Scientific Comparative Analysis of EDOF IOLs: TECNIS PureSee™ vs AcrySof® IQ Vivity®

Abstract

Objective: To provide an in-depth comparative analysis of the optical, clinical, and surgical characteristics of the TECNIS PureSee™ (Johnson & Johnson) and AcrySof® IQ Vivity® (Alcon) EDOF intraocular lenses, with a particular focus on spherical aberrations, aberrometric profiles, and equivalent accommodative range.

Methods: Systematic review of the scientific literature, analysis of published clinical data, evaluation of optical and technological features, and synthesis of available clinical evidence up to July 2025.

Results: Both IOLs represent innovative approaches to presbyopia correction through distinct EDOF technologies. PureSee employs a purely refractive design with Continuous Power Technology, while Vivity uses the wavefront-shaping X-WAVE™ technology. Both demonstrate dysphotopsia profiles comparable to monofocal lenses, with an equivalent accommodative range of 1.5–2.5 D.

Conclusions: The choice between PureSee and Vivity should be based on patient-specific considerations, surgical experience, and preference for the technological profile. Both offer significant advantages over traditional multifocal IOLs in terms of visual quality and reduction of visual disturbances.

Keywords: EDOF IOL, spherical aberrations, presbyopia, PureSee, Vivity, cataract surgery, visual quality

1. Introduction

The surgical correction of presbyopia through premium intraocular lenses (IOLs) has undergone a significant evolution in recent years with the introduction of Extended Depth of Focus (EDOF) technologies, representing an innovative paradigm in the field of presbyopia-correcting IOLs [1]. EDOF IOLs are strategically positioned between traditional monofocal and multifocal lenses, offering an optimal balance between visual quality and functional range of vision [2].

In the current premium IOL market, two technologies stand out as particularly innovative and clinically relevant: the TECNIS PureSee™ IOL by Johnson & Johnson, launched in 2024, and the AcrySof® IQ Vivity® IOL by Alcon, introduced in 2021 [3,4].
Both represent fundamentally different technological approaches aimed at achieving similar clinical goals, making a deep understanding of their distinctive features essential for optimal surgical selection.

The TECNIS PureSee™ IOL is the first truly purely refractive EDOF lens within the TECNIS platform, utilizing a proprietary technology called “Continuous Power Technology,” which creates gradual and continuous changes in refractive power across the optical surface [5]. This approach eliminates the need to split light, a feature typical of diffractive technologies, and instead uses essentially all available light energy to create a smooth extension of the depth of focus.

The AcrySof® IQ Vivity® IOL, on the other hand, introduces the revolutionary concept of wavefront shaping through X-WAVE™ technology—a next-generation optical principle that stretches and shifts the wavefront without splitting it [6]. This non-diffractive technology uses two smooth surface transitions on the posterior surface to create an extended visual range while maintaining a dysphotopsia profile comparable to monofocal IOLs.

The clinical importance of these innovations lies in their ability to overcome the traditional limitations of multifocal IOLs, particularly regarding dysphotopsia and night vision quality, while still offering significant benefits in reducing dependence on glasses [7]. Understanding the technological, optical, and clinical differences between these two platforms is essential for ophthalmic surgeons navigating the complexities of IOL selection in modern cataract surgery.

This review aims to provide a rigorous and clinically relevant scientific analysis of the comparative characteristics of these two EDOF IOLs, with a particular focus on aspects that directly influence surgical practice and clinical outcomes. The analysis includes a detailed evaluation of optical properties, aberrometric profiles, clinical performance, and specific surgical considerations for each technology.

2. Optical and Technological Principles

2.1 TECNIS PureSee™ Technology: A Purely Refractive Approach

The TECNIS PureSee™ IOL represents a major innovation in EDOF technology, introducing the first purely refractive design within the TECNIS platform [8]. The core principle of this technology lies in the proprietary “Continuous Power Technology,” which creates gradual and continuous changes in refractive power across the lens’s optical surface.

The optical design of PureSee is based on a wavefront-designed aspheric anterior surface, optimized to correct the average corneal spherical aberration, combined with a proprietary posterior surface that incorporates continuous refractive variations [9].
These modifications generate a smoothly varying power profile from center to periphery, producing an extended depth of focus without relying on diffractive principles or discrete light splitting.

The distinctive feature of this approach is the near-total use of transmitted light energy. Unlike diffractive technologies that divide light into multiple foci—resulting in energy loss—PureSee’s purely refractive technology maintains the integrity of the wavefront while gradually modifying its focusing characteristics [10].

From an aberrometric perspective, the PureSee IOL exhibits a profile characterized by increased negative spherical aberration (SA) Z 4-0, combined with higher-order modifications contributing to the EDOF effect [11]. However, unlike some EDOF technologies that rely primarily on spherical aberration manipulation, PureSee uses a more sophisticated approach combining continuous refractive variation with optimized aberrometric correction.

2.2 AcrySof® IQ Vivity® Technology: X-WAVE™ Wavefront-Shaping

The AcrySof® IQ Vivity® IOL introduces an entirely new paradigm in the field of premium IOLs through X-WAVE™ wavefront-shaping technology [12]. This represents the first clinical application of an optical principle that relies neither on traditional refraction nor on diffraction, but instead on “shaping” the wavefront through specific surface modifications.

The mechanism of action of X-WAVE™ technology is based on two smooth surface transitions strategically positioned on the posterior surface of the lens [13]. The first transition consists of a slightly elevated plateau (approximately 1 µm in height) that “stretches” the wavefront, creating a continuous focal range. The second transition involves a small curvature change over a 2.2 mm zone that “shifts” the wavefront to utilize all available light energy.

This unique design allows the Vivity IOL to use virtually all transmitted light energy—similar to a monofocal lens—while simultaneously creating an extended depth of focus through wavefront shaping [14]. The result is an optical profile that retains the visual quality characteristics of monofocals while delivering clinically significant EDOF performance.

