Mini-monovision with Eyahnce and RayOne EMV

[nh_user_1148776]

It’s fairly early days for the Rayner EMV, particularly in the US so, yes, data is still coming in. But still the experiences and statements from many high profile surgeons is promising. I want to step back for a moment to shed clarity on the interpretation of the Rayner vs Eyhance defocus curves. I found this video (search: “Early outcomes webinar with Dr Phillips Kirk Labor”). At 7 minutes 30 seconds into the video the Rayner representative clearly explains the curves as being like for like ( i. e. No monovision offset). He makes a point to express this explicitly. I hope this clarifies any confusion on at least this particular point.

Regards,
Indy G

[nh_user_1291666]

I reviewed that video and captured this screen shot at the 6:32 point.
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This is a bit of an unusual way to display the MTF curve with the peak set at 22 D instead of at the 0.00 point of emmetropia used for standard defocus curves. But in any case the relative comparison should be valid. For reasons that are not explained in the video they have chosen to display the EMV curve displaced off to the right by about 0.75 D, instead of at 22 D like their standard aspherical monofocal and the Eyhance. Seems strange to do that. However if one mentally moves that brown EMV curve to the left so it peaks at 22 D to make it comparable to the other two, I would suggest the drop off to the right side is just as steep as the standard lens and inferior to the Eyhance. This is consistent with the MTF curve in that FDA document, and to the other study I referenced which showed the EMV to be virtually identical to the Tecnis 1. I will have to look at the left hand side of those reports again to see if I can see the more gradual hyperopic curve or not.
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I noticed that the Barrett video advocates using this lens with monovison, and not bilateral emmetropia. Then there is this Spanish surgeon material, which the data from which they say they have on file, but there is no reference to a formal study or report. This is the curve I take issue with as it is inconsistent with those other two references and is even inconsistent with their own curves in this screenshot. That makes me remain skeptical of this claimed bilateral emmetropia defocus curve. It looks much more like a monovison configuration. Perhaps at some point Raynor will come out with clinical trial data submitted to the FDA for approval. Right now they don’t seem to have it.
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If this screenshot is accurate then their claims to have a smoother transition between the lenses in a monofocal configuration would have some merit. It does not justify the claim that the EMV provides more depth of focus than the Eyhance though.

[nh_user_1447607]

Thank you Ron and Indy for the constructive discussion, this is really helpful for many folks like me.

[nh_user_1291666]

While my previous post is being moderated. I will make this additional one. I remain concerned that the data provide from the M. Royo, Spanish study is misleading, and the details of it are undisclosed. On a search for it, I found this article instead, which is much more informative in the compaison of the RayOne EMV and the Tecnis Eyhance. Use this to search for it:
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Helio PDF Visual Acuity, Wavefront Aberrations, and Defocus Curves With an Enhanced Monofocal and a Monofocal Intraocular Lens: A Prospective, Randomized Study Mayank A. Nanavaty, MBBS, DO, PhD; Zahra Ashena, MD; Sean Gallagher, BMedSci; Steven Borkum, DipOptom (SA); Paul Frattaroli, MA (Hons), MA (Post-Grad); Emma Barbon, BSc
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The most useful graphs are the standard defocus curves shown at the top of document page 16 (PDF page 7). They clearly show that the Eyhance has a wider depth of focus when implanted both uniocular and binocularly. These graphs make sense based on the other independent data available. They are very different that the M. Royo data. Further these curves do not show the hyperopic bump to the left of emmetropia that Raynor claims the lens to have. If anything the Eyhance is flatter. Conclusion of the study:
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“CONCLUSIONS: The TECNIS Eyhance IOL provided better
DCIVA and broader defocus curves than the RayOne IOL. There
was no difference in CDVA or patient-reported outcomes. Although there were some differences in aberrations when measured with normal pupil size, they were not clinically significant.”
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Based on this information, I would choose the Eyhance over the RayOne EMV for a close eye monofocal solution. If the same offset was used for both lenses the Eyhance would provide better close vision and essentially the same distance vision. If the RayOne was offset by perhaps 0.25 D more than the Eyhance it would provide similar close vision, but the Eyhance would provide better distance vision as it would be offset less. And I think if one has the opportunity the best overall solution would be to use the Tecnis 1 aspheric lens in the distance eye, and the Eyhance in the close eye.

