In part 2 of this 3-part episode of The Spotlight Series Podcast, host Mario Nacinovich and Damien Gatinel, MD, PhD, of the Rothschild Foundation in Paris, discuss the first trifocal intraocular lens (IOL), FineVision. In this section of the podcast, the pair covers different outcomes patients can experience with the trifocal option and how FineVision compares to other IOLs.
Mario Nacinovich:
Well, we are definitely humbled by the fact that we have someone with your brilliance to be able to create this design and create this product, but then the true beneficiary is your actual patient. The other side of this magnificent story is the surgical outcomes and the experiences that you are able to see and realize and manifest in the FineVision trifocal IOL. It’s now been implanted in millions of patients globally.
Damien Gatinel, MD, PhD:
Oh yes.
Mario Nacinovich:
Now just approved in the U.S., soon to be introduced. From your clinical experience, what are the most notable patient-reported benefits? Are there any drawbacks?
Damien Gatinel, MD, PhD:
That reminds me of the first invitation. I didn’t do it because I would be biased, of course. It was made in Belgium, and the outcome was, for the first series of patients, very promising because they got this distance and near and we were focused on the intermediate, and the patients were like, of course it works as well. They didn’t understand why we were so focused on the intermediate vision, so it was very encouraging. Since then, the reports have been that first compared to bifocal, there was no extra problem that’s been confirmed using halometry, questionnaires, etc. Again, the selection of patients is important as for any lenses, because of course you need a functional retina, no ocular complication comorbidities like a glaucoma or a retinopathy, everything. Once the eye is just checked and suitable with multifocal IOL implantation, the best indication will work again in patient really wants spectacular independence, and halos can happen of course, by design.
The point is that if you explain to the patient that they will have halos and that halo is a sign that the lens is different because it brings extra foci that will make them spectacle independent, they’re very inclined to accept it, especially when they have cataracts, because cataracts are way worse than any multifocal lens. When you think about it, when you have a cataract in the eye, it absorbs light. It reflexes. It scatters light in a useless way. When you replace those lenses by a nice optical structure that will split light adequately so that it optimizes, etc., the patient will be happy. They will notice maybe sometimes circular halos, geometrical halos, but they would tell you, and that’s of course important that they can still drive at night, that they can function very nicely. My mom has been implanted with the FineVision lens. She had a real cataract because unfortunately she was scheduled just before COVID happened, and so she was postponed for 2, 3 years. She didn’t want to take the risk to go to the hospital, so her vision dropped.
When she got the cataract surgery, she was so happy that not only she would see better, but she would be spectacle free. I asked her, “Mom, did you see halos?” She says, “No.” And, “Are you sure?” She said, “No.” I showed her a light and she, “Oh, I see this circle.” But she told me before I had big halos at night, which were foggy, and I couldn’t really function well. Now my vision is dramatically improved, and I don’t feel any problem with this. What you need to do to maximize success is again to target zero or slightly plus because if you are on the minus side postoperatively, you may have issues with distance vision. But again, most patients are happy and the clinical studies have shown that patients really would have the lens. Again, what is important also is to have colleagues of ophthalmology surgeons across the world who had cataract and some decided to get the FineVision in their eyes and just go and interview them. They are very happy and…
Mario Nacinovich:
Still performing surgery.
Damien Gatinel, MD, PhD:
They still do surgery, of course, and they recommend the lens, of course. That’s to me the best evidence that this works. Again, if you do proper lens surgery, if you do proper patient selection in patients who really are good candidates, motivated for spectacle independence, this is the lens to use.
Mario Nacinovich:
For the surgeons in the listening audience, are there any typical considerations, tips, techniques for implanting trifocal IOLs versus traditional monofocal, bifocal lenses? Anything that changes?
Damien Gatinel, MD, PhD:
I would say that for those who are fearing to use multifocal lenses because they don’t have the experience, what they should consider is what I said. In patients where there is a real cataract, especially a nuclear one where patient usually lose visual quality, but because of in this myopia, nuclear sclerosis, they can read again because the crystalline lens behave like a bit of a multifocal lens, but not a good one, right? Not transparent. You can use a trifocal lens in those eyes. The patient will say thank you because they’ve been used to this near, which is not so good. They lost a lot of distance. By doing the surgery with the trifocal lens, you will improve the distance, intermediate, and the near, which will be clear, vivid, no color spectrum amputation, especially in blue vision, etc. They will see better colors and they will be very happy.