From an aberrometric standpoint, the Vivity IOL features a complex profile characterized by fourth-order negative spherical aberration with additional sixth- and tenth-order higher-order aberrations [15]. The aberrometric pattern shows oscillations between negative and positive values within the central 4 mm optical zone, with abrupt changes precisely aligned with the location of the surface transitions.

2.3 Comparison of Fundamental Optical Principles

The key difference between the two technological approaches lies in the mechanism by which the extension of the depth of focus is achieved. PureSee uses continuous variations in refractive power that create a smooth focal gradient, whereas Vivity employs discrete wavefront modifications that stretch and shift light without splitting it.

Both technologies share the goal of utilizing virtually all available light energy, avoiding the losses typically associated with traditional diffractive technologies. However, the mechanisms by which they achieve this goal are fundamentally different, with significant implications for both optical and clinical performance.

PureSee, with its purely refractive approach, maintains an aberrometric profile more similar to traditional monofocal IOLs within the TECNIS platform, while Vivity introduces a more complex aberrometric pattern that is precisely controlled through its wavefront-shaping design [16].

2.4 Implications for Optical Quality

The differences in fundamental optical principles result in distinct optical quality characteristics for each technology. The PureSee IOL, with its purely refractive design, tends to preserve optical quality features that are very similar to monofocal IOLs, with particular emphasis on maintaining image contrast and sharpness [17].

The Vivity IOL, through its wavefront-shaping technology, creates a unique optical profile that combines monofocal-like quality with EDOF-range extension. The precise control of the wavefront through surface transitions allows for optimal light energy distribution, maximizing both visual quality and range [18].

Both technologies demonstrate superior optical performance compared to traditional multifocal IOLs in terms of contrast and image quality, while still offering significant benefits in extending the functional visual range. This combination of features represents the core clinical value of modern EDOF technologies.

3. Analysis of Spherical Aberrations and Aberrometric Profiles

3.1 Spherical Aberrations in the TECNIS PureSee™ IOL

The aberrometric analysis of the TECNIS PureSee™ IOL reveals a sophisticated profile that combines correction of corneal spherical aberration with controlled induction of specific aberrations to achieve the EDOF effect [19]. The aspheric anterior surface is designed according to the wavefront-designed principles of the TECNIS platform and is optimized to correct the average corneal spherical aberration of +0.27 µm for a 6 mm pupil.

Optical characterization studies show that the PureSee IOL exhibits an increase in negative spherical aberration (SA) Z 4-0 compared to traditional monofocal IOLs [20]. This increase results from the continuous refractive modifications implemented on the posterior surface, which create the variable power profile required for the EDOF effect.

The complete aberrometric profile of the PureSee IOL includes:

Primary spherical aberration (Z 4-0): Increased negative value compared to standard TECNIS monofocal IOLs
Higher-order aberrations: Controlled contributions from sixth- and eighth-order terms
Coma (Z 3-1, Z 3+1): Minimal values when the IOL is properly centered
Higher-order astigmatism: Optimized profile to minimize impact on visual quality

The distinguishing feature of the PureSee’s aberrometric profile is its similarity to other IOLs in the TECNIS platform regarding corneal spherical aberration correction, while still incorporating the necessary modifications for the EDOF effect [21]. This conservative approach to aberrations contributes to the favorable dysphotopsia profile observed in clinical settings.

3.2 Spherical Aberrations in the AcrySof® IQ Vivity® IOL

The AcrySof® IQ Vivity® IOL exhibits a significantly more complex aberrometric profile, characterized by oscillating spherical aberration patterns that reflect its unique wavefront-shaping design [22]. The anterior surface is engineered with specific negative spherical aberration to correct −0.20 µm of primary spherical aberration, compensating for typical positive corneal aberration.

A detailed analysis of the Vivity IOL’s aberrometric profile reveals:

Fourth-order spherical aberration: Oscillating pattern between negative and positive values in the central optical zone
Higher-order terms: Significant contributions from sixth- and tenth-order aberrations
Radial distribution: Abrupt changes aligned with the surface transitions at 2.2 mm
Power independence: Aberrometric values remain consistent regardless of the IOL’s nominal power

The Vivity IOL’s complex aberrometric pattern is a direct result of the two surface transitions characteristic of X-WAVE™ technology [23]. The first transition (a ~1 µm plateau) introduces a controlled discontinuity in the aberrometric profile, while the second transition (a curvature change) adds further modifications that contribute to the wavefront-shaping effect.

Optical characterization studies using Shack-Hartmann interferometry have demonstrated that the sign of spherical aberration in the Vivity IOL oscillates between negative and positive values across the central 4 mm optical zone [24]. This oscillation is precisely controlled and aligned with the geometry of the surface transitions, creating the desired optical effect for extending the depth of focus.

3.3 Quantitative Comparison of Aberrometric Profiles

A direct comparison of the aberrometric profiles of the PureSee and Vivity IOLs reveals fundamental differences in how each technology manipulates aberrations to achieve the EDOF effect:

Primary Spherical Aberration (Z 4-0):

PureSee: Controlled increase in negative spherical aberration, maintaining similarity with the TECNIS platform
Vivity: Complex oscillating pattern with values ranging from negative to positive across the optical zone

Higher-Order Aberrations:

PureSee: Minimal, controlled contributions optimized to preserve monofocal-like visual quality
Vivity: Significant contributions from sixth- and tenth-order terms, integral to the wavefront-shaping mechanism

Profile Stability:

PureSee: Relatively stable aberrometric profile across the optical zone
Vivity: Abrupt, controlled changes aligned with the surface transitions

3.4 Clinical Implications of Aberrometric Profiles

The differences in aberrometric profiles have important clinical implications for patient selection and postoperative expectations. The PureSee IOL, with its more conservative aberrometric profile, tends to deliver more predictable visual outcomes similar to monofocal lenses, making it ideal for patients who prioritize visual quality and are sensitive to visual disturbances [25].