[nh_user_1291666]

Suggest you wait to see the posts that are currently being moderated before making any decision. Short story is that I would choose the Eyhance over the RayOne EMV for the close eye in a mini monovision configuration.
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EDIT: I just realized I was duped again by Raynor. That last study I gave reference to is comparing the Eyhance to the RayOne Aspheric lens which is different than the RayOne EMV it seems. So there still is no detailed data showing the EMV version is actually better than the standard aspheric one.

[nh_user_1148776]

Oscar,
You’re welcome. If I were you I’d spend a few hours or a day doing more research on both the Rayner EMV and the Eyhance lenses. I think either one is potentially suitable. Ultimately, it’s going to be your decision with, I expect, major weight given to your surgeon’s recommendation. If he/she isn’t familiar or experienced with the Rayner EMV lens then that will likely disqualify that option anyway. But if he/she IS familiar and experienced with the lens, then certainly he/she can give you a more informed assessment than I ever could. I personally went with the Rayner lens because I trusted my surgeon, had confidence in the co-developer of the lens Graham Barrett, and the underlying concept of positive spherical aberration enhancement seemed to make sense to me.
Good luck to you. Let us know how it goes with your surgeon.

Cheers,
Indy G

[nh_user_1148776]

You’ve stated, “For reasons not explained in the video they have chosen to display the EMV curve displaced off to the right by about 0.75 D.”. But HE HAS explained that. He states that the highest MTF values ought not be the main objective of an IOL and that some sacrifice can be made to that metric (as we know the Vivity clearly does, and a rather large sacrifice at that) ) in the pursuit of not only greater myopic range but hyperopic range as well. THAT’S why the Rayner EMV lens works optimally in a mono-vision strategy. The lens offers a bit of “hyperopic shift” in the “near” eye that allows more stereopsis (binocular vision). Indeed, it seems to be that a surgeon can err to slightly negative (say, -0.25 to perhaps -0.50) with this lens, in the distance eye, and have the patient still wind up with excellent distance vision.

There are no inconsistencies in my view in regards to the various graphs given their explanations. As the Rayner rep said, “Modulation transfer functions are great but I think even better are real world defocus curves”. So the MTF curves, while useful to a point are not necessarily indicative 100% to real world experiences. Yes, I agree there is still data coming in, larger studies to be done, but increasingly surgeons (particularlyin Europe/UK) who have tried the Rayner lens have shifted to using it as their “go to” lens.

There is no free lunch with the Rayner EMV, or any other lens for that matter. It’s mainly about how the lens is designed to use the light and how they get there. In the EMV case they get there using positive spherical aberration and perhaps some other lens design element and they spread the light according to where they feel it’s most useful.

Indy G

[nh_user_1447867]

Thanks Ron and Indy for your support and efforts to clarify things.

Ron, I’ve researched the envista and it looks very good, but the visual acuity seems superior in the eyhance. Do you have a clue about the lens which reduces the late-in-bag dislocation?

I’ve had vitrectomies before and when I’m also researching the dislocation risk as well. In this topic, I’m mostly lost and can’t find a lot of information.

Best regards,
Will

[nh_user_1291666]

