PIE or Lasik – that is the burning question question for people above 45 years of age.
This article will define the two procedures, discuss benefits of each, look at advantages and disadvantages of PIE and Lasik and finally will help you discover which is the best procedure for people who have spens more than 4-5 decades on earth.
Most people are familiar with Lasik eye surgery. Lasik is a method of vision correction surgery using laser technology to reshape the eye. Lasik on the hand is a corneal procedure and there is no entry into the eye. So it can be done in a Lasik suite. The recommended age is above 18 years. The corneal shape and thickness distribution has to be normal as well as sufficient for the treatment. IF there is shortage of tissue superlasik or superficial Lasik may be considered. ICL or Implantable collamer lens may be the only option in severe nearsightedness. All these three procedures are static or monofocal procedures. That is they set the power of the eye to a set distance usually infinity. If the eye can change the shape and power of the natural lens than the eye can see middle and near. That means it works well for people under forty-five years of age. Therefore, these are the procedures of choice in the age group 18 to 45 years of age.
The story changes above 45. Only a handful of people would qualify for Lasik eye surgery. These would be the low hyperopes or people wanting blend vision. Of course, they should not be susceptible for dry eyes.
PIE is a newer technology. PIE is short for presbyopia implant in eye. This is a short painless procedure where the contents of the natural lens are exchanged for a manmade plastic lens. The procedure is performed under sterile conditions in an ambulatory surgery center. The implant is made of acrylic or silicone which are very well tolerated by the eye. So naturally this question gets posed very often “Doc which is the better option for me – Lasik or PIE?” For the rest PIE is the best. It allows a person to see at different distances with each eye. Once the procedure is done in both eyes it yields natural binocular vision. And wait there is more. This is a permanent procedure. The patient undergoing PIE will never develop cataracts. PIE does not induce dry eyes. It is also superior to monovision.
Few surgeons are adept with the nuances of this method of permanent vision procedure called PIE. Hence you may not have come across much info till now. Rest assured if you were born before 1975 this is the procedure of choice for you.
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Welcome to Panoptix trifocal lens the latest strategy to reverse presbyopia.
FDA gave approval in the last week of August 2019 to Alcon’s Panoptix trifocal technology. We are excited to welcome another option to the family of PIE (presbyopia Implant in eye). We will explore the nuances of this lens, the lens material, the unique optical design and finally patient satisfaction in clinical and international trials.
Construction of Panoptix trifocal lens
This is a single piece biconvex lens with a central optic made of a high refractive index hydrophobic acrylic material capable of being folded without damage prior to insertion through a smaller wound. The central 6.0 mm optic has two haptics on either end giving an overall lens diameter of 13 mm. In the central 4.5 mm of the optic there is a diffractive portion which divides the light to create +2.17D Intermediate (+1.65D at cornea) and +3.25 D Near (+2.35D at Cornea) add power. Front surface of the lens has negative spherical aberrations to counteract the positive ones generated from the cornea.
Panoptix Toric trifocal lens to correct astigmatism and presbyopia
Panoptix toric has a posterior toric surface marked by 3 dots on each side of the flat axis. If it rotates from intended axis it loses effect. If rotation is more than 30 degrees, it may make astigmatism worse.
Multifocal lenses are defined as having more than one focus. They can have two in the traditional multifocal like tecnis and restor. Trifocals have three foci. Finally quadrifocal have four foci. Panoptix is actually a quadrifocal lens which has been modified to behave like a trifocal to improve distance vision.
If you are interested in physics and optics you can read on otherwise skip this paragraph. In a trifocal there are three points of foci. The distance is set at infinity. The intermediate add should be twice the focal length of the near. If near is at 40 cm than intermediate focus will be at 80 cm. In a quadrifocal we have distance still set up at infinity. The second add is at 1.5 times the near add and the third add is at 3 times the near. So if 1st add is 40 cm 2nd will be 60 and third at 120 cm.
In Panoptix a special enlighten proprietary technology shifts this extended intermediary focus towards infinity or distance. This improves the distance vision.
