patient for
the for that difference, so that it's a little bit
of an economic conversation. You do get a little bit
more reading with a vivity than you do with the
eye hands, but it's a small amount and it's a
conversation to have with patients. Now, if you take these
monofocal plus lenses and you put them in a touric variety,
(15:48):
then they become a premium lens again, so an iehands
touric and Aspire tourk a rain er em v Torque.
All these lenses are considered premium lenses, but just like
everything else we just mentioned, and the lower the additional reading,
the lessest photopsia. So an Ihans lens, in my experience,
has had less to photopsia than a vivity. The other hand,
(16:10):
the Vivity has a little bit more reading. So again
it's the conversation that you have with your patients determines
exactly what they understand and what they would like to have.
And that's that's what I spend most of my time
doing when I'm conversing with patients, is telling them the
difference between these lenses, and when you're all done, it's
usually a very thorough conversation and you feel very good,
(16:33):
the patient feels very good about the options that they chose.
Speaker 1 (16:36):
And it's interesting again, the payment model is a bit
different in Canada, but at the hospital I work at,
I didn't really have a great sense of the prices
and I looked at Ihans versus Vivity surprised Vivity was
actually closer to a multifocal than it was to I haants.
There was a pretty big gap in price, at least
in Canada, where Vividy was almost twice as expensive as
(16:56):
the I hants, which is why I ask that because
for some patients who were debating that, and obviously cost
is a factor, it's helpful to hear what you just
said there that the Vividy is a little bit better,
but it's not that much better necessarily in terms of
the diopters if you're actually thinking about it based on
the studies that are out there. Again, it is better,
(17:17):
some more side effects, but how much better is going
to factor into it when you're taking finances into account?
Speaker 2 (17:23):
Agree completely. In the United States, our model is different.
The i Haands lens is a lens that the patient
gets at no charge to the patient. For the monofocal
non tower I.
Speaker 1 (17:33):
Hands the coxit story, the big.
Speaker 2 (17:37):
Lens costs us and we charge it exactly the same
as out of a multifocal lens. There's no difference to
the United States and the cost of these different lenses.
Speaker 1 (17:46):
Doeger Donofeld where do you aim for these lenses? And
I was told from somebody for vividy, maybe aim minus
point eight and for i haants as well, aim not
quite that myopic, but a little bit of mini monovision.
Because the curves are more forgiving for the distance, but
less forgiving for near. So there's a two prong question here.
(18:06):
One is where you typically aim, and two is I'm
always I don't want to say skeptical, because I'm not skeptical,
and I'm by no means an expert on this, but
when they're designed to work for the distance and then
give you a little bit nearer, it always surprises me
that they say, but you also need to aim a
little bit nearer, because I'm thinking, but I thought the
property of the lens is that inherently you shouldn't need
(18:28):
to aim near. You should be able to aim plano
and it's going to give you a little bit of near.
Speaker 2 (18:33):
Yeah, that's a great question, and I think that question
has been answered best by Steve Shallhorn, who'dte a wonderful
paper looking at tens of thousands of patients and found
that patients satisfaction was highest when you aimed at the
first plus lens, not end at the first minus. So
everything that I've been doing for the last twenty years
has been aiming for the first minus lens. With the
(18:56):
eedoph lenses, you have the advantage that if you end
up a little bit hyperopic because of the extent depth
of focus. You'll still get a very strong twenty twenty
twenty fifteen vision. You just lose a little bit of
reading that in that in that eye. And I have
a mantra, and that is that when patients pay for
a prisbeopic solution, they expect to have some reading, but
(19:20):
they demand having distance. So if you don't hit the distance,
you're not going to be happy. So for the dominant eye,
I generally will aim for plane out or the low
first plus like a plus attemph or something like that.