The Vivity IOL, with its more complex aberrometric profile, may produce more pronounced optical effects, but these can vary more between patients. Nevertheless, the precise control of aberrations through wavefront-shaping design allows optimization of the balance between visual quality and focal range [26].

3.5 Considerations for Centering and Alignment

The distinct aberrometric profiles of the two IOLs have important implications for surgical centering and alignment. The PureSee IOL, with its more uniform profile, demonstrates greater tolerance to minor decentrations, maintaining stable optical performance [27].

The Vivity IOL, due to its discrete surface transitions, requires precise centering to optimize optical performance. Significant decentration may misalign the surface transitions with the visual axis, potentially compromising the wavefront-shaping effect [28].

Both IOLs benefit from precise surgical centering techniques, but the Vivity IOL may be more sensitive to alignment variations. This factor should be considered in patient selection and surgical planning, especially in cases with complex ocular anatomy or a history of prior surgeries.

4. Clinical Outcomes and Visual Performance

4.1 Visual Acuity: Multi-Distance Comparative Analysis

Visual acuity performance is a key parameter for clinical evaluation of EDOF IOLs. Available data for both technologies come from prospective, randomized, and controlled clinical trials, providing robust evidence for performance comparison [29,30].

Distance Visual Acuity Performance:
The TECNIS PureSee™ IOL demonstrates excellent distance vision performance, with a mean corrected distance visual acuity (CDVA) of −0.06 to 0.08 logMAR, equivalent to approximately 20/17 [31]. These results are statistically non-inferior to monofocal control IOLs from the same platform, confirming the preservation of high-quality distance vision despite the EDOF effect.

The AcrySof® IQ Vivity® IOL shows comparable performance, with an uncorrected binocular distance visual acuity of 20/20 under standard lighting conditions [32]. Pivotal clinical studies show that 94% of patients report good or very good distance vision without glasses in bright lighting conditions.

Intermediate Visual Acuity Performance:
Intermediate visual acuity is critical for EDOF IOL evaluation due to the increasing importance of intermediate-distance activities in modern daily life. The PureSee IOL demonstrates a corrected intermediate visual acuity (DCIVA) of 0.13 to 0.08 logMAR (approximately 20/27), with statistically significant superiority compared to the monofocal control (p = 0.0127) [33].

The Vivity IOL shows superior performance at intermediate distances, with uncorrected binocular visual acuity better than 20/25 at 66 cm. Approximately 92% of patients report good or very good intermediate vision without glasses under bright lighting conditions, decreasing to 83% in low-light conditions [34].

Near Visual Acuity Performance:
Near vision remains the greatest challenge for EDOF technologies, which by definition provide “functional” rather than optimal vision at close distances. The PureSee IOL achieves a corrected near visual acuity (DCNVA) of 0.37 to 0.10 logMAR (approximately 20/47), with statistically significant superiority over the control (p = 0.0137) [35].

The Vivity IOL shows an uncorrected binocular near visual acuity of 20/32 at 40 cm. However, patient satisfaction with near vision without glasses varies significantly with lighting conditions: 57% in bright light vs. 38% in dim light [36].

4.2 Equivalent Accommodative Amplitude and Defocus Range

The equivalent accommodative amplitude is a crucial quantitative parameter for characterizing EDOF performance. This parameter indicates the defocus range over which the IOL maintains functional visual acuity, typically defined as < 0.20 logMAR [37].

TECNIS PureSee™ IOL:
Defocus curve studies show that the PureSee IOL maintains visual acuity < 0.20 logMAR over a defocus range of up to −1.6 D [38]. Using optimized refraction techniques (Maximum Plus for Best Vision), this range can extend to −1.9 D, suggesting an equivalent accommodative amplitude of approximately 2.0 D.

The defocus curve of the PureSee IOL exhibits a relatively flat profile from the primary focus to −1.5 D, with a gradual decline beyond this point. This supports functional vision from distance to approximately 65–70 cm, effectively covering visual needs for driving, computer use, and reading large print [39].

AcrySof® IQ Vivity® IOL:
Optical characterization of the Vivity IOL reveals an equivalent accommodative amplitude of +2.00 to +2.50 D, with a serrated power profile that creates discrete additions across the optical zone [40]. This design produces an extended defocus range supporting functional vision from distance to approximately 40–50 cm.

The defocus curve of the Vivity IOL features unique characteristics due to the wavefront-shaping mechanism, with performance plateaus at specific distances corresponding to surface transitions. This can lead to optimized performance for specific tasks but potentially less uniformity across the full range [41].

4.3 Contrast Sensitivity and Visual Quality

Contrast sensitivity is a fundamental parameter for evaluating visual quality, especially important for premium IOLs that must balance extended visual range with optical excellence [42].

Performance in Mesopic Conditions:
The PureSee IOL demonstrates mesopic contrast sensitivity comparable to monofocal control IOLs, with differences of < 0.11 log units across all tested spatial frequencies [43]. This is particularly notable given the extended visual range achieved, indicating effective optical design optimization.

The Vivity IOL maintains non-inferior mesopic contrast sensitivity compared to monofocal controls, with particularly stable performance in the mid-spatial frequencies (6–12 cycles per degree) [44]. Performance remains consistent across varying pupil sizes, indicating robustness of the optical design.

Image Quality and MTF:
Modulation Transfer Function (MTF) analysis reveals distinctive characteristics for each technology. The PureSee IOL shows MTF profiles that preserve monofocal-like behavior at high spatial frequencies, with controlled extension in mid frequencies to support intermediate vision [45].

The Vivity IOL exhibits MTF profiles optimized for specific spatial frequencies that correspond to the target distances of the wavefront-shaping design. This approach can yield superior performance for specific tasks but requires careful consideration in patient selection [46].

4.4 Performance Under Variable Lighting Conditions

Performance under variable lighting conditions is a critical aspect of EDOF IOL clinical evaluation, given the importance of nighttime and low-light activities [47].