ENLIGHTEN ™ Optical Technology
Panoptix lens is built on the acrysof platform of Alcon. More than a million acrysof lens have been implanted. This time tested platform produces glistening’s. These glistening’s can affect vision in some patients.
We will be soon be comparing advantages and disadvantages of panoptix with restor, tecnis multifocal, symfony toric and crystalens.
I can remember the day a young single woman in her forties told me why she hated her readers so much. She said her dates considered her to be in her thirties till her readers came up to check out the menu. Since then and after speaking with many youthful looking individuals, I realized that wearing readers is a true nuisance. As we stress on physical activity and good diets, we are able to keep our bodies younger for a longer amount of time but the eyes seem to be from a different world. People also hate to carry around the readers or hang them from their necks. If they forget them on a trip or the glasses break, it can affect the working day especially for a pilot.
What have the other options been for these people till now?
Let’s consider multifocal glasses termed bifocal, trifocal and progressives. Bifocals have two foci distance and near, trifocal has an additional for near while progressives have multiple foci. The first deficiency like of any eye wear is the limitation of peripheral visual field. This can vary from a nuisance of turning your head to see in periphery to difficulty performing critical tasks like driving. During rainfall or in foggy conditions these can create a real problem and you may as well forget about water activities.
Are progressives really safe? This might seem like a joke but there are people with progressives who get so tired adjusting their head and shoulders to see better that they develop neck and shoulder problems that can require physical rehabilitation. A few might even become susceptible to depression.
Contact lenses can be used to create monovision. We have discussed that elsewhere, so now we can restrict our discussion to multifocal contact lenses. These are soft contact lenses which have alternating rings for distance and near zones. In the center is a primary viewing zone. This is usually for distance (called a center-distance design), but in some model’s center-near designs also are available. These latter are more often used in non-dominant eyes and with large pupils.
The near add power, this can be low, mid or high power. They differ than PIE as they are refractive lenses and not diffractive lenses. Refractive PIE implants have been abandoned.
Why do multifocal contact lenses do not work? With each blink the lenses move. We know even a few microns movement of pie can affect vision. Now imagine constant movements with every blink, and a different amount of movement each time. That means a different version of the world every few seconds. Neuroadaptaion in such circumstances is very difficult. Less than 30% of people can adapt. That may seem like a big number but remember very few people can tolerate contact lenses in that age group. Brain reacts to this by “Killing me slowly with your winks”.
Like any contact lenses, they are difficult to wear especially with dry eyes, hand tremors, small eyes and the like. There is always the chance of scratching or an eye infection.
PIE eliminates the movement aspect and is designed as a diffractive lens which continues to improve with time. Once implanted in sterile conditions, it is immune from infections. It does not cause dry eyes and works in even in amnesiacs who forget where they have placed their glasses or contact lenses.
There are many advantages of PIE surgery when compared to Cataract Eye Surgery. We will enumerate the superiority of PIE Procedure over Cataract Eye Surgery.
Cataract eye surgery, believe it or not, was invented in India over 2000 years ago by a surgeon named Susruta. His concept was to let the cataract mature till the patient could not see at all. He than performed a procedure called needling which pushed the cataract back. Whatever the patient could see was considered a blessing. Over the centuries the techniques and skills of cataract surgery have evolved but the basic concept remains the same, that is remove the cataract and accept whatever the result.
PIE or presbyopia implant in eye is a paradigm shift in this thinking. Almost like how theory of relativity jolted our concepts. PIE is goal directed surgery. We define the goals or outcomes before we begin the journey. The patient and surgeon decide which zones of vision would be of utmost importance. The patient shares history of previous surgeries, current diseases and medications with the surgical team. The surgeon than does a state of the art eye exam including three dimensional scans of macula, cornea and optic nerve. The PIE surgeon than needs to reflect on the combination of all this information obtained to set up a realistic goal, which has to be achieved.
We can turn to football to understand the difference better. Cataract is like the quarterback throwing a ball. The direction and distance is not guaranteed. His job was to throw the ball and that was it. In PIE the quarterback has to throw to score a touchdown. Most of the times it will be on the first attempt. Sometimes it will be a little short of the touchdown line and the wide receiver has to catch and take it across. In every throw a touch down is essential.
