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 Table of Contents  
Year : 2023  |  Volume : 3  |  Issue : 2  |  Page : 346-348

Persistent cyanopsia following non-diffractive extended depth-of-focus intraocular lens implantation

1 Department of Ophthalmology, Beaumont Eye Institute, Royal Oak; Department of Ophthalmology, Oakland University William Beaumont School of Medicine, Rochester, MI, USA
2 Department of Ophthalmology, Oakland University William Beaumont School of Medicine, Rochester, MI, USA
3 Department of Ophthalmology, Oakland University William Beaumont School of Medicine, Rochester; Department of Ophthalmology, Glaucoma Center of Michigan, Southfield, MI, USA
4 Department of Ophthalmology, Beaumont Eye Institute, Royal Oak; Department of Ophthalmology, Oakland University William Beaumont School of Medicine, Rochester; Department of Ophthalmology, Glaucoma Center of Michigan, Southfield, MI, USA

Date of Submission22-May-2022
Date of Acceptance18-Aug-2022
Date of Web Publication28-Apr-2023

Correspondence Address:
Amro A Omari
3535 West 13 Mile Road, Royal Oak, Michigan, 48073
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijo.IJO_1283_22

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We report the first case of cyanopsia following implantation of a non-diffractive extended depth-of-focus (EDOF) intraocular lens (IOL). A 79-year-old male artist underwent cataract extraction with a non-diffractive EDOF ultraviolet absorbing toric IOL (Alcon AcrySof IQ Vivity DAT315) and then experienced persistent cyanopsia in fluorescent lighting following surgery. His symptoms persisted and were visually debilitating. He underwent secondary IOL exchange with a yellow-tinted non-diffractive EDOF toric IOL (Alcon AcrySof IQ Vivity DFT315) and the recurrent cyanosis abated. Surgeons should be aware of cyanopsia following implantation of ultraviolet absorbing IOLs and be prepared to address these complaints should they arise.

Keywords: Cataracts, cyanopsia, extended-depth of focus (EDOF), implantation, intraocular lens (IOL)

How to cite this article:
Chao JT, Omari AA, Herrera AB, Siegel LI, Siegel MJ. Persistent cyanopsia following non-diffractive extended depth-of-focus intraocular lens implantation. Indian J Ophthalmol Case Rep 2023;3:346-8

How to cite this URL:
Chao JT, Omari AA, Herrera AB, Siegel LI, Siegel MJ. Persistent cyanopsia following non-diffractive extended depth-of-focus intraocular lens implantation. Indian J Ophthalmol Case Rep [serial online] 2023 [cited 2023 Jun 2];3:346-8. Available from: https://www.ijoreports.in/text.asp?2023/3/2/346/374892

Cataract surgery and intraocular lens (IOL) implantation have drastically evolved over the past few decades. New technologies with multifocal IOLs give surgeons more options to meet their patients' visual needs. The Alcon AcrySof IQ Vivity (Alcon, Fort Worth, TX) is a non-diffractive extended depth-of-focus (EDOF) IOL that was approved by the Food and Drug Administration in February 2020. It utilizes X-WAVE technology to provide an extended depth of range of vision while maintaining a side effect profile like a monofocal lens.[1],[2] Several lenses come in a yellow tint, which blocks short wavelengths such as blue light.[3] While similar IOL models come in a clear tinted version, there have been reports of patients who experience transient cyanopsia following IOL implantation.[4],[5] To our knowledge, we report the first case of cyanopsia following implantation of an Alcon Acrysof IQ Vivity IOL.

  Case Report Top

A 79-year-old male presented to the ophthalmology clinic for a cataract evaluation due to worsening of vision over the last few years. Aside from a remote history of a peripheral retinal tear in his left eye (OS) that was treated with laser retinopexy, his medical history was unremarkable. His corrected distance visual acuity (CDVA) was 20/25 in the right eye (OD) and 20/50 OS. Examination was significant for nuclear sclerotic cataracts OU and laser barricade around an anterior retinal tear OS. Intraocular pressures (IOP) was 15 mmHg OD and 13 mmHg OS. There was no afferent pupillary defect. His manifest refraction was +3.00 + 0.75 × 175 OD and +3.00 + 2.00 × 170 OS. His keratometry was 45.25/46.00 @ 177 OD and 45.75/47.00 @ 171 OS. The option of a Monofocal lens was presented to the patient due to the history of a retinal tear, even though it was outside the central visual axis. Due to the fact that the patient was a painter and wanted a good range of uncorrected vision with spectacle dependence for fine detail only, he expressed a preference for a EDOF IOL. However, he was concerned about issues with contrast vision. After extensive discussion and research on the patient's end, he preferred an EDOF IOL over a diffractive IOL due to the concerns about glares and haloes. He also preferred an EDOF IOL over a Monofocal IOL with the full understanding that he was not the normal candidate for an EDOF IOL. His reasoning was that the tear was so anterior that it had no functional impact on his vision. Therefore, a toric non-diffractive EDOF IOL was thought to be a good fit (AcrySof IQ Vivity DAT315) since it would provide good distance and intermediate vision without a significant glare profile when compared to other diffractive multifocal lenses.[6]