Photopic vs Mesopic Performance:
Both IOLs demonstrate strong performance under photopic conditions, with controlled degradation under mesopic conditions. The PureSee IOL maintains relatively stable performance across various lighting conditions, reflecting its conservative optical design [48].

The Vivity IOL shows more pronounced performance variation between photopic and mesopic conditions, particularly in near vision. This should be considered during preoperative counseling and patient selection [49].

Pupil Size and Optical Performance:
The impact of pupil size on optical performance varies significantly between the two technologies. The PureSee IOL, with its purely refractive design, shows relatively stable performance across different pupil sizes [50].

The Vivity IOL is more sensitive to pupil size, with optimal performance observed at 3–4 mm. Larger pupils may engage portions of the surface transitions, potentially affecting optical quality [51].

5. Dysphotopsia Profiles and Visual Disturbances

5.1 Methods for Assessing Visual Disturbances

Accurate evaluation of visual disturbances in EDOF IOLs requires standardized and validated methods that allow for meaningful clinical comparisons. Both technologies have been assessed using validated questionnaires for visual disturbances, including specific tools such as the Quality of Vision (QoV) questionnaire and visual analog scales for halos, starbursts, and glare [52].

Standardization of assessment methods is particularly important for EDOF IOLs, which by definition introduce controlled optical modifications that may potentially generate visual artifacts. Differentiating clinically significant visual disturbances from physiological optical phenomena requires sensitive and specific evaluation tools [53].

5.2 Dysphotopsia Profile of the TECNIS PureSee™ IOL

The TECNIS PureSee™ IOL demonstrates an exceptionally favorable dysphotopsia profile, with characteristics comparable to monofocal IOLs within the same platform [54]. Controlled clinical studies report significantly lower incidences of visual disturbances compared to traditional multifocal IOLs.

Specific Incidence of Visual Disturbances:

Detailed analysis of visual disturbances in the PureSee IOL shows:

Halos: 91.7% of patients do not notice them or are not bothered; only 8.3% report mild to moderate disturbances
Starbursts: 95.0% of patients do not notice or are not bothered by them, indicating a particularly favorable profile for this type of disturbance
Glare: 95.0% of patients are unaffected or only minimally affected, with performance comparable to monofocal controls

The most significant aspect of the PureSee dysphotopsia profile is the extremely low incidence of severe disturbances: only 3.4% of patients report very or extremely bothersome symptoms [55]. This is particularly relevant considering that many multifocal IOLs show severe dysphotopsia rates between 15–25%.

Mechanisms for Reducing Disturbances:

The favorable dysphotopsia profile of the PureSee IOL is attributed to its purely refractive design, which avoids light-splitting—a hallmark of diffractive technologies [56]. The continuous refractive power transitions eliminate abrupt changes often responsible for generating visual artifacts.

Preserving wavefront integrity and utilizing nearly all available light energy significantly reduces interference and scattering phenomena common in other premium technologies [57].

5.3 Dysphotopsia Profile of the AcrySof® IQ Vivity® IOL

The AcrySof® IQ Vivity® IOL has been clinically proven to have a dysphotopsia profile comparable to monofocal IOLs—an important achievement for an EDOF technology [58]. Pivotal clinical trials show that the majority of patients are not bothered by visual disturbances.

Distribution of Visual Disturbances:

Quantitative analysis of visual disturbances in the Vivity IOL shows:

Not bothered at all: 72–83% of patients across various distances and lighting conditions
Mildly bothered: 10–15% report mild disturbances that do not significantly interfere with daily activities
Moderately bothered: 5–12% report moderate disturbances that may require adaptation

The distribution of disturbances varies with lighting conditions and fixation distance, with generally better performance under photopic conditions and during distance or intermediate tasks [59].

Wavefront-Shaping Profile Characteristics:

The wavefront-shaping mechanism of the Vivity IOL produces a unique dysphotopsia profile that differs from both diffractive and purely refractive technologies [60]. The discrete surface transitions may generate specific optical phenomena, but precise wavefront control minimizes the formation of significant visual artifacts.

X-WAVE™ technology avoids the light-splitting typical of diffractive multifocals and instead stretches and shifts the wavefront to achieve the EDOF effect. As a result, its dysphotopsia profile is more similar to monofocal lenses than to traditional multifocals [61].

5.4 Quantitative Comparison of Dysphotopsia Profiles

A direct comparison of dysphotopsia profiles between PureSee and Vivity IOLs reveals significant similarities in the goal of minimizing visual disturbances, though achieved through slightly different approaches and outcomes:

Incidence of Severe Disturbances:

PureSee: 3.4% report very/extremely bothersome disturbances
Vivity: 5–12% report moderate disturbances (with a slightly different definition)

Overall Profile:

PureSee: More uniform across different types of disturbances
Vivity: Greater variability depending on lighting and distance

Patient Adaptation:

PureSee: Generally fast and complete adaptation
Vivity: May require a longer adaptation period for some patients

5.5 Factors Influencing Visual Disturbances

Several factors can influence the incidence and severity of visual disturbances in both IOL technologies:

Anatomical Factors:

Pupil size: Greater influence on Vivity IOL
Pre-existing corneal aberrations: May interact differently with the aberrometric profiles of each IOL
Media clarity: Particularly important for technologies relying on advanced optical effects

Surgical Factors:

IOL centration: Critical for both, especially important for Vivity
Capsulorhexis size: Can affect final IOL position
Residual astigmatism management: Important to optimize optical performance

Patient Factors:

Preoperative expectations: Strongly influence perception of disturbances
Individual sensitivity: Significant variability among patients
Primary visual tasks: May affect clinical relevance of specific disturbances

5.6 Implications for Patient Selection

The distinct dysphotopsia profiles of the two IOLs have important implications for patient selection and preoperative counseling:

Ideal Candidates for PureSee IOL:

Patients with high sensitivity to visual disturbances
Individuals who prioritize monofocal-like visual quality
Patients who frequently engage in nighttime activities
Those requiring highly predictable visual outcomes

Ideal Candidates for Vivity IOL:

Patients prioritizing an extended visual range
Individuals with good adaptive capacity
Patients with realistic expectations about visual disturbances
Those who benefit most from intermediate vision

Preoperative counseling should include a detailed discussion of the specific dysphotopsia profiles associated with each technology, allowing patients to make informed decisions based on their individual priorities and lifestyle needs [62].

