It’s been almost 18 months since Alcon altered the presbyopia-correcting IOL market with the AcrySof IQ Vivity IOL. NSW ophthalmologist DR ARMAND BOROVIK discusses how the lens fits into his armamentarium today and real-world insights from an international registry.
It was at an overseas ophthalmology conference in 2019 when NSW cataract, corneal and refractive surgeon Dr Armand Borovik first got wind of the AcrySof IQ Vivity IOL, touted as a ground-breaking presbyopia-correcting intraocular lens (PC-IOL) from Alcon with a monofocal-like visual disturbance profile.
Borovik knows “there’s no free lunch in optics”, but to him Vivity and its wavefront-shaping technology presented a clear advance in the premium IOL category by offering excellent distance, intermediate and functional near vision. Importantly, the majority of patients had reported being unbothered by starbursts, haloes and glare: it was the type of PC-IOL many surgeons had been waiting for.
When the lens first became available in Australia in 2021, it was described as a first-of-its-kind, non-diffractive extended depth of focus IOL underpinned by Alcon’s proprietary non-diffractive X-WAVE technology, which stretches and shifts light without splitting it.1-3
Borovik, who practises privately at Southern Ophthalmology/Lasersight located in Kogarah, Miranda and Wollongong, made it a priority to gain early access to the lens once it became available in Australia. He realised the disruptive technology could fill a gap for eye surgeons seeking a PC-IOL for patients who weren’t suitable for a diffractive IOL, but desire some spectacle independence.
Today, the Vivity IOL is implanted in more than 90% of his private patients – achieving increasingly better outcomes as he has refined his technique.
It’s a far cry from 2017, when Borovik started out in private practice after completing his fellowship in Toronto. Back then, there were plenty of PC-IOL options available, but he was surprised to see how few ophthalmologists implanted them.
“I came into it cautiously because people were concerned PC-IOLs led to side effects and unhappy patients, but I think that’s the case in only a small percentage of patients. Our lives are on our phones, screens and beyond now, so I think we’re doing patients a disservice if we don’t utilise some of the great presbyopia-correcting technology at our disposal, and leave them with spectacle dependence for tasks they perform regularly,” Borovik explains.
“As my practice has evolved, I started out using a mix of predominantly monofocals then multifocals. The patients were generally very happy, but there were some who were unhappy for no good reason with traditional diffractive multifocal-style lenses – and it doesn’t take many unhappy patients for you to change and seek a different solution – and that’s when Vivity entered the equation.”
After speaking with Alcon, Borovik became an early-adopter of Vivity in Australia. In addition, he joined Southern Ophthalmology colleague Dr Alan Flax in becoming an investigator in a global registry analysing the real-world performance of Vivity in 757 patients from Australia, New Zealand, the UK and Europe.
They presented their sub-analysis at the Australian Society of Cataract and Refractive Surgeons Conference in 2022, focusing on post-operative assessments at three and six months. They measured: binocular uncorrected visual acuity (UCVA) at distance, intermediate (66 cm), and near (40 cm), patient-reported spectacle independence, patient-reported satisfaction, and patient-reported visual disturbances.4,5
They found patients demonstrated good binocular UCVA, with a mean UCVA (± SD) of 0.016 logMAR (6/6) for distance, 0.088 logMAR (6/7.5) for intermediate and 0.253 logMAR for near (6/9.6). Further, more than 80% of patients reported never or rarely needing glasses to see at intermediate or distance.4,5
Most patients reported no haloes (92.3%), glare (93.1%) or starbursts (95.5%) at three to six months, as well. 4,5
Ultimately, their study found patients had good UCVA outcomes from distance to functional near, high rates of spectacle independence for intermediate and distance, high levels of patient satisfaction, and low occurrence of visual disturbances.4,5
Real world use
For Borovik, the findings represented a major step forward in PC-IOLs where previously there had always been a trade-off for achieving an extended range of vision.
“Those trade-offs were always glare and haloes around lights – and in the right patient I still use multifocal IOLs today, but if someone is happy to not have as much near vision up-close at 30-40 cm – which is the majority of my patients because they can still function without glasses in their day-to-day life – then Vivity is a great option in that regard,” he says.
“It works differently. Because it doesn’t split light it tends not to have the same side effects of traditional PC-IOLs, and that was translated in the registry data (cited above). The vast majority of patients are very satisfied and it suits their needs nicely with very few side effects – even in patients I’ve seen two years post-surgery.”
As a result, Vivity has become “an easy go-to lens” in Borovik’s private clinic.
“I call it the refractive lens for non-refractive cataract surgeons because it’s easy to use. I think what stops people from using a multifocal lens is the fear of having to deal with an unhappy patient, which is understandable, but Vivity is much more forgiving. That’s why I suspect Alcon has had so much success with it,” he says.
“There’s a few factors to that, including counselling. The patient knows what to expect with their vision afterwards. I inform them they’re going to need reading glasses and if they’re not happy with that, then we’ll look at another option, or I’ll consider implanting the Vivity in their non-dominant eye for some residual myopia; the nice thing about that is you don’t need as much residual myopia as with traditional monovision, so it works well for most of our patients.”
For Borovik, his refractive outcomes have become more predictable as he has made refinements to his approach with Vivity. When the lens first came out, he recalls concerns about some patients not achieving 6/6, but he believes that has decreased over time.
“That’s likely due to patient selection, but also a refinement of the refractive target. We worked out that we need to aim for slight hyperopia to maximise their distance vision. I like to target a slight plus in their dominant eye and the first minus in their non-dominant eye to maximise both far distance and near vision, otherwise patients can be left with some residual myopia, which they’re not happy with in their dominant eye.”
While Vivity is a versatile lens, Borovik says there are some outliers and pathologies that he realised required more caution as he has grown more familiar with the lens.
These include people with co-existing corneal pathology, like scars, keratoconus or Fuchs’ endothelial dystrophy, but it ultimately comes down to each case.
“There’s no free lunches – it’s still premium optics and the modulation transfer function is not the same as a monofocal so they may lose some quality of vision. Anecdotally in my practice, I haven’t had anyone with a bad experience, but some [of these corneal pathology patients] haven’t quite achieved outcomes as good as their visual potential may have been with monofocal optics,” Borovik says.
“In saying that, in patients where I’m performing a combined cataract and DMEK (descemet membrane endothelial keratoplasty), Vivity is still my go-to because I know their endothelial will normalise once their cornea recovers.”
Greater uptake
Innovations like the Vivity IOL are also driving greater use and access to premium IOL technology. Patients are becoming more aware, and more surgeons that were once apprehensive about PC-IOLs due to visual disturbances are beginning to embrace the technology.
This is something Borovik has witnessed first-hand. What’s more, is the relatively small learning curve for surgeons familiar with Alcon’s platforms.
“There’s almost no learning curve. The lens is akin to an AcrySof IQ lens (model SN60WF) with a central elevated plateau in the centre. This is something that is very familiar to most ophthalmologists – and the surgery is no different in that regard,” he adds.
“Some colleagues in my practice had never implanted a PC-IOL, but after talking to me about Vivity and seeing how straightforward it is to look after patients and how happy they generally are, they’ve started using Vivity as their go-to lens as well. They haven’t turned back.”
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