By David F. Chang MD
If you have cataracts, you are considering surgery because your cataracts prevent you from seeing well even with corrective eyeglasses. After cataract surgery, you should be able to see well at far, mid-range, and near distances with new eyeglasses (assuming no other eye health problems). The decision about which type of artificial lens implant to have will affect your ability to see without eyeglasses following cataract surgery. There are 3 categories of artificial lenses for cataract patients to choose from: single focus (monofocal), extended focus (greater range than a monofocal, but not as much as the multifocal), and multifocal (the PanOptix progressive trifocal, with many continuous focal points). They are all permanent and won’t need replacing.
Our eye is like a camera and must continually shift its focus from far to near and to various distances in-between. There are 4 primary distances at which we need to be able to see details.
Zone 1: Far distance (street signs, golf ball, distant animals, theater stage)
Zone 2: Indoor distances (pictures on the kitchen wall, faces across the table, TV 8 feet away)
Zone 3: Arm’s length (dashboard, store shelves, stove, desktop computer, bathroom mirror)
Zone 4: Reading distance (magazine, cell phone, tablet device, medicine bottle label)
Young people have the best system – a flexible human lens that is constantly and automatically adjusting its shape to change focus. This is like having an “auto-focus” camera where you just point the camera (or eye) at something and the focus is automatically and instantly adjusted. With age, we all lose this convenience and end up with a “manual” focus camera—we must manually change the focus by switching between different pairs of eyeglasses for each distance that we need to see. Bifocals and trifocals are like having 2-3 different pairs of glasses combined into one frame. Progressive (“no line trifocal”) eyeglasses allow us to see all four zones by looking through different parts of our eyeglasses as though we had 4 different pairs of glasses stacked one above the other.
With the basic single focus (monofocal) artificial lens implant, you select which of the 4 zones you’d want to see optimally without any eyeglasses on. You then have the same eyeglass options as everyone else over the age of 50 to allow you to see the other zones (i.e., moving the focus farther away or closer up). This could mean separate distance, reading, and computer glasses; bifocals; trifocals; or progressives. You can also continue to wear contact lenses.
How do multifocal and extended focus lens implants differ?
Two types of premium lens implant options—the multifocal and the extended focus lens—are designed to reduce your dependence on glasses compared to if you had received a single focus lens implant. Extended focus lens implants provide greater focusing range due to increased “depth-of-focus.” Compared to the basic monofocal lens implant set for distance (zone 1), patients with the extended focus lens have noticeably better mid-range vision at arm’s length (zone 3), but still require reading glasses (zone 4).
The PanOptix trifocal lens implant is the newest generation multifocal lens implant and is designed to provide continuous focus across all 4 zones. This occurs naturally and automatically, without having to look through different parts of the artificial lens, so the mechanism is completely different than with wearing trifocal eyeglasses. The PanOptix is designed to be distance dominant, prioritizing having clear distance vision. Therefore, having good lighting is important in order to be able to read without eyeglasses. If the print is too small or the lighting is insufficient, you can always put on over-the-counter reading glasses to see better up close.
There may also be situations where very thin distance eyeglasses would boost your ability to see critical details in the far distance. For example, some patients have “glove compartment” eyeglasses for freeway driving at night, whereas daytime driving is fine without glasses. Naturally, there is some individual variability in the range of focus that each patient enjoys, depending on factors such as your age and the health of your retina. We therefore cannot promise to completely eliminate eyeglasses with any artificial lens implant. However, cataract patients receiving the PanOptix lens in both eyes will require eyeglasses less often than with any other current lens option. They typically only need inexpensive, over-the-counter reading glasses and don’t need to wear bifocals, trifocals, or progressive eyeglasses.
What if I have astigmatism?
Astigmatism is a natural blur or misfocus caused by an imperfect shape of the cornea at the front of the eye. Like nearsightedness, astigmatism isn’t a disease, but rather a natural misfocus that requires corrective eyeglasses for the clearest vision. Instead of placing the astigmatism correction into one’s spectacles, it can be incorporated into the artificial lens implant. The name of this built-in feature is “toric” and it can be incorporated into any of the 3 lens implant types (monofocal, extended focus, or PanOptix multifocal). A PanOptix lens containing astigmatism correction is called a toric PanOptix.
Will I see halos?
The PanOptix multifocal implant produces faint halos around a headlight at night as your pupil dilates. Patients typically report that they notice but can tolerate the halos while driving at night. They are rarely noticed during the daytime. The halos are not eliminated with night driving spectacles, but usually become much less distracting with time due to “neuro-adaptation.” Although most patients are not significantly bothered by these halos, there is always some small risk that certain individuals may struggle to adapt to them.
Is every cataract patient a candidate for the PanOptix lens implant?
Patients with the PanOptix lens in both eyes can generally do more without eyeglasses than those with any other lens implant. However, if only one eye needs cataract surgery, there is still a benefit to having the PanOptix, knowing that, the second eye should eventually need cataract surgery, and can receive the same lens at that time. Seeing well without eyeglasses requires that both eyes be perfectly healthy. Therefore, patients with glaucoma or retinal problems such as macular degeneration, macular pucker, or diabetic retinopathy are not good candidates for the PanOptix. We also don’t recommend multifocal lens implants in patients with a lazy eye or crossed eyes or who don’t see well out of both eyes. Finally, the PanOptix will not work well with an irregular cornea surface, which can occur with age, certain diseases, or a history of refractive surgery such as LASIK or RK.