That's where I aim in the dominant eye and the
non dominant eye, I have a conversation with a patient,
(19:40):
but that's a perfect patient to aim from minus point
four minus point five, depending upon how much reading you
want to have. And then if you add the inherent
additional reading you get from the eye hands or the
vivity or the aspire or the radio even v you're
gonna end up with about a diopter if near for
that patient. And that's that's a meaningful amount of near
(20:01):
that's going to give the patient a pretty good functional
vision for most occasions with good light. So if I
can get them to plane on one eye minus in
half in the other eye, they don't lose a lot
of distance. That mini monovision goes a long way to
give them a little bit extra reading, and it's very
well tolerated, but you have to hit the distance. If
you make a patient a minus a half a distance
(20:23):
with any lens, the patient's not going to be happy
with the distance vision they'll and they'll be complaining of
this autopsy, a glare, halo and problems driving. So I'd
rather give patients a little extra distance and forego the
reading and at least one eye and once I have
one eye really nail, then you're playing with house money
and you can do whatever you want with a non
dominant eye.
Speaker 1 (20:43):
That's really really valuable to hear from someone like You've
done so much of this, because in my mind, I'm
stressed sometimes and I'm obviously newer in practice than you.
I'm stressed when I've said to them, we're going to
be able to get you a little bit of nearer.
So I think in the past some of my tendencies
has been to say, well, I'm going to aim with
(21:04):
that dominance a little bit my optic because I really
want to make sure I deliver on that promise I
never promise, obviously, but that promise to them that yeah,
we're going to get you a little bit of intermediate vision.
But I have had some patients who've said, but my
distance isn't so clear, and you're reaffirming that notion there
that despite that whole conversation, the most important thing people
care about is I want to be able to see distance,
(21:26):
and everything else is kind of everything else is bonus.
Speaker 2 (21:31):
It's a bonus. It's an important bonus. But you're absolutely right.
And I've never explanted a lens but the patient didn't
have enough reading. I've explanted many lenses because the patient
didn't have enough distance. So you need to get the
distance right. If you get the distance right, everything tends
to follow. And again with the eat off lens a
little bit, a minimunovision goes a long way. Or for
(21:52):
someone who's more fastidious, you aim both eyes, you know around,
you know plano and that you just tele patient. You'll
be wearing reading glasses a little bit more, but patients
are generally happy with that. It's getting the distance right
that really makes it, that really matters tremendously.
Speaker 1 (22:07):
So to summarize there, because I had it off, so
don't listen to me listeners. For the dominant eye, you're
going to aim plano if anything, You're not going to
aim myopic. You're going to add for the lowest plus
on the iol master, the lens star, whatever biometry you're using.
And then once you've done that, for the non dominant eye,
that's where you're going to have that conversation. That's where
you might aim a bit myopic minus point four minus
(22:29):
point five.
Speaker 2 (22:30):
Yeah, that's a conversation to have with the patients. And
once you have at least one eye functioning with twenty
twenty twenty fifteen visual acuity, it gives you such a
feeling of success and a feeling that you can really
help this patient. If you don't get the distance right,
the patient's not going.
Speaker 1 (22:48):
To be happy. Last question, and again I think I
know the answer, so it's a bit of a loaded question.
But how important for these lenses is it to treat
any astigmatism? And what would be your threshold of astigmatism?
Is it lower than in a monofocal or are you
fairly aggressive and monofocals as well? Whenever there would be
residual stigmatism, these.
Speaker 2 (23:10):
Lenses are moderately forgiving for a stigmatism. But again the
more reading you get, the more near the less forgiving
that they tend to be. So you really want to
make certain that you get the cylinder down as low
as possible. And I basically have a zero tolerance for
a cylinder, and I will you know, the traditional conversation
(23:32):
that you hear among eye doctors is a half adopter
or more you treat. I'm very happy treating a half
adoptive cylinder. And if a patient is happy with a
half a doctor, think how much happy a they're going
to be with no cylinder at all. So I am
very aggressive about doing small astigmatic decisions. I do a
limbo relaxing decision routinely at the soot lamp. It works
(23:53):
very nicely. We use a diamond knife that I design
that's readily available and it's very good for treating low
levels of cylinder. Only exception to this rule is the
aphthera lens from Bowish and Loan. It's the pinhole lens,
and that lens will tolerate up to a direct and
a half cylinder and the patient will still do extraordinarily well.
So if you have a patient who has a lot
(24:14):
of cylinder and they may not be a candidate for
a toric lens and a regular cornea that's an extended
depth of focus that will be tolerant the cylinder up
to a director and a half.