The reason they are stating that MTF (contrast sensitivity) “ought not to be the main objective” is that all of these non pure monofocal aspheric lenses compromise the MTF to obtain more depth of focus. Some compromise it more and some less. But, that has nothing to do with the reason for the EMV being displayed off to the right and without the peak at the 22 D position. To be frank, I think they did it so viewers could not easily compare the shape of the curve of the EMV to the standard aspheric lens. To my eye, if you move the EMV curve back to the left it is not going to have any more range of focus than the standard lens, and less than the Eyhance lens. This strikes me as being deceptive.
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“Modulation transfer functions are great but I think even better are real world defocus curves”. I agree 100%, and the basic problem is that Raynor does not seem to have conducted well document clinical trials to produce credible defocus curves. All they have is that Spanish surgeon’s data which has not been provided for review. The shape of that curve looks very suspicious and is not consistent other available data like MTF curves, and lab measured defocus.
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Raynor claims and my thoughts on them:
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Use of Positive SA to extend the myopic depth of focus - This may very well work to a fairly minor degree, but they have not provided the data to back up the claim. They only provide it in the middle of the lens and the positive SA transitions to negative at the edge. The issue with this is that the lens can be sensitive to decentralization, and the positive SA is lost as the pupil opens up in dimmer light. Probably not an issue for an older person, but could be for a younger person with a pupil size of 5 mm or more. Could also give rise to halos with a larger pupil size.
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Use of Positive SA to extend the hyperopic depth of focus. The screenshot from the presentation shows that to be very significant. However, based on the MTF curves it is not that significant and is pushed out quite a way into the hyperopic zone, but it does show up. This effect is mainly the one that Barrett refers to as a benefit in the near eye of a mini-monofocal configuration. This improves the distance vision in the near eye, and the ability to get some vision from both eyes instead of one. This effect seems unique to this particular lens and is a good idea. I don’t know of any other lens opimized for monovision like this. However, I am not so sure it is significant enough to be of a big benefit. Accurate clinical trial data on the defocus curves would be of value in determining if it really works or not. This hyperopic effect is of value in the near eye, but provides no benefit in the distance eye.
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The bottom line is that Raynor are making some nice claims about this lens, but do not seem to have the FDA quality clinical study data to back them up. On the other hand there is lots of data on the Eyhance. Of the two choices, I think the Eyhance is the safer bet for the close eye in monovision.

[nh_user_1291666]

I am afraid I do not know what the term “late-in-bag dislocation” is about.
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I doubt that there is a significant difference in the distance visual acuity of the enVista compared to the Eyhance. Neither are going to be quite as sharp as the Tecnis 1 or Clareon. For that reason a good combination for mini-monovision is likely to be the Tecnis 1 in the distance eye, and Eyhance in the near eye.

[nh_user_1291666]

My brother has had his first eye done with an enVista monofocal. He had his 6 week optometrist exam today, with the following outcome:
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Sphere +0.25 D, Cylinder -0.5 D Snellen 20/15.
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So he was pretty happy with that. Hard to do better than 20/15, but I think I would have chosen the next higher power lens. He got a +15.0 and I think a +15.5 would have been a bit better. It would have reduced the sphere to -0.10 D theoretically. Probably would have tested out at 0.0 D Sphere. His surgeon likes to target 0.0 D spherical equivalent, and I tried to convince my brother that a -0.25 D target is safer. In any case, even with the +15.5 D he would have still tested at 20/15. The slight difference might be in the closer vision. The more negative you end up the better the close vision. But, he is going to do mini-monovision anyway, so should get lots of close vision from that eye.
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In any case this is just one eye, but it does show that the enVista can give good distance visual acuity.

[nh_user_1447607]

I had a 2 week follow up with my doctor yesterday. I was told the vision in my operated right (dominant) eye is 20/20. I told my overall vision is not that great since the imbalance is high b/w the two eyes.

I am scheduled for the second (left) eye on 12/20 for now. My doctor is suggesting to go with same lense with 0.75D offset to get the near vision and says most people will adopt to this offset. Based on what I read in this thread/forum, I can see few options for my left eye (non-dominant):

1. Eyhance lens with 0.75D offset (mini-monovision)
2. Eyhance lens with no offset and use readers for near vision
3. Tecnis 1 or Clareon with no offset and use readers for near vision (this is based on Ron suggestion earlier to get more distance visual acuity, assuming dominant eye switching is not a concern)

I am not sure how much distance visual acuity I lose with option 1 or 2, compare to option 3. The last thing I want is to go with any option, but wear glasses for distant vision.

Appreciate any expert suggestions for my options.

BTW, I live in Massachusetts (US), I asked about Rayner EMV in my doctor office (not the doctor), it seems they don’t know anything about it. So, I am not considering that option for now.

