I am going to have cataract surgery next year and i am thinking over my options. I have astigmatism but I can't afford a toric iol. I was going to go with the Tecnis 1 Piece ZCBOO and set it for intermediate vision. and wear eyeglasses to correct for distance vision and astigmatism. I know the Eyhance ICBOO is designed to improve intermediate/near vision, but since I am going for intermediate vision anyway, it would seem that the Eyhance would be redundant and the the Tecnis I Piece would be the better choice. What do you all think about my reasoning.? Thanks.
I think your logic is good. The depth of focus with 20/32 or better visual acuity with the standard Tecnis lens is about 2.0 D. The Eyhance only increases this to about 2. 4 D. This is probably not significant when you are under correcting to get intermediate and nearer vision.
For both eyes? What's your plan for near vision?
JimLuck Since I was going aim for intermediate vision, I think, per what Bookwoman has posted, that I should get a good bit of near vision. For distance, and for my astigmatism, I was going to have that corrected with a new prescription for my eyeglasses.
Ron, I'm glad you agree with me. :-)
Eyhance should give most people good intermediate / dashboard vision but results will vary for near. How much astigmatism do you have to correct?
davis I think I have 2D. I was going to go with the Tecnis 1 monofocal, not the 'Eyhance.
Here's a BMC Opthamology published study that compares defocus curves for the Eyhance against the Tecnis monofocal. If these results can be obtained, there's a lot more to be gained by targeting the Eyhance to -1 or -1.25D than you could get with the monofocal. If all goes well and residual astigmatism is avoided, then you could have functional distance and functional near in addition to intermediate.
That curve strikes me as extremely optimistic for the Eyhance. It shows an extension of the depth of focus at a LogMAR of 0.2 that exceeds 1.0 D! That is way beyond what is required to officially call the lens an EDOF. The curves I have seen show it gaining about 0.35 to 0.4 D over the monofocal. This falls just short of the 0.5 D required to call it an EDOF, and J&J appropriately do not call it an EDOF. I also have not seen the flat area to the left of of the 0.0 D on other curves. The curves shown in the 2021 IOL Newcomers article seem more realistic to me.
I have one Eyhance so far and got 20/20 at distance and J3 at near in the surgeon's office 12 days after surgery. At 3 weeks+, I have functional vision from 12" to infinity in that eye. I can drive unaided with that eye and read an electronic tablet/phone at 12". My other eye is -5D with additional astigmatism and not helping at all since I'm not correcting it (I quit contacts several years ago.) We targeted -1D and achieved -0.9D with < 0.25D astigmatism.
Perhaps these results won't hold up after I get an IOL in the other eye but right now if I close off the other eye, my IOL eye does pretty well in many (not all) real world conditions. In lower light or at dusk with a slightly larger pupil (~4mm) my experience is that the Eyhance vision will be worse than a monofocal because it's worse than my other corrected eye. At dark (5mm pupil), the Eyhance is outstanding with superb contrast sensitivity. The results you get with the Eyhance really depends on the conditions you test it under. Published defocus curves vary widely depending on the characteristics (astigmatism, age, pupil size, etc) of the eyes studied.
My result is consistent with the "extremely optimistic" curve from BMC Ophthalmology pictured above but would be considered nearly impossible with the curve in the IOL Newcomers article in the Review of Ophthalmology. There are several other Eyhance studies that show more favorable results for the Eyhance than the Review of Ophthalmology article. Here's another:
Kang, Korean Journal of Opthamology 2021: Visual Performance and Optical Quality after Implantation of a New Generation Monofocal Intraocular Lens
So...Ron brings up an interesting point - why wouldn't J&J advertise Eyhance as an EDOF if it qualifies? Consider the advantages of being the best monofocal on the planet and in a group known for having the least undesirable visual distrubances. Or place the product in a newer EDOF category that is trying to sell itself as having fewer visual issues than multifocals but perhaps weaker contrast sensitivity and more night driving issues than monofocals.
J&J probably made a great business decision to place the Eyhance into the monofocal category. Eyhance won't beat Vivity at EDOF unless they can convince people that Vivity's night driving / contrast sensitivity issues are dealbreakers. Eye surgeons don't seem too concerned about them so Eyhance as an EDOF was likely to be a losing proposition.
Anyone targeting intermediate vision should consider Eyhance. If you achieve a target between -1.5D and -1D with minimal astigmatism, there's a reasonable chance you'll get decent near and far vision that might be ok to drive with. My experience is that the area to the left of 0D defocus (+1.5D to 0) is fairly flat and in line with some (not all) published studies. I've listed two studies that support the flat defocus curve, consistent with what I'm experiencing. There are at least 10 studies that have been done on the Eyhance and I haven't reviewed all of them but most note improvements in contrast sensitivity, especially at night. I've noticed that as well.