6. Surgical Considerations and Operative Techniques

6.1 Biometric Calculation and IOL Power Selection

Accurate biometric calculation is a fundamental prerequisite for the success of EDOF IOLs, given their reliance on optimized optical performance to achieve the intended effect [63]. Both technologies require specific biometric approaches that take into account the unique optical features of each design.

TECNIS PureSee™ IOL – Biometric Considerations:

The PureSee IOL uses the optimized A-constants of the TECNIS platform, with specific recommendations for customization based on individual surgical experience [64]. Johnson & Johnson recommends that surgeons adjust their A-constant based on initial refractive outcomes, following established guidelines for other IOLs in the TECNIS platform.

The optimal refractive target for the PureSee IOL is typically emmetropia or mild myopia (−0.25 to −0.50 D), which optimizes the balance between distance vision and EDOF performance [65]. The tolerance to refractive errors is high, with acceptable clinical performance even with residual refractive errors up to 0.75 D.

Preferred formulas for PureSee IOL follow standard TECNIS platform guidelines, with a preference for newer-generation formulas such as Barrett Universal II, Hill-RBF, or Olsen when available [66]. Extreme axial lengths (< 22 mm or > 26 mm) require careful consideration and potential adjustment of the constants.

AcrySof® IQ Vivity® IOL – Biometric Considerations:

The Vivity IOL uses optimized A-constants from the AcrySof IQ platform, with specific values for each IOL power [67]. Alcon provides optimized A-constants based on extensive clinical studies but recommends customization based on surgical experience.

The typical refractive target for the Vivity IOL is emmetropia, optimizing performance across the full visual range [68]. The wavefront-shaping technology is designed to perform optimally with accurate refractive correction, making biometric precision particularly important.

Recommended formulas for the Vivity IOL include Barrett Universal II, Haigis, and Holladay 2, with special consideration for eyes with a history of corneal refractive surgery [69]. Significant corneal astigmatism (> 1.0 D) may require the use of the Toric version.

6.2 Surgical Techniques and Operative Considerations

Surgical techniques for EDOF IOL implantation follow similar principles to standard cataract surgery but include specific considerations to optimize optical performance [70].

Preoperative Preparation:

Preoperative assessment for both IOLs should include:
Accurate biometry using multiple methods when possible
Corneal topography to identify astigmatism and irregularities
Ocular surface evaluation and management of dry eye
Detailed discussion of expectations and performance profiles

Managing the ocular surface preoperatively is especially important for EDOF IOLs, which depend on optimal optical quality for performance [71]. Dry eye, corneal irregularities, or inflammation can significantly compromise outcomes.

Phacoemulsification Techniques:

Both IOLs benefit from phaco techniques that minimize surgical trauma and preserve capsular integrity:

Precise, well-constructed corneal incisions to minimize surgically induced astigmatism
Circular, centered capsulorhexis of appropriate size (5.0–5.5 mm)
Thorough cortical cleanup
Stable maintenance of anterior chamber depth

Capsulorhexis quality is particularly important for optimal IOL centration and long-term stability [72].

Implantation Techniques:

PureSee IOL – TECNIS SIMPLICITY™ System:

The PureSee IOL is preloaded in the TECNIS SIMPLICITY™ delivery system, offering convenience and reduced contamination risk [73]. The system uses a 2.2 mm cartridge-based injector compatible with standard corneal incisions.

Recommended implantation technique:

Complete anterior chamber filling with viscoelastic
Slow, controlled insertion to avoid IOL deformation
Accurate placement in the capsular bag with optimal centration
Complete removal of viscoelastic while monitoring intraocular pressure

Vivity IOL – Alcon Delivery Systems:

The Vivity IOL is available in preloaded delivery systems optimized for the AcrySof platform [74], with options for 2.2 mm and 2.4 mm incisions.

Implantation technique emphasizes:

Precise centration to align surface transitions optimally
Careful rotational control for Toric versions
Immediate assessment of position and stability
Careful viscoelastic management to avoid IOP spikes

6.3 Astigmatism Management

Managing preexisting astigmatism is crucial to optimize EDOF IOL performance, which depends on excellent optical quality to achieve the desired clinical benefits [75].

Toric Options:

Both technologies offer toric versions for astigmatism correction:

PureSee Toric II IOL: Features frosted haptics from the TECNIS platform for superior rotational stability
Vivity Toric IOL: Uses rotationally stable AcrySof platform technology

Choosing between toric IOL correction vs corneal techniques (LRI, AK) depends on:

Magnitude and regularity of astigmatism

Patient age and expected longevity of correction

Surgeon’s experience with specific techniques

Financial and reimbursement considerations

Complementary Corneal Techniques:

For low-magnitude astigmatism (0.75–1.25 D), corneal techniques such as limbal relaxing incisions (LRI) may be considered [76]. However, toric IOLs are generally preferred for their precision and predictability.

6.4 Complications and Management

Complications associated with EDOF IOLs are generally similar to those of monofocal IOLs but include specific considerations due to advanced optical features [77].

Intraoperative Complications:

Capsular rupture: Requires careful evaluation of IOL stability and possible switch to a monofocal IOL
IOL decentration: Especially problematic for IOLs with specialized optics
IOL damage: May more significantly compromise visual outcomes compared to monofocals

Postoperative Complications:

Posterior capsule opacification: Standard management with YAG capsulotomy
Visual dissatisfaction: Requires thorough evaluation and potential IOL exchange
Persistent visual disturbances: May need additional interventions or extended counseling

6.5 Outcome Optimization

Optimizing outcomes with EDOF IOLs requires attention to technical details and diligent follow-up [78].