My advice for the surgery is to do it of course in a perfect way, avoid complications, and make of course intra-capsular implantation. Those lenses do not work well in circus. In case of complication, maybe you should maybe reconsider the lens choice and put them monofocal depending on the situation. But again, when the surgery, that’s something I tell my patient, it’s a tip, like I tell the patient, you will have this lens only if the surgery is perfect, which means that, and most of the time it is, so not only the patient feels that he’s going to get this lens, but also that the surgery was perfect because he got the lens. All right? That’s a little tip to give. Also if you have a problem, the patient will not be as disappointed as if you didn’t warn this that the lens…
Mario Nacinovich:
Management of expectations is important.
Damien Gatinel, MD, PhD:
Yeah. You have to manage expectation. I would say also that you need to tell the patient that those lenses work but not in a dark. They will be able to read at a restaurant, but if the restaurant is very dim using a little help or putting close to the…
Mario Nacinovich:
iPhone light.
Damien Gatinel, MD, PhD:
Yeah. iPhone or even the candlelight will make them maybe able to read. But there is the minimum light level to read as with any other lens. That’s again also important. It is also important to explain that IOL power calculation must be accurate. If you allow me, I will advertise on the PEARL-DGS because it was built using a data set of FineVision lenses. This formula works particularly well with the FineVision lens and encourage the users to use the PEARL-DGS. But, of course, keep your best formula that you are used to and make sure that you reach a metropia or on the plus side and that will work. But tell the patient in advance that, if for some reason there is a refractive surprise, a laser enhancement may be beneficial for them to achieve the best visual performance. So if you say those things, the surgery must be perfect. If there is a little refractive surprise in the prediction, don’t say IOL power calculation because the patient…
Mario Nacinovich:
That’s why they don’t understand.
Damien Gatinel, MD, PhD:
No. Plus if you say calculation, and if it’s wrong, they will feel like you did the wrong calculation. But if you say prediction, they are more inclined to understand that and that’s what it is because you can really not predict with 100% accuracy where the lens will sit in the eye. When you explain this to the patient, they will accept that if there is a little refractive surprise, then they will have to do a laser enhancement. What I would say is that the FineVision lens in its design also is made so that throughout the power range, the design, by design, I’m saying the split between the anterior and posterior surface power is the same. There are lenses where the power is more posterior, more anterior. The FineVision, because it’s also optically desirable, is very balanced.
The anterior surface and the posterior surface are almost symmetrical, which means that there is not so many thick lens calculation issues. Other lenses can be sometimes different depending on their power because the process of the lens manufacturing makes that the entire surface will be the same for the first 5 to 3 power and then changes and that creates irregularity in the design. FineVision is not like this. It’s the same balance, symmetrical between the anterior and the posterior. That reduces also the chance of refractive inaccuracies in your prediction.
Mario Nacinovich:
I’d like to talk a little bit about some of those other lenses, and since the introduction of FineVision as the world’s first patented trifocal intraocular lens, several new trifocal designs have been released globally, not here in the United States. From your clinical and scientific perspective, how do the optical profiles and the clinical outcomes of these newer trifocal IOLs compare to the FineVision lens?
Damien Gatinel, MD, PhD:
Yeah. Speaking about optical profiles first, interestingly, the FineVision was the first trifocal lens, and of course there were competition lens launched after that because this medical need was acknowledged again. The confirmation was that, for example, let’s take PanOptix. PanOptix is not a trifocal. It’s a quadrifocal. I think Alcon couldn’t really infringe on the patent, so they had to find something new. If there would be a best trifocal design, would you think Alcon would not take it? No, they did not. Because I think what they realized is that if we choose to do a trifocal, then the best way to do it is what these guys have been doing.
Mario Nacinovich:
When it existed, you can get an approval, perhaps?
Damien Gatinel, MD, PhD:
Yeah. If you want to do a primary trifocal lens, I think because of course if there was a better way to do it, why would you do a quadrifocal lens for which you extinguish one for sight doesn’t make sense in some ways. It means that if you consider the field and say, okay, let’s do another route. If you do a trifocal lens, that’s the way to do it. Let’s find another way. I’m glad Alcon didn’t infringe. They respected the patent, which is good. PanOptix is not a bad lens, but that’s a confirmation that if you want to do a trifocal lens, well this is the way to do it, I think. What I’m saying, this also is because other competitors released other trifocal lines, but when you look at them, they are more, like I say nicely a tribute cover maybe because they really get inspired by the FineVision design, but they try to modify it. In other words, they play the same melody but the different rhythm or they change a bit the song, but it’s the same song.