Speaker 1 (24:25):
Oh, that's that's a fair amount. That's that's pretty.
Speaker 2 (24:27):
Neat, yeap, kind of a cool lens.
Speaker 1 (24:31):
Doctor Donfeld, do you have any final thoughts on eatof lenses.
You've provided a lot of really good important insight and
to have helped frame me, and I'm sure many of
the listeners helped frame for me how to have this
conversation with patients and how to help them and myself
make decisions.
Speaker 2 (24:45):
Yeah, edopp lenses have really been a disruptive technology that's
really changed the way that I talk to patients and
gives me the opportunity to provide a visual compromise that
wasn't available previously. And just like any lens that's available today,
there are pluses and there are minuses to these lenses,
and understanding these lenses is so important to patient care
(25:08):
and that's why this podcast is so important. And I
want to thank you for the job you do in
organizing this podcast and putting this all together because this
is really important information for doctors and patients alike.
Speaker 1 (25:19):
Well, I very much appreciate the kind words. I very
much appreciate you joining me for the podcast, Doctor Eric Donefel,
thank you so much for joining me my pleasure, and
thank you everybody for listening to another episode of blind Spot.
Have a great day.
Hey everybody, I'm zaoh Mednick and welcome to another episode
of blind Spot. If you're enjoying this podcast, please rate
and review it on Apple Podcasts or Spotify. We really
appreciate it when you do that and it helps spread
the word of the podcast. This episode is sponsored by
Sun Pharma Canada and we appreciate their support for helping
in the production of this podcast. With so many intraocular
(00:33):
lenses on the market, it can be tough to guide
a patient through cataract surgery and what decision they should
make for their particular eye. As newer lenses continue to
emerge on the market to treat presby opia, there is
so much to counsel patients on. One of the newer
players on the market, so to speak, are Eatoff's extended
depth of focused lenses. They're not quite monofocal lenses that
(00:54):
let you see at one distance, but they're also not
quite multifocal lenses, which let you see distance intermediate in near.
It's somewhat of a hybrid. Edoffs can kind of be
looked at as an in between lens for patients who
don't want him on afocal but who aren't necessarily candidates
for a multifocal or who don't want multifocals for whatever reason.
So what do we need to know about this new
(01:15):
set of lenses, How well do they work? And how
should we be advising patients about them. I'm joined today
by doctor Eric Donnenfeld, who joined me on a previous
episode discussing femtosecond laser assistant cataract surgery. Doctor Donnenfeld is
a clinical professor of optomology at New York University. He's
an internationally recognized expert with over two hundred and twenty
five peer reviewed papers, forty five book chapters, and three books,
(01:37):
as well as many named lectures around the world. He's
past president of ASCARS and OMG, trustee of Dartmouth Medical School,
editor in chief of iWorld, and the president of the
International Intraocular Implant Club. He was an initial FDA investigator
of Ristasis zydra, laser vision correction, corneal cross linking, the
femtosecond laser, and many refractive IOLs. Doctor Donnefeld was named
(01:57):
America's Best eye doctor in twenty twenty one, twenty twenty two,
and twenty twenty three by Newsweek, and The Ophthalmologist named
him one of the fifty most Influential People in oph
Theomology for twenty twenty to twenty twenty three. He's a
Fellow of the American Academy of Ophthalmology and has received
its Honor Award, Senior Honor Award, Life Achievement Honor Award,
and Secretariat Award. All Right, doctor Eric Donisfeld, welcome back
(02:18):
to the podcast. Thanks for joining me again.
Speaker 2 (02:20):
That's the pleasure. It's gonna be fun tonight.
Speaker 1 (02:23):
All right, good, you're you're enthusiastic about this topic, and
I'm curious to hear your thoughts on these lenses, the idofs.
I don't know if you'd say they're newer to me.
They feel like a newer player on the market, so
to speak, over the last several years, something that we're
implanting more impatience. And how would you describe an edof lens,
if that's even the right umbrella term, because I know
there's a lot of different lenses that some people might
(02:45):
categorize under that umbrella. Some people call some of these
lenses monofocal, plus some of them call them adopt.