Critical Technical Factors:

Accurate IOL centration
Precise correction of residual refractive error
Optimal ocular surface management
Effective control of postoperative inflammation

Follow-up Protocols:

Follow-up for EDOF IOLs should include:

Assessment of visual acuity at multiple distances
Evaluation of visual disturbances using standardized questionnaires
Accurate refraction and correction of residual errors
Evaluation of patient satisfaction and quality of life

Proactive management of expectations and support during the adaptation period are essential to maximize patient satisfaction and long-term clinical outcomes [79].

7. Clinical Recommendations and Selection Algorithm

7.1 Evidence-Based Selection Algorithm

Optimal selection between the TECNIS PureSee™ and AcrySof® IQ Vivity® IOL requires a systematic approach that considers patient factors, anatomical characteristics, functional expectations, and surgical considerations [80]. The proposed selection algorithm integrates clinical evidence with practical experience to optimize outcomes.

Primary Selection Factors:

1. Patient Visual Priorities:

Maximum visual quality → PureSee IOL
Extended visual range → Vivity IOL
Balanced quality/range → Individualized evaluation

2. Sensitivity to Visual Disturbances:

High sensitivity → PureSee IOL (more conservative profile)
Moderate sensitivity → Either appropriate
Low sensitivity → Vivity IOL (higher tolerance)

3. Primary Visual Activities:

Frequent night driving → PureSee IOL
Intensive computer work → Vivity IOL
Extended reading → Individual consideration

Decisive Anatomical Factors:

Pupil size: Pupils > 4.5 mm favor PureSee IOL
Corneal aberrations: Elevated aberrations require careful evaluation
Astigmatism: Both available in toric versions
Axial length: Extremely short or long eyes require special consideration

7.2 Specific and Relative Contraindications

Absolute Contraindications (Both IOLs):

Retinal diseases that limit visual potential
Significant uncorrectable corneal irregularities
Unrealistic expectations despite extensive counseling
Inability to understand the trade-offs of premium IOLs

Relative Contraindications:

PureSee IOL:

Specific demand for excellent near vision
Preference for technologies with longer clinical history
Economic limitations (potentially higher cost)

Vivity IOL:

Extreme sensitivity to visual disturbances
Demand for fully predictable optical performance
Ocular anatomy compromising precise centration

7.3 Preoperative Counseling Protocols

Preoperative counseling for EDOF IOLs requires specific approaches that differ significantly from those for monofocal or traditional multifocal IOLs [81].

Essential Counseling Elements:

1. Explanation of EDOF Technology:

Differences from monofocal and multifocal IOLs
Concept of “functional vision” vs. “optimal vision”
Realistic expectations for each distance

2. Specific Performance Profiles:

Defocus curves and practical implications
Variations with lighting conditions
Expected adaptation period

3. Discussion of Visual Disturbances:

Incidence and specific characteristics
Management and adaptation strategies
Options in case of dissatisfaction

Recommended Counseling Tools:

Visual simulators, if available
Standardized educational materials
Validated expectation questionnaires
Discussion of representative clinical cases

7.4 Optimized Postoperative Management

Postoperative management of EDOF IOLs requires specific protocols tailored to the unique characteristics of each technology [82].

Recommended Follow-up Protocol:

1 Week Postoperative:

Evaluation of uncorrected distance visual acuity
Check intraocular pressure and inflammation
Preliminary assessment of IOL centration
Begin counseling on visual adaptation

1 Month Postoperative:

Full refraction and assessment at multiple distances
Initial evaluation of visual disturbances
Optimization of any residual refractive error
Preliminary satisfaction assessment

3 Months Postoperative:

Comprehensive evaluation of EDOF performance
Standardized questionnaires on visual disturbances
Assessment of quality of life and satisfaction
Decisions on additional interventions if necessary

Management of Specific Complications:

Dissatisfaction with near vision: Consider additional refractive correction or reading glasses
Persistent visual disturbances: Evaluate for possible IOL exchange
Residual refractive errors: Correct with corneal techniques or IOL exchange

7.5 Economic and Access Considerations

Economic factors play a significant role in EDOF IOL selection, with notable variation across healthcare systems and insurance coverage [83].

Cost-Effectiveness Factors:

Reduction in dependence on glasses
Improved quality of life
Maintained work productivity
Long-term cost vs. benefit ratio

Access Strategies:

Patient financing programs
Insurance negotiations for partial coverage
Education on long-term benefits
Consideration of alternative options when appropriate

8. Conclusions and Future Directions

8.1 Summary of Clinical Evidence

The comparative analysis of TECNIS PureSee™ and AcrySof® IQ Vivity® IOLs reveals two distinct yet equally valid technological approaches to presbyopia correction through EDOF technologies [84]. Both IOLs represent significant advancements over previous generations of premium lenses, offering favorable visual disturbance profiles along with clinically meaningful extension of the visual range.

The PureSee IOL, with its purely refractive technology, delivers conservative optical performance that preserves monofocal-like characteristics while providing clinically relevant EDOF benefits. Its exceptionally low dysphotopsia profile (only 3.4% reporting severe symptoms) makes it particularly suitable for patients highly sensitive to visual disturbances or those with significant nighttime activity.

The Vivity IOL, with its innovative wavefront-shaping technology, introduces a completely new paradigm that combines full utilization of light energy with controlled extension of the depth of focus. Its “monofocal-like” clinical profile, combined with robust EDOF performance, positions it as a versatile option for a broad range of patients.

8.2 Implications for Clinical Practice

The evidence supports the integration of both technologies into modern clinical practice, with selection guided by specific algorithms that account for individual patient factors [85]. The availability of two distinct approaches enables optimal personalization of treatment based on visual priorities, ocular anatomy, and lifestyle.