Cataract surgery is only performed when the cataract is advanced that it interferes in daily work. The doctor has to determine if the cataract is ready for surgery. Further the insurance guidelines have to met and in the case of HMO someone has to approve it. A person above forty five is free to choose PIE whenever he so desires. The doctor and patient make the decision. There are no middleman. So a person does not have to suffer with deteriorating vision
Cataract Surgery is a term encompassing various techniques. The entire lens could be removed or some parts could be left behind. Injections, sutures and patches might be employed. Of, course after the procedure the patient needs some type of glasses. PIE involves a very specific technique. There are no injections, no pain, no patches and no sutures. A presbyopia implant has to be placed well centered in a pristine position. After the successful procedure person should meet the predetermined goals of seeing at various distances without glasses.
PIE has evolved from combination of cataract and lasik eye surgery. It utilizes principles of astigmatism and power correction of lasik eye surgery and applies them to an evolved from cataract surgery.
Presbyopia implant in eye has been the new revolution in vision restoration. It has eclipsed Lasik as the number one choice to improve vision in people over age fifty years.
A good tailor as well as a good surgeon knows that one size does not fit all. This holds true even with PIE. There are four classes of FDA approved PIE. These are Accommodative, extended depth of field (EDOF), Trifocal and Multifocal.
Accommodative PIE: This class of PIE were the first to be approved by FDA in 2005. They heralded the advent of PIE. Crystalens was the first out of the stable. It had various modifications till it evolved int Crystalens HD. Today we have Crystalens AO and Trulign. They are made of silicone. Crystalens AO has aspheric optics whereas Trulign has aspheric optics and built in astigmatism correction. They work by assuming a curved shape in the eye, increasing the range of focus. This shape and the unique design of the lens may also allow it to move forward and backward mimicking the natural lens. This lens has proved very useful in patients who have had previous eye surgery like lasik vision correction, radial keratotomy and other corneal procedures.
Extended Depth Of Field (EDOF)PIE: They are in a class of their own. They resemble multifocal PIE in appearance but function on a different optic principle. They increase the natural depth of field. It provides a continuous field of vision, though the range is not as extreme as in multifocal. Symfony and Symfony toric are the two contenders here. As you may have guessed from the names, sympfony toric can also correct astigmatism. Hence, they find great use in eyes with astigmatism. Both also are used in eyes where crystalens may not be an option.
Trifocal PIE: These PIE have apodaizations or rings in their center. The unique heights of the rings of this lens allow the incoming light to be split into three foci. One for distance, second for intermediate and third for near. Optical engineers can modulate the height of rings and distance between rings to design varying focal length for each zone. Currently we have Panoptix and astigmatism correcting Panoptix toric.
Multifocal: These are the lenses which arrived earlier than trifocal. They are truly bifocal but were labelled multifocal to distinguish them from bifocal glasses and contact lenses. Their mechanism of action is totally different than bifocal glasses. In bifocal glasses the top segment is for distance and lower for near. These are refractive lenses. This method was tried in the previous century but was not successful. Multifocal PIE are diffractive in construction and have a focal length for distance and one for near with an overlap for middle. They allow more light for far and therefore better distance vision. Restor and Tecnis are the two lenses in this class.
A surgeon who is an PIE expert needs to be proficient in all these types of presbyopia implants. Matching the best PIE to the patients’ after understanding the goals of the patients is paramount to success. This can sometimes involve implanting a different class of PIE in each eye.
Superiority of PIE over Monovision can be demonstrated theoretically as well as recounted by various people.
We have two eyes. Each eye sees the world differently. The generated images are fused in the brain giving rise to binocular vision. This allows us to judge distances accurately. Binocular vision allows us to change lanes on either side, put thread in a needle and more tasks in our daily life. Top baseball and basketball players have been shown to have superior binocular vision. In youth this binocularity is available to us at all distances. As we hit the forties the near vision begins to deteriorate. This is due to the gradual linear failure of the autozoom mechanism of the natural lens. To restore the near binocular vision reading glasses or cheaters were invented.