Speaker 2 (02:51):
Yeah, so that's a great, great segue. But before we begin,
you know, I think the edof lens stands for extended
depth of focus are kind of a segue between our
conventional monofocal where you saw a distance and nothing in between,
and the multifocal, which gives you full range of vision
but has disphutopsy at Glarren halo. And the Edolph lens
(03:12):
is a lens that's kind of been adopted to kind
of fit in that middle ground where it gives you
a little bit of reading, but it doesn't take away
a lock in the distance. So you ask for a definition,
and the government has really come up with a definition
of what an Adolph lens is. To be an official
Adolph lens, it has to have non significant difference in
(03:33):
distance quality of vision to a monopocle lens, so it
can't be worse than a monopocle lens. It has to
be about the same disphotopsia profile, and it has to
have about a half a diopter or more of added
mid range and near vision. So it has to meet
that criteria if a half adopter of reading without losing distance.
(03:54):
And right now in the United States, there are two
lenses that meet those criteria and they're considered premium lenses.
The first one was the Symphony, which is a difractive
lens from Johnson Johnson, and then came the Vivity from Alkhon.
Both them meet the criteria of giving you a half
a docter more of reading. At the same time, you
(04:14):
don't lose distance visual quids significantly compared to a regular lens.
Now you mentioned another category which is kind of in between,
and that is the monofocal plus. Some people call these
edoph lenses as well, but they're not officially ados, but
they function like them. And these are lenses that give
you a little bit of additional reading, a little bit
(04:36):
more mid range. They don't sacrifice distance, but they're not
considered a premium lens, so you can't build for them,
but they do give you a little extra And there
are a couple lenses out there that do this. There
is the Eye Hands which kind of invented this from
Johnson Johnson. There's the Rainer EMV and Bauschem Loom has
(04:57):
the Investor Aspire LEEDS and then finally there are two
of the lenses that meet the criteria of extended depth
of focus, and those are the new lens from our Excite,
the light adjustable lens, which is a lot of adjustable
lens plus, which gives you about a half adopter more
of additional reading, and that is a premium lens. And
then there's the ephthero lens, which is a pinhole lens
(05:20):
that does give you additional reading and it doesn't sacrifice distance.
So there are a lot of choices that are out there.
Speaker 1 (05:26):
Those are really really thorough and clear summary. And I'm surprised,
maybe because I'm in Canada near in the States, the
billing model is a bit different, so I'm not as
acutely aware of some of that definition. And because you
said it obviously influences what you're allowed to charge for
as a premium lens, So that's helpful that there actually
is a definition out there that really is quite clear.
(05:47):
You mentioned that the symphony, for example, is diffractive. How
do these lenses work differently? And I guess we can
talk about whichever lenses you like, because I'm sure they
all work differently. But vivid, I know, is probably the
more common one that I see and can other people
are using. And for the monofocal plus the ihands is
a very common one. How do those lenses actually work
(06:07):
compared to some of the multifocals, And in a sense
that's not a fair question because multifocals don't all work
the same. You have difractive and you have non difractive multifocals.
But how do they generally work for someone trying to
understand that?
Speaker 2 (06:19):
Well, most of the etof lenses other than the symphony
which is a diffractive iol, are refractive IOLs, and they
give additional reading by stretching the zone of vision. Essentially,
they provide a little larger and they can do that
by providing negative fherre collaboration or positivephere collaboration, which is
the rain of MV, which is the only one that
(06:39):
does it that way, or it can just have a
little increased steepness in the centrable lens that gives you
just a little bit extra reading in that in that area.
But these are refractive lenses. They don't split light for
the most part, other than the symphony lens, and for
that reason there's a better quality of vision. There isn't
(06:59):
this footage your profile you have from a multifocal lens.
But on the other hand, you don't get nearly as
much reading. You get definitely a little bit less reading.
But they lend themselves very nicely to a mini monovision
or someone who just says, you know, I have specific
visual needs. I want to be able to see the
dashboard of the car. I want to see the food
(07:20):
on my plate. I want to put on makeup. And
if I had to put glasses on to thread a
needle or to look at, you know, a small font
very close, I'll put glasses on for that. But today's age,
most of our time near is not really that close.