That confirms that, again, if you want to do a trifocal lens, this is the best way to do it. Or you can do something different, quadrifocal, etc. But that’s a confirmation, right? That’s for the optical principles. Now, for the clinical outcomes. I don’t think that you could really find study that say that this lens is better than that lens. The problem is also those lens must be optimized for specific cornea asphericity, etc. Moving from optical principles before the clinical results to optical bench study, if you choose the eye model that makes your lens working better because the asphericity of the cornea you choose is exactly that your lens is compensating for, then of course you will show a better curve than the competitor and vice versa. Bench study always are maybe…
Mario Nacinovich:
Skewed?
Damien Gatinel, MD, PhD:
Skewed. Yeah. We tried, we did some, but we tried to avoid that pitfall or we said in a paper discussion always that, of course, if you change some parameters, you may find different results. Now that he caused a clinical situation, eyes are all different. I can even say myself that maybe there are eyes where another lens will work better because by chance the asphericity will match. At that stage we don’t know how to do it. We have to adopt a kind of general approach. Again, I think clinical studies didn’t really show that FineVision would lose against even newer lenses for the reason I explained that is there are either tributes or different designs but not superior to the FineVision. If you are used to another trifocal in the U.S. and you want to try the FineVision, you could really do it without any fear that you will lose against the previous chance. Just try it, and if you like it, I will be happy. Maybe you too.
Mario Nacinovich:
I will be happy.
Damien Gatinel, MD, PhD:
I’m sure this will be a very safe route.
Mario Nacinovich:
I’d like to do a quick discussion with you, and I’d like to take you through the various visual performance characteristics. Without naming the other brand names, but with regards to FineVision and all other trifocal IOLs, you let me know better for FineVision, equal, or if it’s not relevant in terms of…
Damien Gatinel, MD, PhD:
Okay.
Mario Nacinovich:
If we talk about intermittent…
Damien Gatinel, MD, PhD:
Better. Oh. I’m sorry.
Mario Nacinovich:
If we talk about intermediate vision…
Damien Gatinel, MD, PhD:
Yes.
Mario Nacinovich:
…where does FineVision match in terms of the other trifocals?
Damien Gatinel, MD, PhD:
That’s interesting. The FineVision is said to be optimized for 70, 75 centimeters. That has been something criticized by competition or lens for reason that they couldn’t do the same balance simple profile. Right?
Mario Nacinovich:
If you can’t meet the standard, complain about it.
Damien Gatinel, MD, PhD:
Right. I’ve never heard anything that would really make FineVision inferior for intermediate vision because, of course, if you compare different lenses, the intermediate vision may not be exactly at the same plane, but in a human eye all of this is smoothed by a biological system that has aberrations, imperfections, and these made those trifocal peaks blended into a kind of long extended, like a bridge. You have pillars, but eventually it will be like a bridge. That’s going to be like a roller coaster of contrast up and down. Let’s take the bridge analogy. You have a long bridge. You need 3 pillars. Right? You have distance, near, and you need to put one in the middle. FineVision strategy was to put it in the middle exactly, because 3.51750, in other words near 3.5, intermediate, 175 is the half, next something again that’s…
Mario Nacinovich:
The pure middle.
Damien Gatinel, MD, PhD:
Pure, efficient, and simple. By the way, this is why we didn’t have to add new steps because this rule works, is equivalent to say we will just make every other step higher or lower. If you put your mid-pillar in a different area, you can. To say it’s better at the end, what you want is a continuous flat bridge, right? I don’t think it makes a difference. I’ve never heard any patients saying, well, when I read this, it’s okay, but here I don’t. It’s usually a question people, patients do not understand.
Mario Nacinovich:
Continuous, consistent.
Damien Gatinel, MD, PhD:
Right. Because patients, for them, if they are unaware of all these subtleties we’re discussing, they don’t really think of distance, near, intermediate. They live as they live and they’re like, when I watch TV, it’s fine. When I work on the desk, is fine, and when I read is fine. Of course the desk, the computer screen one day will be 70, next day will be 65 depending on how they posture themselves, how they put, myself, you know, I have a laptop I put on the table. Sometimes I put it here because I’m drinking something. Sometimes I’m here because I’m tired. Patients do the same, I think, and they never complain that they have to put the computer specifically here or there or the tablet or whatever. They don’t say…
Mario Nacinovich:
They’re not recognizing it.