Many people do not like to carry around readers. Some even hate wearing them. Around fifty years ago or someone came up with the idea to use contact lens to give reading ability to one eye while keeping the other eye for distance. This eliminated not only reading glasses but also binocularity. As no other option was available this method of monovision was replicated with lasik and even with cataract surgery. Sone surgeons have used newer implantable lenses like acrysof and softec HD to do monovision in people seeking refractive surgery.
Now we have newer technology where we don’t have to compromise on reading or binocular vision. Presbyopia implant in eye or PIE allow us to see at all distances with depth perception.
These new generation of presbyopia implants are a technological marvel compared to monofocal softec HD. Hence their cost price is over ten times of softec HD and other monofocal lenses.
There are many people who have had monovsion in the past and now selected PIE as an option to improve their life. They recount the benefits they had missed. They say it feels more natural and makes them more youthful. They don’t have to turn their head all the time while driving. Reading is less strainful. The biggest problem the monovison people have is if some foreign body enter their eye. This takes away the distance vision completely. It could be very dangerous if it were to happen while driving.
There are four varieties of PIE. They are accommodative, extended depth of field, trifocal and multifocal. They can be utilized to restore binocular near vision even if one is wearing monofocal contacts, multifocal contacts, or had undergone RK, lasik, PRK or other refractive surgery in the past.
Comparing and contrasting Presbyopia implants ReSTOR+2.5 D VS ReSTOR+3.0 D
ReSTOR®+2.5 D IOL
ReSTOR ® +2.5 D IOL with ACTIVEFOCUSTM optical layout for the patients with energetic lifestyles, such as those who
The ACTIVEFOCUS optical layout is crafted to take those patients’ distance vision a step further while offering the well balanced near as well as intermediate efficiency with the objective of reducing spectacle dependency for tasks like:
* Active-lifestyle individuals join activities that need intermediate as well as distance vision such as golf, tennis, home cleaning and also driving.
ACTIVEFOCUSTM Optical Design
Using sharp distance vision plus well balanced efficiency at near as well as intermediate focal points, the AcrySof® IQ ReSTOR®+2.5 D IOL features:
Light distribution at a 3.0 mm pupil aperture:
ReSTOR®+3.0 D Multifocal IOL
Ophthalmologists should recommend IQ ReSTOR ® +3.0 D IOL with a pupil-adaptive layout for their appropriate patients who desire:
Developed to minimize spectacle dependency in all distances for the broadest array of vision, this sophisticated IOL can aid your patients refocus on the activities they love:
Pupil-Adaptive Optic Design
Providing exceptional performance at whatsoever distances, the AcrySof ® IQ ReSTOR ® +3.0 D IOL includes a pupil-adaptive optical layout crafted to maximize efficiency in all lighting conditions with the following features:
ReSTOR ® +3.0 D IOL disperses light much more uniformly in between the near and distance focal points in photopic problems, preferring distance much more as the pupil broadens in mesopic problems.
Light distribution at a 3.0 mm pupil aperture:
AN APPROACH TO CHOOSING PRESBYOPIA CORRECTING IMPLANTS IN THE CONTEXT OF RESTOR 2.5 VS SYMFONY.
With reference to Presbyopia Correcting Implants, it is an accepted fact amongst ophthalmologists that extended depth of focus lenses have actually increased interest in presbyopia-correcting lenses for surgeons as well as patients. As this topic relates, these implants provide an extended focal range rather than 2 unique focal points as in a multifocal lens. Although optically the Tecnis Symfony uses a unique system, functionally the Tecnis Symfony works likewise to a low add multifocal in offering patients distance as well as intermediate vision.
However like any type of lens that prolongs beyond a single focal point, the EDOF Symfony does have its constraints. Despite an ideal emmetropic result, a couple of patients complained about “spiderweb” glare, specifically while driving at night. These complaints become much more common when there is residual refractive error. These implants are certainly much more flexible of residual refractive error than conventional high add multi-focals, however, Doctors have actually learned to avoid doing mini-monovision with them due to these undesirable visual phenomena.