It's really at arm's length, and that's where these edof
(07:40):
lenses really shine.
Speaker 1 (07:42):
So reading a book, your phone, those are kind of
the examples I can think of where really are up
close near. But laptops, dashboard that's more common, but phone
basically in books, reading or iPads. Is it accurate to
tell people that those are the things you'd be more
dependent on if you get need off on where more
(08:04):
dependent on wearing reading glasses?
Speaker 2 (08:06):
I think that's a very good summary of exactly what
to expect. However, a lot of patients who have the
ethof lenses will just increase the fonts on their smartphone
or on their kindle and they'll be able to, you know,
to read just holding a little bit further away. It's
a matter of just holding it six to ten inches,
a little further away than you might normally, and you'd
(08:29):
be amazed at how much time you spend at that distance.
It's a new world than there was before. You're not
reading small fonts from sixteen inches away. Twenty four inches
is kind of the new norm. So almost anything you
can do at twenty four inches you can do with
these eat off lenses.
Speaker 1 (08:46):
The side effect profile really helps determine how you're going
to advise a patient here, because if somebody says, yeah,
I really want all levels of vision, you'll say, okay,
so sure go with the multifocal. Obviously, there's personality factors,
and there's a lot of other factors too, if they're
a candidate, if they have that dry eye, if they've
gotten epi retinal membrane stuff like that. Which my understanding
and we'll talk a bit about that afterwards, is that
(09:07):
the eatoffs are more forgiving for but ultimately one of
the big factors is going to be how many side
effects is this patient willing to endure or are you
willing to risk with this patient. So I've seen patients
with a vividy for example, who they still have. I
don't know exactly what I would call it, if it's
(09:27):
a halo or but they've got some dispotopsias, so they're
not devoid of dyspotopsias. Is that correct? You know?
Speaker 2 (09:35):
The one thing about optics is you don't get something
for nothing. Yeah, anytime you gain something, you have to
give something up. And it's just a question of how
much you're willing to sacrifice to get that extra reading.
And the vivity is a great lens. It gives you
a good amount of mid range vision. But if you say,
is a quality of vision with a vivity the same
(09:55):
as it is with a monophople and the answer is
to no, it really is not the same. You do
sacrifice a little bit of quality of vision. And I
do have some patients who have not been happy with
eatof lenses where I've actually had to explain them to
put monofocal lenses. But for the most part, I think
you said it perfectly. The ead off lenses are more
forgiving than the multifocals. They tend to be much better tolerated.
(10:17):
There's much less just photoposy, and patients very rarely complain
of problems with these lenses. We just actually are doing
an FDA trial now with a new etof lenses, which
will be a premium lens that you have up in Canada,
and that's the Piracy lens from Johnson and Johnson. And
of all the eatof lenses that I've used so far,
(10:38):
this one has to me the best mix of great
quality vision at distance and a good intermediate vision without
much sacrifice. These have been very very happy patients and
the lenses doing very well in Canada and in Europe,
and we're looking forward to having it here in the
United States.
Speaker 1 (10:56):
When we talk about the quality of vision, you're referring
to this photopsias and then maybe I'm wrong to separate
into two categories, but I think of in my mind
at least as photopsis thinks they're going to actively complain about,
and then just the quality of how clear the vision is.
I already, based on what you've said, I'm going to
adjust how I speak to a patient because what I've
typically said might not actually be true. I kind of
(11:19):
lump multifocals and eat offs together and I say, listen,
you're going to give up something. The quality of the
vision might not be as sharp, and what I say,
is we take some of the light from the distance
in order to help you see it near. But it
sounds like that's not actually optically true based on your
explanation of that it's more of a refractive lens than
a diffractive lens. But I guess it doesn't really matter.
(11:41):
The point does stand that the actual clarity of the vision,
it is fair to say to a patient. And I'm
reiterating this even though I think you already said this,
because I think it's important. The fact does still stand
that it is reasonable to say to a patient, Listen,
you do still get your clearest, best distance vision if
you go with the monofocal. Is that still something people
can and feel confident saying to their patients.