[nh_user_1291666]

My thoughts would be to go with an Eyhance with a target offset of -1.0 D. Based on all the information I have seen on the Eyhance it provides about 0.35 D extra depth of focus over a monofocal. If you offset it by -1.0 D you will end up with a total depth of focus over a monofocal of -1.35 D. That should be pretty good for reading, and it also should not affect your distance vision if you already have 20/20 in your other eye. Yes, of course an offset of -0.75 D will work too, but it will put your ability to read finer print especially in dimmer light more at risk.
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Going with a monocular lens or even an Eyhance with no offset is going to lock you into needing readers.
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My first choice in your situation would be to go with the Eyhance at -1.0 D, and if your surgeon objects, then the Eyhance at -0.75 D would be the second choice. If cost is any consideration, then a Tecnis 1 at -1.5 D is also an option. It will give the same reading ability as the Eyhance at -1.0 D, but will be a little weaker in the intermediate range.

[nh_user_1448700]

Hi Indy,

Thanks for discussing your Rayner EMV experience here. I’ve been researching IOLs and have watched a lot of videos discussing both the Eyhance and the Rayner lenses. But it really helps to get insight from people who’ve actually had the lenses implanted.

A few questions, if you don’t mind. You say you read J1 print with one eye plano and the other with a 0.75 offset. At what sort of distance would that be? I believe near vision testing is usually done at around 40cm/16 inches; can you read J1 sized print at that distance? That would be amazing. Or is the J1 at an intermediate distance? At what near distance does your vision start to blur? Do you feel comfortable reading a book or do you use readers for that kind of close work?

And for your intermediate vision, is the vision crisp, and does it seem “natural”? I guess what I mean is, since you’re using a mini-monovision setup, does the blended vision feel as natural as if your were using glasses set to give normal intermediate vision? Can you use a computer comfortably for an extended period of time?

And lastly, with distance vision of 20/30, would you feel comfortable driving a car, or just going through your day, without any kind of additional lenses? Do you have an additional pair of glasses to “sharpen up” your distance vision, for situations where you feel you want things really clear? Right now, my corrected glasses vision is 20/20, so I’m not exactly certain what 20/30 vision is like.

Also, I enjoy amateur astronomy (or used to, before my cataracts began to make that difficult), so having vision that is correctable to 20/20 (or even better, if possible) is pretty important to me. It’s also why I’ve rejected multi-focal iols in favor of monofocal, to avoid, as much as possible, the prospect of dysphotopsias, like halos or glare.

Sorry for all the questions, but like most folks who post here, I’m trying to get a real feel for how vision with iols might be, especially using mini-monovision.

Thanks,
Brad

[nh_user_1148776]

I can’t put myself out there as an “expert” but I think it’s reasonable to ask how near your vision begins to degrade with your distance eye. Can you see well at arm’s length with your 20/20 distance eye? Are you able to see even nearer than that? I think ideally you’ll want some overlap in the intermediate range between the distance and near eyes in a monovision setup if possible. Of course that depends on your goals, but as for me I would not want to have an intermediate blurred zone at computer or dashboard distance. It’s something to consider.

Regards,
Indy G

[nh_user_1291666]

