I am someone who struggles to decide between lobster and filet mignon at a nice restaurant. Having surf and turf as a menu option solves my dilemma. The same principle appeals to many of my advanced technology refractive IOL patients. Let me explain why.

PARALYSIS BY ANALYSIS

An intelligent patient in her 60s returned for a cataract surgery evaluation 3 years after she had been scheduled for surgery with a Clareon Vivity IOL (Alcon). Out of curiosity, I asked why she had canceled and delayed surgery for so long despite her poor vision. She explained that she simply could not decide which IOL she wanted. This anecdote highlights the angst and anxiety many patients experience when trying to determine which IOL is best for them.

Without an accommodating IOL, no available lens provides complete spectacle independence without optical side effects. With more designs than ever before, IOL selection has become increasingly complex for both patients and ophthalmologists. The permanence of the decision often makes patients fearful of choosing the wrong lens—a concern that becomes magnified by conversations with friends or online accounts of patients who regretted their choices.

THE BEST OF BOTH WORLDS

Patient satisfaction would be much higher—and IOL selection far simpler—if we had a lens that, when implanted bilaterally, provided excellent binocular distance and intermediate vision, good vision for driving at night, and the convenience of viewing a cell phone or reading in bed without glasses. Although this ideal IOL does not yet exist, we can reliably meet these objectives by combining a refractive EDOF IOL, such as the Vivity, in the dominant eye with a diffractive trifocal IOL, such as the PanOptix, in the nondominant eye.

Since the expansion of the Vivity’s power range last year, I have increasingly recommended this Vivity/PanOptix (VP) hybrid approach as the primary strategy for many patients. I have found that this combination consistently delivers excellent binocular distance and intermediate vision and allows patients to perform most near tasks under adequate lighting. I inform them that they will need to wear inexpensive, over-the-counter readers for extended reading and demanding near tasks such as sewing.

EXPLAINING THE OPTION TO PATIENTS

I explain to patients that the Vivity’s strength is its excellent night vision performance, whereas the PanOptix offers better near vision—such as for seeing a cell phone. The VP hybrid approach therefore offers the best of both worlds. I reassure patients that, because we are targeting the same distance and intermediate vision in each eye, they will not feel imbalanced or need time to adapt, as is often the case with pseudophakic monovision. When I describe this approach as being like ordering surf and turf, patients invariably smile and appreciate that they are receiving the distinct benefits of both premium options—a positive rather than a compromise.

Beyond the optical benefits, I have been impressed by how much easier the VP hybrid recommendation makes the IOL selection decision for patients. The surf and turf proposal is often immediately met with an enthusiastic response such as, “I really like that idea” or “That sounds really great.” This stands in stark contrast to the hesitation and indecision that often accompany a patient’s choice between an EDOF and multifocal IOL alone, when they say things such as, “You’ve given me a lot to think about” or “I need to do more research before deciding.”

IMPLEMENTING THE VP HYBRID STRATEGY

I recommend implanting the PanOptix lens in the nondominant eye to make it easier for the brain to suppress the rings around lights at night. I determine which eye to operate on first based on the patient’s priorities. For example, someone whose chief complaint is night driving glare due to a cortical cataract would undergo surgery with the Vivity in their dominant eye first. In contrast, someone with nuclear sclerosis who is benefiting from the incidental convenience of lenticular myopia might first receive the PanOptix in their nondominant eye. Regardless, I explain to patients that they are essentially test-driving one lens first and that some patients choose the same IOL for their second eye because they like it so much.

Another approach is to implant a Vivity lens targeted for distance in the first eye and targeted for slight myopia in the second eye to enhance near visual function. For this strategy to be successful, the outcome in the distance eye must be close to if not at plano. Thanks to binocular summation, the VP hybrid approach should provide superior distance vision and will be much more forgiving if the first eye ends up with some residual refractive error.

FROM BACKUP PLAN TO PREFERRED STRATEGY

For patients who are bothered by the PanOptix halos in their first eye, I have regularly offered a Vivity for their second eye. Similarly, for patients who are disappointed by their lack of near vision with the Vivity, I have often offered the PanOptix for their second eye. These clinical experiences gave me the confidence to begin routinely offering the VP hybrid as the primary strategy. Patients view receiving different IOLs positively when it is the intended approach. In contrast, when they expect to have the same IOL bilaterally, receiving a different IOL in their second eye is perceived as an unexpected deviation from the norm because something did not go as planned with the first eye.

With the VP hybrid plan, once patients experience the limitations of their first IOL postoperatively, they already expect the second, complementary platform to enhance their visual performance. I find that this reduces their postoperative concerns, complaints, indecision, and anxiety. Most patients continue with the hybrid strategy for their second eye as originally planned. When they do not, it is because they are thrilled with the outcome in the first eye, so no one is disappointed.

REDUCING INDECISION AND IMPROVING SATISFACTION

For appropriate candidates, I now use the VP hybrid approach more frequently than bilateral PanOptix implantation. Many patients who previously would have selected bilateral Vivity IOL implantation owing to concerns about nighttime halos now choose the hybrid strategy as well.

Because both lenses are produced by the same manufacturer, they share the same material, chromophore, index of refraction, and A-constant. For a large percentage of my patient population, the VP hybrid approach has improved satisfaction, reduced anxiety and postoperative complaints, and—as with surf and turf—notably lessened their preoperative indecision over which IOL platform to choose.