Speaker 2 (12:02):
You know, I would be a little bit broader on
that and say that for the majority of patients, there's
no significant difference in distance vision between a monofocal lens
and the ethof lenses. Not a significant difference other than
maybe the symphony, which is a diffractive lens. I think
for the refractive lenses, no significant difference. But there is
(12:23):
a small subset of patients who will say that the
vision with the eat off lens is not as good
as it is with a monofocal lens, but for the
majority of patients, it's just not true. For the majority
of patients, they see no significant difference. And that's what's
made this lens so exciting for patients is that most
patients really enjoy the extra intermediate and they don't feel
(12:44):
like they're sacrificing anything. But having said that, there are
some patients where they will notice the difference, and those
tend to be patients who have underlying pathologies that put
them at risk. And just like with a multifocal lens,
when I examined a patient and you brought this up before,
and I think you hit the nail on the head
when you mentioned it, is that there are certain risk
(13:05):
factors that are going to give patients more risk of
having this photopsis. You mentioned dry eye, We can mention homa,
epiretinal membranes, cornial refractive surgery, krataconas, certainly mild mild octasia.
These are all patients who are going to have a
(13:25):
greater risk profile with a multifocal, less risk factor with
an eatoff, and the least risk factor with a monophoble lens.
Speaker 1 (13:35):
And typically would you still feel comfortable in a mild
ati retinal membrane, let's say, or somebody with mild dry eye.
Would you still feel comfortable where you'd say, yeah, the
eatoff is actually a pretty reasonable option. I'll tell them,
like you said, the risk profile is a little bit higher,
but this is a reasonable lens for somebody who who
does have some of these conditions you just mentioned.
Speaker 2 (13:57):
Yeah, And that's really the art of medicine and where
you know, you still need to have that doctor patient
conversation where we talk about different issues, and that's a
very important issue to discuss, and it's an informed consent decision.
And I will say to the patient there's a small
increased risk in your case with this lens, but the
(14:20):
risk is small and most patients don't notice it. But
the risk is not zero. And as long as the
pasal understands that and they're willing to compromise, I think
that it's a very reasonable lens to put in for
most patients who have mild risk factors. Now, when you
have a severe risk factor active careticonus and stage glow coma,
(14:41):
these are patients where I just would go with a
straight monofocal every single.
Speaker 1 (14:45):
Time for the monofocal plus versus the eatoff. How do
you make that decision? Again, it's an art, it's a conversation.
But what's typically the threshold where you'll say to somebody,
you know what, I think you're probably better for the
eyeants than the vividy for example.
Speaker 2 (15:03):
Well, it's very interesting. There's really very little difference when
it comes down to actual refractive difference between an eye
hands and aavivity. It might be a tenth or two
tenths of a diopter. Additional, the I hands in the
monofocal non toric version is a considered a government issue
lens where insurance would cover it here in the United States,
(15:26):
whereas a vivity we would be charging the patient for
the for that difference, so that it's a little bit
of an economic conversation. You do get a little bit
more reading with a vivity than you do with the
eye hands, but it's a small amount and it's a
conversation to have with patients. Now, if you take these
monofocal plus lenses and you put them in a touric variety,
(15:48):
then they become a premium lens again, so an iehands
touric and Aspire tourk a rain er em v Torque.
All these lenses are considered premium lenses, but just like
everything else we just mentioned, and the lower the additional reading,
the lessest photopsia. So an Ihans lens, in my experience,
has had less to photopsia than a vivity. The other hand,
(16:10):
the Vivity has a little bit more reading. So again
it's the conversation that you have with your patients determines
exactly what they understand and what they would like to have.
And that's that's what I spend most of my time
doing when I'm conversing with patients, is telling them the
difference between these lenses, and when you're all done, it's
usually a very thorough conversation and you feel very good,
(16:33):
the patient feels very good about the options that they chose.
Speaker 1 (16:36):
And it's interesting again, the payment model is a bit
different in Canada, but at the hospital I work at,
I didn't really have a great sense of the prices
and I looked at Ihans versus Vivity surprised Vivity was
actually closer to a multifocal than it was to I haants.