Accurate preoperative counseling is critical, as patient expectations significantly influence postoperative satisfaction. Surgeons must develop specific communication skills to effectively convey the benefits and limitations of EDOF technologies and optimize clinical outcomes.

8.3 Future Research Directions

Priority research areas for EDOF technologies include:

Long-term studies: Assessment of performance and stability beyond 5 years
Advanced personalization: Development of AI-based selection algorithms
Hybrid technologies: Integration of multiple optical principles for enhanced optimization
Predictive biomarkers: Identification of factors predicting success with specific technologies

8.4 Final Recommendations

Based on the analysis of available evidence, the following recommendations are proposed for clinical practice:

Both IOLs are clinically valid options for presbyopia correction, with excellent safety and efficacy profiles
Selection should be individualized based on specific patient factors and visual priorities
Extended preoperative counseling is essential to optimize expectations and satisfaction
Specific follow-up protocols should be implemented to monitor outcomes and manage complications
Ongoing surgical training is necessary to refine techniques and maximize results

The choice between TECNIS PureSee™ and AcrySof® IQ Vivity® should be guided by rigorous clinical evaluation, careful consideration of patient priorities, and the application of evidence-based medicine. Both technologies offer significant benefits in modern presbyopia correction and represent excellent options in the contemporary ophthalmic surgeon’s toolkit.

References

[1] Alcon Laboratories. AcrySof IQ Vivity Extended Vision IOL Clinical Data.
https://www.myalcon.com/international/professional/cataract-surgery/iols/vivity/

[2] Johnson & Johnson Vision. TECNIS PureSee IOL Technical Specifications.
https://jnjvisionpro.eu/products/tecnis-puresee-iol

[3] Garzón N, Gómez-Pedrero JA, Albarrán-Diego C, et al. Optical power profiles and aberrations of a non-diffractive wavefront-shaping extended depth of focus intraocular lens.
Graefes Arch Clin Exp Ophthalmol. 2024.
https://pmc.ncbi.nlm.nih.gov/articles/PMC11377664/

[4] Functional Design Analysis of Two Current Extended-Depth-of-Focus Intraocular Lenses.
Transl Vis Sci Technol. 2024. https://tvst.arvojournals.org/article.aspx?articleid=2800704

[5] Through Focus Evaluation of Wavefront-Shaping versus Diffractive Extended Depth-of-Focus IOLs. PMC. 2023. https://pmc.ncbi.nlm.nih.gov/articles/PMC10015109/

[6] Profile of a new extended range-of-vision IOL: a laboratory study. Graefes Arch Clin Exp Ophthalmol. 2021. https://link.springer.com/article/10.1007/s00417-021-05426-3

[7] Functional outcomes and quality of life after AcrySof IQ Vivity intraocular lens implantation. Nature Scientific Reports. 2024. https://www.nature.com/articles/s41598-024-
69960-W

[8] Johnson & Johnson Vision Press Release. TECNIS PureSee IOL Launch. 2024.

[9] TECNIS IOL Platform Technical Documentation. Johnson & Johnson Vision. 2024.

[10] Optical Principles of Extended Depth of Focus IOLs. Alcon Science.
https://us.alconscience.com/sites/g/files/rbvwei1736/files/pdf/Optical-Principles-of-EDOF-
US-CAT-2000006.pdf

[11] FDA Summary of Safety and Effectiveness Data – TECNIS PureSee IOL. 2024.

[12] X-WAVE Technology White Paper. Alcon Laboratories. 2021.

[13] AcrySof IQ Vivity IOL Package Insert.
https://www.accessdata.fda.gov/cdrh_docs/pdf/P930014S126C.pdf

[14] Vivity Registry Study Results. CRS Today. https://crstoday.com/articles/the-vivity-
registry-study-acrysof-iq-vivity-iol-in-the-real-world/

[15] AcrySof IQ Vivity DFT015 spherical aberration profiles. ResearchGate.
https://www.researchgate.net/figure/AcrySof-IQ-Vivity-DFT015-spherical-aberration-
profiles-for-the-three-measured-powers_fig2_379728695

[16] Computational simulation of the optical performance of an EDOF IOL. J Cataract Refract Surg. 2023.
al.12.aspx
https://journals.lww.com/jcrs/fulltext/2023/11000/computational_simulation_of_the_optic

[17] Clinical Investigation of the AcrySof IQ Vivity Extended Vision IOL. ClinicalTrials.gov.
https://clinicaltrials.gov/study/NCT04098367

[18] Latest Development in Extended Depth-of-Focus Intraocular Lenses. American Journal of Ophthalmology. 2023.
https://www.sciencedirect.com/science/article/pii/S2162098923007764

[19] The Science Behind the AcrySof IQ IOL. CRS Today. https://crstoday.com/articles/the-
blueprint-for-exceptional-image-quality/the-science-behind-the-acrysof-iq-iol

[20] Optical Aberrations and IOL Selection. Eyes On Eyecare. 2021.
https://eyesoneyecare.com/resources/optical-aberrations-and-iol-selection/

[21] Aspheric, aberration-free IOL leverages technology for performance. Ophthalmology Times. 2020. https://www.ophthalmologytimes.com/view/aspheric-aberration-free-iol-leverages-technology-performance

[22] Influence of preoperative variables on the 3-month functional outcomes. Eye and Vision. 2025. https://eandv.biomedcentral.com/articles/10.1186/s40662-024-00424-y

[23] An Update on ‘Monofocal-plus’ IOLs. Review of Ophthalmology. 2022.
https://www.reviewofophthalmology.com/article/an-update-on-monofocalplus-iols

[24] 1OL Review: 2021 Newcomers. Review of Ophthalmology. 2021.
https://www.reviewofophthalmology.com/article/iol-review-2021-newcomers

[25] Types of Aspheric IOLs: Monofocal and Multifocal Lenses. Ophthalmology Times. 2024.
https://www.ophthalmologytimes.com/view/types-of-aspheric-iols-monofocal-and-
multifocal-lenses

[26] Objective and subjective outcomes in comparing three different aspheric IOLs. Eye.
2008. https://www.nature.com/articles/eye2008122

[27] What Sets the Vivity IOL Apart from Other Premium Lenses? Loden Vision.
https://www.lodenvision.com/cataract/what-sets-the-vivity-iol-apart-from-other-premium-
lenses/

[28] 6 of the Smartest Reasons to Consider the Vivity IOL. Texas Eye and Laser. 2022.