Targeting anything near plano with Eyhance would essentially be trading away any near vision (less than 2 feet) for very little improvement in distance vision (perhaps 20/25 vs 20/20). Not a trade-off I'd make. Targeting between -1.5D and -1D ensures that flat portion of the defocus curve to the left of 0D (assuming it exists for most people) is brought back into your range of usable vision (less than infinity feet away). My experience is that the flat part of the curve exists and can be achieved if residual astigmatism and bad surgical outcomes can be avoided.
Plano targeting:
20/10 is double the distance visual acuity of 20/20 and three times the distance visual acuity of 20/30. 20/20 is 50% greater distance visual acuity than 20/30.
Snellen 20/10 = LogMAR -0.30 = Meter 6/3 = Decimal 2.00 Snellen 20/12.5 = LogMAR -0.20 = Meter 6/3.8 = Decimal 1.60 Snellen 20/16 = LogMAR -0.10 = Meter 6/4.8 = Decimal 1.25 Snellen 20/20 = LogMAR 0.00 = Meter 6/6 = Decimal 1.00 Snellen 20/25 = LogMAR 0.10 = Meter 6/7.5 = Decimal 0.80 Snellen 20/32 = LogMAR 0.20 = Meter 6/9.5 = Decimal 0.63
Sounds to me like you've got a great base to proceed with a monovision solution when/if it comes time to do your other eye.
My eyes (bilateral Eyhance) handle being at -1D very differently than yours it seems. I have a variety of sphere & cylinder lenses and can simulate -1D sph, 0 cyl or -.25 cyl etc. On a 10' chart my left eye at -1D sph 0 cyl can claim a fuzzy 20/20 but only just. My right eye at -1D sph 0 cyl can't claim 20/20 though. Neither eye at -1D sph 0 cyl can claim 20/20 using an actual 20' chart monocularly but can binocularly. However, even the 20/100 letters are fuzzy. I would choose to correct that vision to drive or just enjoy the outdoors for example.
At -1D sph 0 cyl looking outdoors through a window seems OK-ish until I remove the Trial Frame. Huge difference in distance image quality at 20/15 vs -1D sph 0 cyl.
You can order -1 D single vision glasses online probably for less than $20 delivered. That would give you an idea of the difference and I'm sure it would benefit the decision making for your other eye. It might confirm your theory that -1 D near and intermediate gains out-way the distance losses for you.
Focal points:
300 feet = -0.01 D 200 feet = -0.02 D 100 feet = -0.03 D 50 feet = -0.07 D 20 feet = -0.16 D 10 feet = -0.33 D 6 feet = -0.55 D 3 feet = -1.09 D 2 feet = -1.64 D 18 inches = -2.19 D 12 inches = -3.28 D 10 inches = -3.94 D 8 inches = -4.92 D 6 inches = -6.56 D
With monofocals (excluding monovision), it kind of comes down to when would being glasses free be the most beneficial and how easy it is to have the corrections you need available when you need them when deciding on distance, intermediate or near targets. It's a very specific to the individual choice.
Greg, I have seen three cornea/anterior segment specialists in Atlanta, GA. All three said the Eyhance is an excellent monofocal, but they all said it had been "over-hyped" as far as improving near/intemediate vision. Based on their experience, they said most patients will still need eyeglasses. Also, I understand that Dr. Ben LaHood, a renowned Australian cataract surgeon, told a member here that if a patient was not going to have a toric IOL implanted, the Eyhance, because it is an EDOF, would make it more difficult to correct astigmatism with eyeglasses. He recommended the Tecnis I instead.
Thanks billy111. I may need to delay getting the Eyhance in the 2nd eye if the expected residual astigmatism can't be corrected.
IMO, success with the Eyhance depends on targeting something close to intermediate vision -1D to -1.5D and being happy with drivable distance vision that is a bit short of 20/20 in the best conditions more like 20/40 in the worst. People who drive/work outside at night will really like the lens. I'm sure people who get Eyhance results close to plano will have no usable phone vision and mediocre intermediate vision. Surgeons going this route with Eyhance will have unhappy patients, especially so if they miss on the + side. I think they are leaving way too much good vision to the left of the defocus curve. Based on billy's comment, those with significant uncorrected astigmatism might be unhappy as well.
Thanks Myope_PSC.