There was a pretty big gap in price, at least
in Canada, where Vividy was almost twice as expensive as
(16:56):
the I hants, which is why I ask that because
for some patients who were debating that, and obviously cost
is a factor, it's helpful to hear what you just
said there that the Vividy is a little bit better,
but it's not that much better necessarily in terms of
the diopters if you're actually thinking about it based on
the studies that are out there. Again, it is better,
(17:17):
some more side effects, but how much better is going
to factor into it when you're taking finances into account?
Speaker 2 (17:23):
Agree completely. In the United States, our model is different.
The i Haands lens is a lens that the patient
gets at no charge to the patient. For the monofocal
non tower I.
Speaker 1 (17:33):
Hands the coxit story, the big.
Speaker 2 (17:37):
Lens costs us and we charge it exactly the same
as out of a multifocal lens. There's no difference to
the United States and the cost of these different lenses.
Speaker 1 (17:46):
Doeger Donofeld where do you aim for these lenses? And
I was told from somebody for vividy, maybe aim minus
point eight and for i haants as well, aim not
quite that myopic, but a little bit of mini monovision.
Because the curves are more forgiving for the distance, but
less forgiving for near. So there's a two prong question here.
(18:06):
One is where you typically aim, and two is I'm
always I don't want to say skeptical, because I'm not skeptical,
and I'm by no means an expert on this, but
when they're designed to work for the distance and then
give you a little bit nearer, it always surprises me
that they say, but you also need to aim a
little bit nearer, because I'm thinking, but I thought the
property of the lens is that inherently you shouldn't need
(18:28):
to aim near. You should be able to aim plano
and it's going to give you a little bit of near.
Speaker 2 (18:33):
Yeah, that's a great question, and I think that question
has been answered best by Steve Shallhorn, who'dte a wonderful
paper looking at tens of thousands of patients and found
that patients satisfaction was highest when you aimed at the
first plus lens, not end at the first minus. So
everything that I've been doing for the last twenty years
has been aiming for the first minus lens. With the
(18:56):
eedoph lenses, you have the advantage that if you end
up a little bit hyperopic because of the extent depth
of focus. You'll still get a very strong twenty twenty
twenty fifteen vision. You just lose a little bit of
reading that in that in that eye. And I have
a mantra, and that is that when patients pay for
a prisbeopic solution, they expect to have some reading, but
(19:20):
they demand having distance. So if you don't hit the distance,
you're not going to be happy. So for the dominant eye,
I generally will aim for plane out or the low
first plus like a plus attemph or something like that.
That's where I aim in the dominant eye and the
non dominant eye, I have a conversation with a patient,
(19:40):
but that's a perfect patient to aim from minus point
four minus point five, depending upon how much reading you
want to have. And then if you add the inherent
additional reading you get from the eye hands or the
vivity or the aspire or the radio even v you're
gonna end up with about a diopter if near for
that patient. And that's that's a meaningful amount of near
(20:01):
that's going to give the patient a pretty good functional
vision for most occasions with good light. So if I
can get them to plane on one eye minus in
half in the other eye, they don't lose a lot
of distance. That mini monovision goes a long way to
give them a little bit extra reading, and it's very
well tolerated, but you have to hit the distance. If
you make a patient a minus a half a distance
(20:23):
with any lens, the patient's not going to be happy
with the distance vision they'll and they'll be complaining of
this autopsy, a glare, halo and problems driving. So I'd
rather give patients a little extra distance and forego the
reading and at least one eye and once I have
one eye really nail, then you're playing with house money
and you can do whatever you want with a non
dominant eye.
Speaker 1 (20:43):
That's really really valuable to hear from someone like You've
done so much of this, because in my mind, I'm
stressed sometimes and I'm obviously newer in practice than you.
I'm stressed when I've said to them, we're going to
be able to get you a little bit of nearer.
So I think in the past some of my tendencies
has been to say, well, I'm going to aim with
(21:04):
that dominance a little bit my optic because I really
want to make sure I deliver on that promise I
never promise, obviously, but that promise to them that yeah,
we're going to get you a little bit of intermediate vision.