Damien Gatinel, MD, PhD:
No. When they drive they say my GPS, you know, because that’s something very important also, by the way, not only computer but GPS. I’m not saying some I can say ways or equivalent, right?
Mario Nacinovich:
Yes.
Damien Gatinel, MD, PhD:
It’s usually very intermediate distance and patient never say when a driver let you do this or that and you understand that any car is different. Sometimes they put it here. Sometimes put it there. No.
Mario Nacinovich:
Understood.
Damien Gatinel, MD, PhD:
Again, that’s not going to be making a difference clinically speaking. It’s more like marketing differentiation or.
Mario Nacinovich:
Let’s talk about the comparison in terms of light distribution. Advantage, FineVision?
Damien Gatinel, MD, PhD:
I think so because again, light distribution was made so that the distance vision has to be preserved. Again, historically speaking, when we work on this, we were very afraid that we would lose quality, distance and near. We didn’t want to make intermediate vision at the expense of the distance and the near. Apodization was the answer to this problem. Again, it’s a nice trick because when you need light, the pupil dilates. If your pupil does not dilate, it means it doesn’t need light. Right? It dilates a bit, gets more light, and apodization makes sure that in this situation of light lowering, the relative amount of light for distance increases.
Usually when you drive at night, your pupil dilates a bit. That’s where you need light. If you read and you need light, you can still use a lamp, so that’s not as important. But when you drive, you cannot illuminate the road or you cannot make daylight back when it’s nighttime. Right? You need to cope with this and apodization makes the relative amount of light getting higher and higher. Hence, it really favors, I think, FineVision for distance. That’s why I think based on what I know of what my colleagues say, that’s really a honest statement. It’s not a marketing statement that usually say, Damien, I’ve used many lenses, but the FineVision is probably the one that works the best in dim light conditions.
Mario Nacinovich:
The last thought is in terms of these photopsia rates between FineVision and subsequent trifocal IOLs, your thoughts?
Damien Gatinel, MD, PhD:
It depends on what you mean by this photopsia. Again, little halos are expected by design. Will they be bothering? Can happen. But the percentage is rare. I think it’s within like a 1-digit percentage of patients who heavily complain so…
Mario Nacinovich:
Or like your story about your mom…
Damien Gatinel, MD, PhD:
Yes.
Mario Nacinovich:
…only recognized when pointed out.
Damien Gatinel, MD, PhD:
Right. Of course clear lens. If you have a minus-two 45 year old patient, he’ll be probably more sensitive to halos because he didn’t have it before. But real cataract patients usually are naturally…
Mario Nacinovich:
They’ve acclimated to it.
Damien Gatinel, MD, PhD:
Yeah. They are brought in a world where day by day their vision quality got to a level so that these little halos will not be a problem because they will have so much light back on the retina because of the restoration of high transparency that they won’t feel it.
Mario Nacinovich:
Despite these growing number of competitors employing all these alternative trifocal designs, different technologies, FineVision continues to be widely regarded across the world for its simplicity, its elegance. What features of its optical architecture or the clinical results, what is it? If you had to say to a surgeon, a U.S. surgeon, who’s never used it, they’ve only heard about it, what is it that underpins its ongoing preference among your surgeon colleagues?
Damien Gatinel, MD, PhD:
I would say predictability. Again, we really have patients who are expecting true spectacle independence. If you really want to be predictable in that promise, you need really to consider trifocal lenses because again, other designs refractive enough do not provide enough near vision, and they have also special power variation in the lens design that makes when the pupil constructs the refraction goes towards myopia. When those eyes implanted, when lenses are refracted, they show myopic refraction.
Mario Nacinovich:
Absolutely.
Damien Gatinel, MD, PhD:
That’s expected because this is where the lens work in the near. If you refract a patient with a FineVision, if it’s plano, you’ll see plano because the vision is really plano. Of course, there is light split, but it’s different. Again, this very deterministic mechanism of diffraction creates the foci where you need them to be in a very reproducible manner. It’s more robust to cornea variation. It’s more robust to pupil variation. Even in the case of the FineVision, you can optimize the design to make this a benefit that is, again, apodization and pupil dilation, as I explained. It’s a robust, proven, efficient optical principle that will make your patient truly spectacle independent, as long as you do a good surgery and you achieve a metropia. That’s what I would really put as the first benefit of those lenses as opposed to other categories.
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