Brad, I do not have the Rayone EMV lens, but I do have mini-monovision with pure monofocal lenses. I will leave the RayOne EMV personal experience comments to those that have it. On a spherical equivalent basis my distance eye is -0.25 D, and my close eye is -1.40 D. The distance eye has an Alcon AcrySof IQ Aspheric lens, while the close eye has an Alcon Clareon Aspheric lens. Both are pure monofocal lenses with a -0.20 um SA correction built into the lens. At the optometrist office I can easily see 20/20 and perhaps half of the 20/15 line with my right eye, or both eyes. It doesn’t make much difference, but my distance eye is doing the lions share of the contribution. At the standard Jaeger chart distance of 14" I can easily read the J1 line in bright sunlight, and vision starts to jam out at about 10-12". This of course is with my closer eye. My distance eye starts to become useable at about 18-20" and my visibility of my car dash is very good with both the distance eye and close eye. I have irregular astigmatism in my close eye, and to some degree that limits my near vision. But, all in all I almost never wear my prescription progressives, and occasionally use +1.25 readers for very fine text in dimmer light conditions.
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If your overall objective is to have the best possible visual acuity for astronomy I would suggest getting a pure monofocal in the distance eye, as I would assume that is the only eye you will use for monofocal astronomy. In theory the average eye has +0.27 um of spherical aberration. There is some controversy on whether or not that should be corrected to zero for the best visual acuity. J&J who make the Tecnis 1 lens put -0.27 um SA into their lens to correct to zero theoretically. Alcon believe the optimum is to have some residual SA and put -0.20 um SA in their lens. B+L believe a residual of +0.0 SA is ideal and make their enVista lens neutral to leave what is in the cornea unchanged. They say it sacrifices some visual acuity but increases the depth of focus and and tolerance for the lens position/eye not being perfect. If you look back at an image I posted about 10 days ago, you can see a graph from B+L that illustrates that point. And if that is not complicated enough, some believe you should measure your own specific cornea to determine what the SA value actually is, and then choose the lens that provides the best SA correction. The often quoted +0.27 for the cornea is only an average. I suspect most surgeons do not do this, and you would have to find one that has the capability and is willing to do it, if you want to go down that road. If you don’t, then my thoughts are that the Tecnis 1 or Alcon Clareon are the best choices, depend on who’s theory you want to believe, if the objective is ultimate best visual acuity.
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The same logic can be applied to the near eye, but I would argue that ultimate visual acuity is not as necessary in the near eye. In your case you will not be using it for astronomy. There could be an argument for using an EDOF or near EDOF lens like the Eyhance to get a bit extra distance vision. So ophthalmologists that use it call it hybrid monovision. It will work of course, but to get very good close vision you do have to offset the lens. I am convinced with monofocals the optimum offset is -1.5 D. On the Eyhance it may be -1.25 D. And to be realistic one needs to set a target range like -1.25 to -1.50 for a monofocal, and say -1.0 to -1.25 for the Eyhance.
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For sure one can improve vision with monovision by using progressive glasses as well. One reason is that with the fairly course steps available in IOLs there will almost always be some residual sphere and cylinder error that could be corrected. Progressives can do that very well, and also at the same time take out the monovision differential by fully correcting the close eye for distance. I have a pair of glasses that do exactly that, but I seldom wear them. It does bring back the issues of progressive glasses with needing to look up and down to get the right effect. You don’t have that with eyeglass free monovision. You have a full field of view.
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There is one issue with using eyeglasses for correction however, and that is when you have an EDOF or near EDOF IOL. These lenses introduce some optical “tricks” to extend the depth of focus, that eyeglasses cannot correct. Eyhance varies the power of the lens from the center to the periphery. The RayOne EMV varies the amount of positive SA from the center to the periphery. And the enVista simply has a larger amount of positive SA residual. None of these optical effects can really be fully corrected with an eyeglass lens. And the other issue is that these lenses do not have as sharp of a peak in visual acuity at their optimum focus point. This makes it harder for the optometrist (really you) to determine “which is better, 1, or 2?” which is the trial and error process used to pick your prescription power. For all of these reasons I think one will get the best eyeglass corrected mini-monovision when pure monofocals are used for IOLs.
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There is the issue of cost, but I did not consider that when making my choices. If I have one regret it is that I should have chosen the minimal power toric instead of the non toric I got for my close eye. This was not a cost decision but was based on some doubt if I would get better vision considering that my astigmatism was irregular. I am now sure in hindsight that the toric would have given me better vision, and it was a mistake not getting it.
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Hope that helps some.

[nh_user_1148776]

Hi Brad,
My pleasure. Some context. You may or may not have read that my first eye, my left distance (and turns out non-dominant) eye, was done about 4.5 years ago with a Zeiss monofocal. I’m getting 20/15 for distance in that eye all the way in with clear vision to a bit under arms’ length… maybe 22 inches although I’ve never taken a tape measure to it. My “near” eye was done in latter September of this year with the Rayner EMV with an end result - 0.75D from my distance eye. My surgeon told me he typically aims for between - 0.35D to -1.0D offset for mini-monovision with the Rayner lens. When I heard this I was surprised because it meant to me that I’d have very little issue adapting because previously, with my unoperated remaining near eye, I was dealing with a 2 diopter difference between the eyes and I was struggling a bit with that. So anyway, that’s the background.