It's been a very long time since I was corrected to 20/15 so I've forgotten what it was like. Frequently, one of my eyes wasn't correctable beyond 20/25 so seeing near 20/20 seems about as good as I'm likely to get. Plano probably also gives you better low light vision at distance than hitting a minus target. Still the risks of missing to the plus side seem to far outweigh the benefits, at least for me.
I'm in the US and contacts / eyeglasses require prescriptions and optometrist visits that are expensive. A lot of doctors don't want to help "simulate" IOL vision and one claimed it wouldn't work anyway. I guess you can't simulate the lack of accommodation but I'd still like the idea of simulation.
I am interested in finding a way to get some -3D or -4D daily use contacts (or trial lenses) to work with but I'm not sure there's a legal way to do so in the US unless you find an optometrist willing to help. Then again, you appear to be resourceful and might even be in the US as well. I got out of contacts years ago because of dry eye issues and inability to wear them for long periods.
Right now, I'm much more afraid of losing my near vision than sharpening my distance. As you indicate, I could probably see 20/15 with a -0.75D or -1D lens in addition to my IOL. And what I have now might seem unacceptable in comparison. I'll probably get prescription sunglasses as some point for driving but only because I'll be using sunglasses anyway. I'm still correctable to 20/20 in my non-IOL eye and without correction can still read pill bottles and just about anything I can't read with the IOL.
I have the 2nd surgery scheduled for next week but am strongly considering waiting based on some comments made on this forum.
Myope_PSC,
Your results aren't all that much different than mine for distance (barely 20/20 in one eye). Distance vision seems to decline rapidly as light gets dimmer - faster than a natural lens with early cataract. My IOL distance vision is still a bit slow to focus and I'm hoping that goes away when I correct/fix the 2nd eye. That leaves large letters a bit fuzzy for a few seconds. That seems to be getting better over time though.
Maybe all IOLs are like this since accommodation is lost with nearly all of them. You might not experience the rapid dimming with a plano Eyhance. Night vision is still great.
It's possible that simulating -1D with a plano Eyhance and a corrective lens just isn't as good as an Eyhance (or EDOF) alone at -1D. Billy's comments suggest it might be harder to correct astigmatism with an Eyhance...maybe that also extends to sphere. Not knowing how the Eyhance IOL works makes it difficult to know if it could be expected to work as well with the smaller image projected from the corrective lens. From what little I understand, having the light coming directly to an EDOF or Eyhance lens probably gives better results than putting the light through a corrective lens before it hits the IOL.
I have ZCB00 IOLs in both eyes. One is -0.5D, the other is -1.75D. Focal distance for -1.75D is about 22", so you could call it intermediate. With my near (-1.75D) eye at 12", I can only read down to a J7 or J8 on a Jaegar chart--and that's "figuring out what it says" not really reading. If the Eyhance had been an option for me, I would have gone for it in my near eye. I would find even a little bit more near vision to be useful--getting small things a couple inches closer with decent vision would be nice. The ZCB00 defocus curve I used shows vision getting worse than 20/32 for near vision at about 16", which is about where my vision starts rapidly becoming annoying without glasses. I'm not saying my vision is bad. I can hold small text at arm's length and read it pretty well, but if I'm reading something critical--like dosage on a pill bottle--or doing extended reading, it's better with readers on.
That seems unusual for vision with your -1.75 D eye. Do you have uncorrected astigmatism? Even with astigmatism and a spherical equivalent of about -1.4 D in my near eye, I can read J1 in full sunlight, and J3 with indoor lighting. I believe the standard distance for the Jaeger chart is 14". I have to keep reminding myself that if I don't see well when trying to read, the solution is more distance, not less. Exactly opposite to the way I was before with higher myopia.
I asked my surgeon if there would be any problem correcting residual astigmatism after toric Eyhance lenses and he said there would be no problem. From that, I assume that correcting residual astigmatism after non-toric Eyhance would be just as easy if not easier. I've been to an optometrist twice and there has never been any indication of any difficulty getting accurate cylinder axis and power numbers. I ended up on the plus side indoors not plano. I mention indoors because it changes to plano when I'm out in daylight. One eye is an easy 20/20 indoors or out. The other is not as sharp indoors but becomes a crisp 20/20 outdoors. Despite being on the plus side, indoors in good lighting, using a purchased 20' distance eye chart, my RE is 20/15 calculated by reading the 20/20 line letters from 27 feet away & LE is 20/12 calculated from reading the 20/16 line letters from 28 feet away. Binocularly, outdoors in daylight, I get to 20/10 tested by being able to read the 20/20 letters of that same chart from 40' or the 20/16 letters from 37' away. Also in daylight, I can read the smallest text on a Jaeger reading test sheet no problem. It doesn't actually have to be outdoors as sunlight coming in through a window causes the same effect. I can hold the Jaeger test sheet at 14" or so and struggle reading the smallest print but if I swivel my chair around to face the window with sunlight coming in it becomes easy to read the smallest print. There's a lab study that compares the ICB00 and ZCB00 that predicts a myopic shift with 2mm pupil size and hyperopic shift with 4.5mm pupil size. I think I get both the myopic shift and a pinhole effect in daylight and that why I get both great distance vision good reading vision.
