*4.1. Qualification*

Due to the non-diffractive structure of the lens and one elongated focus, the EDOF lens can be implanted in patients who do not qualify for multifocal lens implantation or are afraid of either the photic phenomena or reduced contrast sensitivity. In the case of multifocal lenses, the eligibility criteria are the strictest, and patients should be free of ocular diseases in order to achieve the best possible vision after surgery. As can be seen in Table 1, the patients who were qualified for cataract surgery with a non-diffractive EDOF lens had eyes with various ocular pathologies or past refractive surgeries, which did not impair the prognosis for improved vision after surgery, and thus patient satisfaction after surgery was high. The profile of patients in this case is similar to that of patients qualified for surgery with monofocal lens implantation.

#### *4.2. Postoperative Results*

The non-diffractive EDOF lens provides good acuity of distance vision, intermediate distance and functional near vision, confirmed by previous studies [19]. In our study, patients who had the Vivity lens implanted achieved a significant improvement in VA at all distances. The UCDVA at 4 m monocular is similar between the EDOF, the MONO

group and the MULTI group. In the case of the monocular UCIVA at 80 cm, VA is better for patients in the EDOF group than for the MONO and MULTI groups (UCIVA EDOF = 0.0, MULTI = 0.1, MONO = 0.3, respectively). In the case of monocular UCNVA, patients in the EDOF group achieved a worse VA than patients in the MULTI group and better than in the MONO group, as confirmed by other published studies comparing EDOF lenses with multifocal and monofocal lenses [15,19–21]. The worse monocular UCIVA at 80 cm for the MULTI group compared to the EDOF group may be due to the fact that the PanOptix lens has a focus to intermediate distance at 60 cm [15].

To the best of our knowledge, no study has been published, comparing at the same time the Vivity lens with monofocal and multifocal to date. In a large randomized study, Bal C. et al. compared postoperative outcomes in patients implanted with a Vivity lens compared to an aspheric monofocal lens. They described better intermediate and near distance vision after implantation of the Vivity lens and a similar visual impairment profile compared to the aspheric monofocal IOL [20].

In the study by Kohnen T. et al. the postoperative outcomes after bilateral Vivity lens implantation with target refraction set to emmetropia were assessed (32 eyes—16 patients). Patients achieved: binocular uncorrected VA for distance, intermediate distance and near distance, respectively, 0.01 ± 0.05 logMAR at 4 m, 0.05 ± 0.05 logMAR at 80 cm, 0.07 ± 0.06 logMAR at 66 cm and 0.25 ± 0.11 logMAR at 40 cm [22]. The results obtained in our study, for EDOF lens implantation with target refraction set to emmetropia were very similar (Me [Q1; Q3]): binocular UDCVA at 4 m 0.00 ( −0.09; 0.00) logMAR, binocular UCIVA at 80 cm 0.00 (0.00; 0.03) logMAR, and binocular UCNVA at 40 cm 0.30 (0.22; 0.36) logMAR, respectively.

Arrigo A. et al. describes the authors' own experiences in healthy eyes (108 eyes— 54 patients) after EDOF Vivity lens implantation. Very good results of distance vision and intermediate distance were described; in the case of near vision, the need for an addition of at least +1.0 D was indicated. Monocular UCDVA was 0.1 ± 0.04 logMAR, monocular BCDVA was 0.0 ± 0.03 logMAR, respectively [23]. Patients in our study with an implanted Vivity lens also needed a near vision supplement of about 1D or more and median monocular UCDVA was 0.0 logMAR, median monocular BCDVA was 0.0 logMAR.

The use of the minimonovision system in the case of the Vivity lens improves the VA for near vision and increases the degree of independence from ocular correction. In the paper by Newsom T. et al. describing the results of binocular Vivity lens implantation with target of slight myopia −0.75 D, 29 of 33 eyes achieved UCNVA binocular 0.2 logMAR or better [24]. Very similar results were obtained in our patients wih minimovision, whose median binocular UCNVA was 0.2 logMAR.