Does the PanOptix lens implant increase the risk or recovery time of my surgery?
Your cataract surgery is performed the same way regardless of the type of lens implant selected. Therefore, the surgical risks are not increased or altered by using one type of lens or another. Postoperative physical restrictions are no different either because all of these lens implants go through the smallest incisions. You should always expect your vision in the operated eye to be temporarily blurry during the first week after surgery regardless of the type of artificial lens implant used. Most patients wait approximately one month before getting new prescription eyeglasses following cataract surgery. Patients with the PanOptix typically regain good natural outdoor and indoor vision in their operated eye by one week following surgery.
Does insurance cover the premium cost to upgrade to a PanOptix implant?
Unfortunately, it does not. Health insurance, including PPOs, HMOs, and Medicare, covers a cataract operation with a basic monofocal lens implant when the cataract is bad enough for surgery to be considered “medically necessary.” Patients may elect to have the more expensive PanOptix multifocal lens implant by paying the cost difference out of pocket. The additional fees are not covered by any insurance because the added convenience of reducing your dependence on eyeglasses is not considered “medically necessary.” We ask that you pay this premium out-of-pocket fee in advance. Rarely, unexpected situations might arise during surgery where we determine that a PanOptix lens implant might not be as stable in your particular eye due to the condition of the lens capsule. We would implant a basic single focus lens implant in this situation, and the extra premium fee will be refunded.
Can patients without cataracts have the PanOptix?
People over the age of 50 wearing strong prescription glasses but with no other eye problems may elect to have multifocal lens implants in order to see much better without glasses. Health insurance covers none of the costs, however, if there is no cataract present. Because the natural lens must still be removed before implanting the PanOptix, the procedure is performed in the same way as cataract surgery. Thus, patients electing to have lens implant surgery to reduce their need for glasses will never have to worry about developing cataracts later on in life.
Who might need a LASIK “enhancement” after a PanOptix implant?
Like contact lenses or prescription eyeglasses, every artificial lens implant model (monofocal or multifocal) is manufactured in more than 50 different powers to meet the individual requirements of our entire population. As with prescription eyeglasses or contact lenses, your eye will only see well in the distance if the appropriate artificial lens implant power is selected. To prescribe eyeglasses or contact lenses, we utilize trial and error to preview different lens powers placed in front of your eye. When you are asked, “which is better, one or two?” you are selecting the lens power that you see best with in the distance. However, because the artificial lens implant is inserted inside the eye only after your natural lens (cataract) has been removed, it is impossible for you to “try out” different powers before surgery. Artificial lenses come in power steps of 0.5 diopters, while glasses come in steps of 0.25 diopters. Furthermore, once it is implanted, we cannot easily exchange the lens implant the way we could with contact lenses or eyeglasses.
Fortunately, an appropriate lens implant power can be estimated using mathematical formulas that utilize preoperative measurements of your eye’s dimensions. Although the measurements are very accurate, we must estimate some individual variables that prevent this process from being 100% perfect. One variable is the final precise position where the implant will end up inside your eye. Another individual variable that may reduce your ability to see without glasses is astigmatism, which is a naturally occurring imperfection in the optical shape of your cornea. The overall process is accurate enough so that most PanOptix patients will see well without glasses in the distance. For example, if perfect 20/20 distance vision is an “A”, you could end up with an “A” or you might end up with “B+” distance vision without glasses. With the latter, you could then choose to wear thin prescription glasses to get your distance vision to an “A” for those occasional tasks that require more precise or critical far distance focus, such as night driving.
Despite flawless surgery, some patients with lens implants are still not able to see as well in the distance without glasses as they would like. This unpredictability is understandable because we are dealing with a human organ and each individual’s unique healing process. What can be done if this is because the lens power is “off”? One option is to wear glasses or contact lenses as needed. A theoretical solution might be to exchange the PanOptix implant for another with a different power. However, it may be more precise to instead “enhance” or fine-tune any residual prescription with an external laser procedure on the cornea, such as LASIK or PRK. LASIK can also correct any remaining astigmatism coming from your cornea. The odds that this would need to be done with a PanOptix are usually less than 5%, but the chances are greater in patients with a lot of astigmatism or who are wearing very strong prescription glasses to begin with. The need will also depend upon how much better one wants to see without glasses. However, because there would be an additional cost and procedure involved, you should know about this possibility in advance before making your decision to have a PanOptix lens implant.
What do you recommend I do?
Whether to invest the extra costs to reduce your need for eyeglasses or contacts is a personal decision that does not involve eye health or surgical safety. Start by evaluating how often you wear your eyeglasses, and how strong your desire is to see as well as possible without them. Different individuals may value such convenience quite differently. Our role, as your eye surgeon, is to explain your options to you. We have extensive experience with all types of lens implants and frequently lecture to other eye surgeons on this subject.
No current technology will guarantee that you’ll never need eyeglasses, and how well you perform with PanOptix lens implants can vary because of individual factors. Nevertheless, they are an excellent option for patients who need cataract surgery and want to decrease their reliance upon eyeglasses as much as possible. Although this is an expensive option, you will be looking through the lens implant you select during every waking minute for the rest of your life. You will never need to replace the lens, and unlike expensive hearing aids, they cannot fall out and get lost!