He underwent cataract surgery of the left eye, which was uneventful. His vision at distance and near was 20/25 postoperatively. However, he described significant cyanopsia OS that was only present with fluorescent lighting. He described the visual disturbances as a “blue and violet” hue around sources of illumination. These symptoms became more persistent after several weeks. He subsequently underwent a trial with yellow-tinted glasses that lead to a complete resolution in his visual symptoms. He was provided with reassurance and offered the option of waiting for possible neuroadaptation to the cyanopsia. Nonetheless, the patient was motivated to have an IOL exchange. The patient was also presented with an option of placing a similar lens in the fellow eye. The reasoning was that if done within the next few weeks, this would achieve neuroadaptation faster since the visual stimuli from both eyes would be equal. The patient refused to proceed without an IOL exchange in his left eye. He even sought a second opinion, and the other surgeon agreed that an IOL exchange would be the best option for him. The decision was made for a secondary IOL exchange within a few weeks of the initial surgery. The aim was to reduce the risks of the IOL exchange, as this would be more technically challenging once the lens capsule begins to fibrose. We were also confident that this would resolve his symptoms, since the yellow tinted glasses completely abated his cyanopsia. The exchange was achieved with the yellow tinted version of the EDOF IOL without the ultraviolet absorbing coat (Acrysof IQ Vivity DFT). Following the IOL exchange utilizing the “Twist and Out” technique originally described by Pandit et al., he noted full resolution of his cyanopsia on postoperative day 1 and was subsequently scheduled to have cataract surgery in his other eye.[7] Two months following his IOL exchange OS and cataract surgery OD, he was 20/20 in both eyes at distance and near.

  Discussion Top

Visual disturbances such as positive and negative dysphotopsia have been reported after cataract extraction and IOL implantation.[8] In positive dysphotopsia, patients describe streaks or arcs of light and typically a dark temporal crescent in negative dysphotopsia. Negative dysphotopsias are thought to be related to the square-edged haptics and overlap between the IOL optic and capsular bag. Management options include piggyback IOL, IOL exchange with an IOL of lower refractive index, and reverse optic capture. Many patients demonstrate neuroadaptation to negative dysphotopsias with conservative observation alone.[9]

As the crystalline lens ages, it develops yellow and brunescent hues, which aids in blockage of shorter wavelengths of light. Some cataract patients suffer from subjective visual perception of an overlying blue hue of varying intensity in their visual fields immediately following cataract surgery. This phenomenon, known as cyanopsia, is primarily due to sudden changes in transmission of light resulting from the switch of the aged crystalline lens in its cataract state to an IOL.[10] Shorter wavelength components hitting the retina are significantly increased by IOL replacement. However, this phenomenon is known to become less conspicuous after several weeks of IOL implantation, likely due to adaptation of color vision mechanisms. Hayashi et al.[4] reported no statistically significant differences in contrast sensitivity, glare profile, and CDVA in patients implanted with yellow-tinted IOLs versus clear IOLs. They did note that 13.9% (P = 0.0234) of their patients experienced cyanopsia 2 weeks after surgery in the clear-tinted IOLs and none in the arm with yellow-tinted IOLs. All patients reported resolution of their cyanopsia at their 3-month follow-up in their study.