Around 60% of cataract patients choose presbyopia-correcting lenses, and here’s an approach the eye surgeons actually found to be extremely rational based on data from several research studies they have actually performed on patient satisfaction.
Initially, we’ll just talk about patients who are good prospects for a multifocal or EDOF lens. They have healthy and balanced maculas, controllable completely dry eye as well as fairly aberration-free corneas.
If a patient has astigmatism more than 0.5 D and also desires distance and intermediate vision, the Symfony toric is a an option.
For patients who prefer distance, intermediate as well as near, I do not recommend targeting a mini-mono-vision with an EDOF Symfony lens. A lot of these patients do not tolerate the spider-webs in the non-dominant, near eye. With low astigmatism, it likewise makes sense to do this with a Tecnis multifocal 2.5/3.25 also.
Now lets look at Restor active focus. It is yellow in color. It also provides ability to correct astigmatism.Again we do not recommend monovision with these. We have tried mini monovision in patients who were aleready employing that strategy with contact lenses. Those pateints did well. A better option, these patients will certainly do well with a ReSTOR ActiveFocus 2.5 in the leading as well as a +3.0 ReSTOR in the non-dominant eye. Therefore, we can achieve goal of reducing spectacle dependence for activities like Driving and Dashboard viewing, Playing or watching live sports & attending theatre or performance events. While Tecnis SYMFONY IOL lessens the effects of presbyopia and enable the patients to see clearly.
|SYMFONY Tecnis Symfony is an extended depth of field lens. It works a low add multifocal in offering patients distance as well as intermediate vision. Patient’s complaints about “spiderweb” around lights, specifically while driving at night. Tecnis Symfony is certainly much more flexible of residual refractive error than conventional high add multifocals for patients who prefer distance and also intermediate (but not near) vision and if they have low astigmatism. Appropriate for patients who prefer distance, intermediate as well as some near vision. It has high refractive accuracy but can rotate.||ReSTOR ActiveFocus 2.5 While ReStOR works on those patients who have astigmatism more than 0.5 D With ReSTOR, patients have complaints of glare and also halos. They do not face “spiderweb” glare problems. They do well with a ReSTOR ActiveFocus 2.5 in the leading as well as a +3.0 ReSTOR in the non-dominant eye. ReSTOR one may have desire more opportunity for a range of vision versus monofocal. For patients who are not willing to compromise distance vision for a full range, ReSTOR is an appropriate answer. ResTOR is having more rotational stability for both eyes, again targeting emmetropia. This is important with toric lenses|
In the present scenario, multifocal intraocular lenses (MF IOLs) are the most stable,reliable and dependable method for the surgical correction of presbyopia. While looking at the facts, residual astigmatism is one of the leading causes of dissatisfaction after the implantation of a MF IOL.
These IOLs require emmetropia for the attainment of the best visual results, and small amounts of astigmatism that may limit visual performance significantly. Thus, astigmatism has to be completely corrected in order to obtain the maximum efficiency of a MF IOL. Hence, we like to correct astigmatism by various methods. If it is astigmatism with spherical equivalent of zero, we perform limbal relaxing incisions at the time of cataract surgery or during follow-up period. When there is associated myopia or hyperopia we deploy advanced wavefront idesign laser vision correction achieve emmetropia.
Today our topic of discussion will be Symfony or Tecnis Multifocal lens for Presbyopia Treatment.
Hi. I am Doctor Khanna, here with some models of intraocular lens implants when we do cataract surgery or we want to get rid of glasses and you are not a candidate for Lasik surgery. For example, if you are 56 years old and you want to be able to see far, middle and near, then you are up for presbyopic implants. There are different types of presbyopic implants. Today, we are going to talk about the differences between ‘Tecnis’ and ‘symfony’, which are both from Johnson and Johnson.
This is how the lenses look like. This is a clear lens and this is ‘Tecnis’ and ‘symfony’. ‘Symfony’ has less rings than ‘Tecnis’ and it is considered an EDOF (extended depth of field) lens. Whereas, ‘Tecnis’ has certain ridges, which splits the incoming light into distant and near. You can see distant and near and the bimodal curve, lets you see middle. ‘Symfony’ acts like a pin hole camera where you can see middle, distance and somewhat near.