But I have had some patients who've said, but my
distance isn't so clear, and you're reaffirming that notion there
that despite that whole conversation, the most important thing people
care about is I want to be able to see distance,
(21:26):
and everything else is kind of everything else is bonus.
Speaker 2 (21:31):
It's a bonus. It's an important bonus. But you're absolutely right.
And I've never explanted a lens but the patient didn't
have enough reading. I've explanted many lenses because the patient
didn't have enough distance. So you need to get the
distance right. If you get the distance right, everything tends
to follow. And again with the eat off lens a
little bit, a minimunovision goes a long way. Or for
(21:52):
someone who's more fastidious, you aim both eyes, you know around,
you know plano and that you just tele patient. You'll
be wearing reading glasses a little bit more, but patients
are generally happy with that. It's getting the distance right
that really makes it, that really matters tremendously.
Speaker 1 (22:07):
So to summarize there, because I had it off, so
don't listen to me listeners. For the dominant eye, you're
going to aim plano if anything, You're not going to
aim myopic. You're going to add for the lowest plus
on the iol master, the lens star, whatever biometry you're using.
And then once you've done that, for the non dominant eye,
that's where you're going to have that conversation. That's where
you might aim a bit myopic minus point four minus
(22:29):
point five.
Speaker 2 (22:30):
Yeah, that's a conversation to have with the patients. And
once you have at least one eye functioning with twenty
twenty twenty fifteen visual acuity, it gives you such a
feeling of success and a feeling that you can really
help this patient. If you don't get the distance right,
the patient's not going.
Speaker 1 (22:48):
To be happy. Last question, and again I think I
know the answer, so it's a bit of a loaded question.
But how important for these lenses is it to treat
any astigmatism? And what would be your threshold of astigmatism?
Is it lower than in a monofocal or are you
fairly aggressive and monofocals as well? Whenever there would be
residual stigmatism, these.
Speaker 2 (23:10):
Lenses are moderately forgiving for a stigmatism. But again the
more reading you get, the more near the less forgiving
that they tend to be. So you really want to
make certain that you get the cylinder down as low
as possible. And I basically have a zero tolerance for
a cylinder, and I will you know, the traditional conversation
(23:32):
that you hear among eye doctors is a half adopter
or more you treat. I'm very happy treating a half
adoptive cylinder. And if a patient is happy with a
half a doctor, think how much happy a they're going
to be with no cylinder at all. So I am
very aggressive about doing small astigmatic decisions. I do a
limbo relaxing decision routinely at the soot lamp. It works
(23:53):
very nicely. We use a diamond knife that I design
that's readily available and it's very good for treating low
levels of cylinder. Only exception to this rule is the
aphthera lens from Bowish and Loan. It's the pinhole lens,
and that lens will tolerate up to a direct and
a half cylinder and the patient will still do extraordinarily well.
So if you have a patient who has a lot
(24:14):
of cylinder and they may not be a candidate for
a toric lens and a regular cornea that's an extended
depth of focus that will be tolerant the cylinder up
to a director and a half.
Speaker 1 (24:25):
Oh, that's that's a fair amount. That's that's pretty.
Speaker 2 (24:27):
Neat, yeap, kind of a cool lens.
Speaker 1 (24:31):
Doctor Donfeld, do you have any final thoughts on eatof lenses.
You've provided a lot of really good important insight and
to have helped frame me, and I'm sure many of
the listeners helped frame for me how to have this
conversation with patients and how to help them and myself
make decisions.
Speaker 2 (24:45):
Yeah, edopp lenses have really been a disruptive technology that's
really changed the way that I talk to patients and
gives me the opportunity to provide a visual compromise that
wasn't available previously. And just like any lens that's available today,
there are pluses and there are minuses to these lenses,
and understanding these lenses is so important to patient care
(25:08):
and that's why this podcast is so important. And I
want to thank you for the job you do in
organizing this podcast and putting this all together because this
is really important information for doctors and patients alike.
Speaker 1 (25:19):
Well, I very much appreciate the kind words. I very
much appreciate you joining me for the podcast, Doctor Eric Donefel,
thank you so much for joining me my pleasure, and
thank you everybody for listening to another episode of blind Spot.
Have a great day.
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