A similar study by Miyata[11] that used a neutralization method found that at 1 month, 14.5% of patients with clear Monofocal IOLs described cyanopsia (P = 0.049), although there was no statistical significance at 3 months. To clinically identify patients with cyanopsia, they utilized chromatic plates in which patients with cyanopsia would label plates with a yellow tint as white. The authors also found that cyanopsia was more frequent in monocular IOL implantation versus binocular IOL implantation (P = 0.035) and recommended using a yellow-tinted IOL in cases of planned monocular implantation. Our report is consistent with this later finding as our patient's cyanopsia could be temporarily resolved with the use of yellow-tinted spectacles. Following implantation of the yellow-tinted IOL, our patient had immediate resolution of his visual symptoms. He had his second eye done two weeks after the lens exchange, also with the yellow-tinted version (Acrysof IQ Vivity DFT). At his one-month follow-up, he had no recurrence of his visual disturbances, and his visual acuity was 20/20 at distance and near with a final refraction of −1.00 + 0.75 × 027 OD and −1.00 + 0.50 × 168 OS.

Literature specific to cyanopsia in diffractive and non-diffractive IOLs is limited. However, several studies have noted differences in visual disturbances. Kohnen[12] conducted a study in which 25% of patients implanted with the non-diffractive AcrySof IQ Vivity IOL (Alcon) reported halos compared with rates of 60% to 70% reported for diffractive IOLs. The non-diffractive Vivity scored better on night visual acuity and produced less glare and halos than the same manufacturer's PanOptix trifocal.

Diffractive IOLs typically create two distinct images at near and far. A near-dominant central area is surrounded by concentric rings of decreasing height that diffract light to near and distance. EDOF IOLs create an elongated focus of vision. A combination of effects such as the echelette design, reduced chromatic aberration, and negative spherical aberration allows this lens to extend the depth of focus without compromising distance visual acuity. Visual disturbances are thus lower in EDOF IOLs as light is not “split” to provide several distinct foci.

  Conclusion Top

Multifocal lenses have a higher association with visual disturbances such as positive and negative dysphotopsia, and transient cyanopsia. As newer models and types of intraocular lenses are released, surgeons should be aware of the possible optical disturbances and the various options to manage them.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Ligabue E AR, Dick B, Devgan U, Wortz G, Whitsett J, Assil K, et al. In the pipeline: AcrySof IQ vivity. Cataract Refract Surg Today 2020. https://crstoday.com/articles/2020-apr/in-the-pipeline.  Back to cited text no. 1
Werner L. Intraocular lenses: Overview of designs, materials, and pathophysiologic features. Ophthalmology 2021;128:e74-93.  Back to cited text no. 2
Mukai K, Matsushima H, Sawano M, Nobori H, Obara Y. Photoprotective effect of yellow-tinted intraocular lenses. Jpn J Ophthalmol 2009;53:47-51.  Back to cited text no. 3
Hayashi K, Hayashi H. Visual function in patients with yellow tinted intraocular lenses compared with vision in patients with non-tinted intraocular lenses. Br J Ophthalmol 2006;90:1019-23.  Back to cited text no. 4
Nakano S, Miyata A, Kizawa J, Kurosaka D, Miyata K, Oshika T. Blue light-filtering and violet light-filtering hydrophobic acrylic foldable intraocular lenses: Intraindividual comparison. J Cataract Refract Surg 2019;45:1393-7.  Back to cited text no. 5
Winther-Nielsen A, Corydon L, Olsen T. Contrast sensitivity and glare in patients with a diffractive multifocal intraocular lens. J Cataract Refract Surg 1993;19:254-7.  Back to cited text no. 6
Pandit RT, Devgan U, Chapman JM Jr. Twist and out intraocular lens removal. J Cataract Refract Surg 2020;46:1072-74.  Back to cited text no. 7
Masket S, Fram NR. Pseudophakic dysphotopsia: Review of incidence, cause, and treatment of positive and negative dysphotopsia. Ophthalmology 2021;128:e195-205.  Back to cited text no. 8
Masket S, Rupnick Z, Fram NR, Kwong S, McLachlan J. Surgical management of positive dysphotopsia: U.S. perspective. J Cataract Refract Surg 2020;46:1474-9.  Back to cited text no. 9
Kitakawa T, Nakadomari S, Kuriki I, Kitahara K. Evaluation of early state of cyanopsia with subjective color settings immediately after cataract removal surgery. J Opt Soc Am A Opt Image Sci Vis 2009;26:1375-81.  Back to cited text no. 10
Miyata A. Neutralization method for detecting the incidence of color perception changes after cataract surgery. J Cataract Refract Surg 2015;41:764-70.  Back to cited text no. 11
Kohnen T. Nondiffractive wavefront-shaping extended range-of vision intraocular lens. J Cataract Refract Surg 2020;46:1312-3.  Back to cited text no. 12


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