Now given that I have pretty good intermediate (i. e. dashboard, computer) vision with my “distance” eye, that dovetails well with the intermediate range I’m getting from my “near” eye. There’s some nice overlap there. All intermediate vision is very comfortable and I can go all day on a computer. My near(right) eye “crisp” range is from about 11 inches to somewhere beyond arms’ length. Now, J1 is quite a tiny print size and I’m borderline reading it at arms’ length in my near eye alone, but I can read it with both eyes engaged. The difference between a “c” and an “o” or between a “P” and an “F” can be a challenge at arms’ length, however. Inside of arms’ length to 11 inches I can do it with increasing reliance on my Rayner “near” eye, of course. Inside of 11 inches with my near eye (the Rayner EMV) things become increasingly blurry.

Now, to address my distance vision with my “near” eye. As I previously mentioned I was measured at 20/30 for distance with the Rayner EMV on its own. Nevermind the numbers, but for me just in terms of the experience of it, my “near” eye distance vision is better than I imagined. This was maybe the most pleasant surprise of all. I’m not suggesting it’s perfect… It’s not as good as my distance eye, but it’s not too far off it. I venture to say that if both my eyes were 20/30 I probably wouldn’t need glasses most of the time.

I, too, am an amateur astronomer by the way, and it’s something I specifically mentioned to my surgeon in the initial consultation 4 1/2 years ago as part of my lifestyle. I think you can achieve an overall 20/20 result (without correction) for distance if you go mini mono-vision. As standard practice, you’d want to get your dominant eye (your telescope focuser eye) set for distance I think (maybe with a monofocal, or an EDOF). If successful, then you’re low hanging fruit with an extended depth of focus lens like an Eyhance or a Rayner EMV offset around - 0.75D to -1.0D in the near eye for reading and intermediate (and some distance help too) . It really depends on what you’re looking for and what your surgeon says he/she can likely deliver on. It’s a conditional probability–If you can get the first eye nailed down nicely for distance, then the rest should fall into place with a very high probability.

After having had cataract affected vision for probably 7 years, I’m stunned I have the vision I have now. When I went into my first consultation over 4 1/2 years ago and my surgeon told me I could be glasses free most of the time I thought it was too good to be true. I’ve yet to need glasses since my second surgery. The only time I could see needing glasses is perhaps for a marathon session of small print reading at the 11 - 17 inch range. But all I need to do to get my binocular reading vision to kick in is to extend my arms a bit and then my distance eye kicks in. So for all practical purposes I’m glasses-free. I hope this helps.

Regards,
Indy G

[nh_user_1447607]

Thanks Indy and Ron for the responses.

Currently, I can see fine at arm’s length - I don’t know I can say it as ‘well’.

Other problem I am having is I can’t watch TV for long time with both eyes, I am closing my non-operated (left) eye for few secs in between. I believe this is b/c my left eye is so blurry for all three visions and imbalance b/w the eyes high.

The question/concern is whether this issue still be there if I go with an offset of -1.0D. I am trying to test it my self, it seems it is not feasible since the cataract in other eye

[nh_user_1148776]

Oscar,
I understand what you’re saying. I, too, was a bit freaked out as to how my distance vision would turn out with just about any offset. What reassured me though was a video on YouTube where this guy illustrated what 1.0D, 2.0D looked like. Check out “Antonio the Optometrist” channel and the “Myopia (near sighted) vs Normal Vision” video. At 1. 0D things aren’t that bad and I knew that the two eyes would work together in a mini-monovision scenario quite well particularly after neuroadaptation.

Indy G

[nh_user_1291666]

All I can say is that I would expect you would do fine with a target of -1.0 to -1.25 D in the second eye with an Eyhance, based on my own personal experience with a -1.40 D close eye with a monofocal. It is unfortunate however to be in a situation where you cannot test it ahead of time with a contact.