Being on the plus side does not normally help distance vision though because 0.00 or plano is as good as it gets. Keep in mind that 20' focal point (20/20) is -0.16D though. It needs to be confirmed if others experience a myopic shift with Eyhance and 2mm pupil size. Some doctors will target +0.25 when the patient needs really good distance vision or to overcome night myopia for example. Being on the plus side does impact near vision though as you've mentioned. Indoors and dim lighting, for me it's often +1.00 for computer, +1.50 for kitchen tasks etc. & phone reading when I don't want to make do without and +2.5 for reading in bed. I've ordered progressives for when I need help to see if they simplify things for me. Hopefully they'll be almost universal "readers" for me.
Myope_PSC's nice explanation of an Eyhance defocus curve that shifts nearly 1D hyperopic as pupil size increases from 2mm to 5mm is consistent with what I'm seeing from one IOL eye at -0.9D. Great distance vision at night but the small print on the phone hard to read, even at 16 inches. In bright sunlight facing north (away from the sun in the US,) I can see 20/20 or better. Driving south, east or west during a bright day when my pupils are at their smallest, I'll struggle to read small faraway signs a bit, vision falls to maybe 20/30. Indoors with sun coming in a large bank of windows, I can see well at 16 inches and functionally at 12 inches and about 20/20 at distance. A cloudy day reduces the functional window vision to about 16 inches. I struggle more than expected at work in dimly lit computer labs with lots of students working on screens asking for help. I figured that computer monitor vision would be strong but it’s not very good without excellent lighting. A hyperopic shift in the defocus curve would explain why intermediate vision falls off rapidly in dim light, despite focusing at -0.9D. Perhaps progressives would help. It’s hard to distinguish the effects of dim light from a defocus curve shift. I’d be interested in how they design experiments to separate the effects. The unexpectedly superb night distance vision I experience with a -0.9D Eyhance would suggest a hyperopic-shifting defocus curve with increasing pupil size is real. My distance vision is also slow to focus and that may be the pinhole effect Myope_PSC mentions. I’d hoped my slow-to-focus vision would clear up when I get the other IOL. If it is the pinhole effect, it may be difficult to adapt and utilize it for driving but perhaps it will be more useful for reading. Anyway, the hyperopic shift as the light gets dim seems to mostly work for me., except in my work environment. I’ll use sunglasses when my pupils are small anyway so putting in an extra -1D helper lens won’t be a nuisance. I’d like to avoid carrying readers everywhere and putting them on / taking them off dozens of times each day when I’d like to see near/intermediate in mediocre light. Not sure if I’ll be able to read screens in lower light even if I target -1.25D to -1.4D in my other eye though.
While the cylinder and axis numbers might be easy for the optometrist to obtain, the sphere may depend on your pupil size and eliminating the pinhole effect. The sphere would seemingly change as the defocus curve shifts for dark sunglasses vs clear lenses and bright sun vs low light. Dark sunglasses and low-light indoor glasses might need a bit less minus power since the pupil is larger.
The way my manual lensometry refractions have been performed, the pinhole effect would be tough to eliminate. J&J recommends a "max-plus" refraction that starts fuzzy on the plus side then moves toward minus and stops when vision is good enough. This avoids over-correction on the minus side that would take away from near/intermediate vision. It might under-correct if pinhole vision is used.
I agree. For me, my "real world" prescription has less "plus" than what it is in the optometrists chair. I also think that my small amount residual astigmatism goes away when I'm out in daylight with a very small pupil size. I just need non prescription sunglasses. Fortunately my optometrist is willing to accommodate. It took me a while to figure all this out. I was so puzzled by my first Rx because it made my distance vision worse than no glasses at all. As a previous myope, new glasses used to always mean better distance vision. The final Rx for me is a compromise but still permits 20/15 vision.
People that end up very near plano might not notice the shifts as much if they turn out to be common. The study I looked was a simulation so it might not be what actually happens with people or with the majority of people. Another study mentioned the lab study and didn't get the same results. It's good to be aware of the possibility of it occurring though.