How are you going to choose between the two? If you have long hands, then choose ‘Symfony’ but if you want to real closely then choose ‘Tecnis’. If you have had previous surgery like radial keratotomy then ‘symfony’ might be a better choice. In terms of side effects, ‘Tecnis’ has glare initially which faded away and ‘Symfony’ you can see a spider web. The best option is to discuss these various choices with your surgeon and to make sure that the surgeon is comfortable with the choices.
If you have more questions about Symfony or Tecnis Multifocal lens for Presbyopia Treatment call (310) 482 1240. You can always read my book on amazon ‘The Miracle of PI in Eye’.
Have a wonderful day.
While bidding adeu you may say Good riddance to contact lenses too.
Imagine getting up in the morning and looking at the alarm clock with your naked eyes. You then grab your smart phone to check on your email and the latest from your friends on face book. While eating breakfast you skim through the newspaper. Continuing the trend, you drive with no glasses to work and then go on to play golf. After playing the best golf of your life, you get a quick swim in which is a pleasure without glasses or contact. On way home you pick up groceries without squinting. Then you cut some organic veggies for a nice dinner. Catching up on bedtime reading, you wonder why you did not get this unbelievable rejuvenating therapy before.
How is that possible? But first why not talk about why you even need glasses for reading. or I think I may have presbyopia.
Presbyopia is medical jargon for ageing eyes.
What causes presbyopia?
There is increasing stiffening of natural lens and decreasing strength of eye muscles. The zoom mechanism of the natural lens undergoes deterioration.
Old is difficult to define. This condition is present in mid forties. It may appear a little earlier in farsighted people. People with smaller pupils may display a delay in onset of presbyopia.
We have a few choices to overcome this natural malady.
Pie is the creme de le creme of methods to rejuvenate ageing eyes. Let us explore how it is superior to other methods which combat effects of taking too many revolutions around the sun.
PIE is more advantageous than Glasses
Heck yeah. You agree with this or you would not be reading this page.
It’s safe to say PIE overcomes all these nuisances.
Pie gives binoucularity which is better than Monovision
This is a process of setting the focus of one eye on close-up objects and the focus for your other eye on far-away objects. In doing this, your brain combines the two images to create a clear picture. This is a relic from the twentieth century. Primary disadvantage is one looses binocular vision.
PIE allows you to preserve binocular depth of field vision.
Brain prefers PIE to multifocal contact lenses
Multifocal contacts move with every blink. The image presented to the brain fluctuates confusing it. That is why many people are not able to adapt to multifocal contact lenses.
PIE are stable and do not move. Brain neuroadapts improving vision.
Contact can lead to sight threatening cornea infections for as long as you wear them.
PIE is not exposed to the elements or bugs.
Types of PIE
Multifocal PIE let you see far and near
These include the ReZoom, ReSTOR, Symfony and Tecnis lenses. Multifocal IOLs are lenses that have concentric rings of varying focal power, like a bullseye. Some rings provide focus for near objects, others for mid-range objects, and some for seeing objects at a distance.
The Tecnis Multifocal Foldable IOL also has concentric rings for different distances. It received FDA approval in January, 2009 for use in cataract surgery, where the natural lens is replaced. In the clinical trials most participants achieved 20/25 distance vision or better and 20/32 or better for near vision. It is designed using Wavefront data – the same precise level of information that is gathered when you are having Wavefront LASIK.
Accommodating PIE implants mimic natural lens
These lenses are designed to change focus. An accommodating IOL allows you to see distant objects, and then is can change focus and allow you to see objects that are close up. The only accommodating IOL approved in the United States is the Crystalens. This was true in 2005 and is still true in 2014. We even have toric crystalens called trulign.
Wherever you live you will want to enjoy good vision. If you want to see near and far , please contact our
office today. Los Angeles ophthalmologist Dr. Khanna and his staff can help you find the new technology PIE that is best for your lifestyle and needs. Please call today to schedule your free vision screening so that you can see far and near and your computer too.
By Rajesh Khanna MD