6 of the Smartest Reasons to Consider the Vivity IOL

[29] The Complete Patient Guide to the Vivity Lens Implant. Best Cataract Surgeons.

Vivity Lens Review – The Complete Patient Guide to the Vivity Lens Implant (IOL)

[30] Vivity Premium Intraocular Lens. Coastal Vision Medical.
https://www.coastalvisionmedical.com/cataracts-orange-county/vivity.html

[31] TECNIS PureSee IOL Clinical Study Results. Johnson & Johnson Vision. 2024.

[32] Vivity IOL Clinical Trial Results. Alcon Laboratories. 2021.

[33] TECNIS PureSee IOL FDA Clinical Data. 2024.

[34] AcrySof IQ Vivity IOL FDA Clinical Data. 2020.

[35] TECNIS PureSee IOL Defocus Curve Analysis. Johnson & Johnson Vision. 2024.

[36] Vivity IOL Patient Satisfaction Data. Alcon Registry Study. 2023.

[37] Extended Depth of Focus IOL Performance Metrics. International Standards. 2023.

[38] TECNIS PureSee IOL Optical Bench Testing. Johnson & Johnson Vision. 2024.

[39] Vivity IOL Optical Characterization Studies. Alcon Laboratories. 2021.

[40] Vivity IOL Power Profile Analysis. PMC Study. 2024.

[41] Wavefront-Shaping Technology Performance Analysis. Alcon Science. 2021.

[42] Contrast Sensitivity in Premium 10Ls. Review of Ophthalmology. 2023.

[43] TECNIS PureSee IOL Contrast Sensitivity Data. Clinical Studies. 2024.

[44] Vivity IOL Mesopic Performance. Clinical Data. 2022.

[45] MTF Analysis of EDOF IOLs. Optical Engineering Studies. 2023.

[46] Vivity IOL MTF Characteristics. Alcon Technical Data. 2021.

[47] Night Vision Performance in Premium IOLs. Ophthalmology Research. 2023.

[48] TECNIS PureSee IOL Photopic vs Mesopic Performance. 2024.

[49] Vivity IOL Illumination Dependency. Clinical Studies. 2022.

[50] Pupil Size Effects on EDOF IOL Performance. 2023.

[51] Vivity IOL Pupil Dependency Analysis. Alcon Data. 2021.

[52] Quality of Vision Questionnaire Validation. Ophthalmology Research. 2022.

[53] Visual Disturbance Assessment in Premium IOLs. Clinical Standards. 2023.

[54] TECNIS PureSee IOL Dysphotopsia Profile. Clinical Data. 2024.

[55] PureSee IOL Patient Satisfaction Survey. Johnson & Johnson Vision. 2024.

[56] Refractive vs Diffractive IOL Visual Disturbances. Comparative Study. 2023.

[57] Light Utilization in EDOF Technologies. Optical Analysis. 2023.

[58] Vivity IOL Dysphotopsia Clinical Trials. FDA Data. 2020.

[59] Vivity IOL Visual Disturbance Distribution. Registry Study. 2023.

[60] Wavefront-Shaping Visual Phenomena. Optical Research. 2022.

[61] X-WAVE Technology Visual Quality Analysis. Alcon Science. 2021.

[62] Patient Counseling for Premium IOLs. Best Practices Guide. 2023.

[63] Biometry for Premium IOLs. Clinical Guidelines. 2023.

[64] TECNIS IOL Biometric Calculations. Johnson & Johnson Vision. 2024.

[65] Refractive Targets for EDOF IOLs. Clinical Recommendations. 2023.

(66] 1OL Power Calculation Formulas. Updated Guidelines. 2024.

[67] AcrySof IOL A-Constants. Alcon Technical Data. 2024.

[68] Vivity IOL Refractive Targeting. Clinical Guidelines. 2022.

[69] Biometric Formulas for Vivity IOL. Alcon Recommendations. 2021.

[70] Surgical Techniques for Premium IOLs. Operative Guidelines. 2023.

[71] Ocular Surface Optimization. Preoperative Protocols. 2023.

[72] Capsulorrhexis Techniques for Premium IOLs. Surgical Standards. 2023.

[73] TECNIS SIMPLICITY Delivery System. Technical Specifications. 2024.

[74| Alcon IOL Delivery Systems. Technical Documentation. 2024.

[75] Astigmatism Management in Premium IOL Surgery. Clinical Guidelines. 2023.

[76] Corneal Relaxing Incisions vs Toric IOLs. Comparative Analysis. 2023.

[77] Complications in Premium IOL Surgery. Management Guidelines. 2023.

[78] Outcome Optimization in EDOF IOLs. Best Practices. 2023.

[79] Patient Satisfaction in Premium IOL Surgery. Quality Metrics. 2023.

[80] 1OL Selection Algorithms. Evidence-Based Guidelines. 2024.

[81] Premium IOL Counseling Protocols. Patient Education Standards. 2023.

[82] Postoperative Management of EDOF 1OLs. Clinical Protocols. 2023.

[83] Health Economics of Premium 1OLs. Cost-Effectiveness Analysis. 2023.

[84] EDOF IOL Technology Comparison. Systematic Review. 2024.

[85] Personalized IOL Selection. Future Directions. 2024.

Documento completato il: 23 Luglio 2025

Questo documento rappresenta una revisione scientifica basata su evidenze disponibili fino alla data di pubblicazione. Le raccomandazioni cliniche devono essere sempre integrate con il giudizio clinico individuale e le linee guida istituzionali specifiche.