Rementería-Capelo LA et al. describes the postoperative results after binocular Vivity lens implantation in patients with ocular pathology. A monocular UCDVA was achieved in the test group of 0.03 ± 0.8 logMAR, compared to the control group with an implanted Vivity lens without eye pathology −0.1 ± 0.07. The statistical difference between binocular UCDVA in both groups was not described, as was the case of defocus curves and contrast sensitivity [25]. The result of this study is similar to ours, which evaluated the visual acuity of both healthy patients and those with ocular pathology (median of monocular and binocular UCDVA was 0.0 logMAR). These results, although described on small groups and with a wide range of ocular disorders, give evidence that ocular disorders do not disqualify from Vivity lens implantation. Postoperative results in these patients are very good.

#### *4.3. Spectacle Dependance*

Therefore, EDOF lenses can be positioned between monofocal and multifocal lenses, they provide good uncorrected visual acuity for distance and intermediate, but uncorrected visual acuity for nearsightedness may be insufficient. In our study, glasses were needed by 35% of subjects from the EDOF group, by 96% of subjects from the MONO group and by no one from the MULTI group (this was a statistically significant dependency—*p* < 0.001). In a study by Rementería-Capelo LA et al., 40% of patients in both study groups (with and

without ocular pathology) reported never using close-up glasses [25]. Similar results were described by Kohnen et al. (38%) [22]. The higher degree of independence from spectacle correction among our patients with EDOF lens implantation may be due to the different profile of qualified patients for the procedure. In addition, our EDOF group was not a homogeneous group and some patients had the target set to emmetropia and some had the minimovision system applied. This was due to patient preference and their desire to improve their near vision. In addition, each patient prefers a different reading distance, which also contributes to the different results.

As you know, the use of a minimovision system in the cases of the Vivity lens improves near vision acuity and increases the degree of independence from spectacle correction. Newsom T. et described a high level of satisfaction and a greater degree of independence from ocular correction with the monovision system than without monovision with implantation of the same lens [24].

#### *4.4. Occurance of Photic Phenomena*

In our study, a small number of patients after EDOF implantation reported photic phenomena (14% patients). Patients who reported the occurrence of dysphotopsia described these side effects as minor, not disrupting normal functioning, similar to the previous reports [20,22,23]. Compared to patients in the MONO group, the incidence of dysphotopsia is slightly more frequent, but it is definitely seen less than in patients in the MULTI group. The study by Rementería-Capelo LA et al. described that patients reported a higher prevalence of halos and glare than other reports on Vivity IOL, especially in the study group, with ocular pathologies: 60% halo, 54% glare, compared to the control group, where the incidence of halo was 28% and 48% [25]. Kohnen et al. found that 25% reported halo and 25% glare [22]. Arrigo et al. reported that 30% and 33% of patients reported halo and glare [23]. The differences between the studies may be due to differences in the questionnaires used in the study and the "inquiry," an active question about the presence of dysphotopsia, and this has been shown to increase reporting rates [26].

A paper by Newsom T. et described that the use of a monovision system when implanting a Vivity lens compared to target refraction set to emmetropia does not increase the frequency of photic phenomena [24].

#### *4.5. Contrast Sensivity*

Although this was not the main aim in the study also described was the contrast sensivity. Some patients, due to the fear of decreased of contrast sensivity after surgery, choose not to implant multifocal lenses and select EDOF lenses. According to the manufacturer, the Vivity lens has a safety profile similar to that of monofocal lenses [11,19]. In our study, contrast sensitivity in patients implanted with the Vivity lens did not differ significantly from patients implanted with a monofocal lens and was better than that of patients implanted with a multifocal lens. It is difficult to relate the results of this study to others, since contrast sensitivity was tested only with nearsighted charts and only under photopic conditions.

In our study, we encountered a few limitations. First, it was conducted at a single center, so the number of patients in the study was limited. Secondly, each study group included both healthy patients and patients with eye pathology and after refractive surgery. Studies focusing on specific ocular pathologies or on patients after specific refractive procedures, with larger numbers of patients, would be necessary to best determine which type of IOL would provide the greatest benefit for a given group of patients. In addition, comparing data from our study with other published studies is problematic due to different inclusion/exclusion criteria, study conditions and procedures.
