Since presbyopia-correcting IOLS hit the U.S. market, starting with the AMO Array (Allergan; Irvine, Calif.), they’ve helped patients achieve at least partial freedom from glasses or contacts. According to the International Society of Refractive Surgery’s 2015 U.S. Trends in Refractive Surgery Survey1, presbyopic IOL implantation is not a high-volume surgery, although new lenses keep emerging on the American market.

The additional patient costs for presbyopic IOLs and the risk of nighttime visual symptoms may be barriers to their adoption, and suitable candidates require care and attention when choosing the best lenses to meet their visual goals. Below, experienced surgeons discuss lens planning for presbyopic IOL patients.

Eye Health

Ocular health makes presbyopic lens selection possible. “Obviously, do all the testing, including topography, and make sure the patient doesn’t have dry eye. I think the topography and the health of the cornea and the retina are the most important things,” says Jennifer Loh, MD, of Loh Ophthalmology Associates in Coral Gables, Florida. “You really have to make sure there’s no other pathology that’s going to affect the patient’s outcome, and if there’s some treatable pathology, such as dry eye, treat it right away. That’s number one,” she says.

“I’m a big believer in repeating tests: Measure twice, cut once,” adds Dr. Loh, who doesn’t limit her screening to covered services. “You can do an OCT of the macula to rule out retinal pathology. If a patient actually has macular degeneration, for example, then it’s a covered service, but not as a screening test. Corneal topography and OCT of the macula are not covered services. Patients have to have a problem like keratoconus or retinal pathology to get these paid; insurance won’t cover either as a screening tool. But they’re important because you can pick up so many things that will affect outcomes,” she says.

Stephen V. Scoper, MD, vice president of Virginia Eye Consultants in Norfolk and a consultant to Alcon, evaluates testing performed by his staff to see if his patients meet the criteria for a multifocal. “I examine the patient, of course, and I look at all of the testing,” he says. He offers suitable patients the AcrySof IQ ReSTOR +2.5 multifocal IOL with Activefocus (Alcon; Fort Worth, Texas) or the toric version. “If I know the patient is interested in an Activefocus, I’ll look at the topography and the keratometry to see how much astigmatism they have. I’ll look at their higher-order aberrations. I’ll look at the angle kappa. I’ll look at the macular OCT to make sure their macula is completely normal, and I’ll put fluorescein in their eye to make sure they don’t have significant ocular surface disease,” he says.

Patient Expectations

Once screening is complete, Dr. Loh starts talking to her patients to help them select the best presbyopic IOLs. “Assuming you have a person who is physically a suitable candidate for presbyopic lenses, really trying to understand what they want by listening to what they say is critical,” she says. “I’ll repeat some of my questions for them a few times, just to make sure that they understand.” Dr. Loh also uses a short written questionnaire for prospective refractive surgery patients to learn more about their visual priorities, and the CheckedUp system (Cirle; Miami, Fla.) to educate them about refractive cataract surgery and IOL selection. “Using a little iPad, really well-developed, cartoonlike videos explain the basic concepts of cataract surgery and the different types of lenses to the patient,” she says. “You still need to talk to your patients a lot, of course, but it helps to introduce the topic.”

Dr. Loh handles the lens-selection talks with her patients. “I want to find out about any hobbies, occupations and preferences they have for their vision. Some people just want to
The toric version of the Tecnis Symfony extended-depth-of-focus IOL is designed to offer good vision across all distances while remediating astigmatism.
do computer work and have distance vision to play golf and sail.  Other people really want to read up close.” She notes that some presbyopic IOL candidates have surprisingly specific visual goals. “For example, I saw an attorney who told me point-blank that he expected to see without glasses at exactly 12 inches from his face,” she recalls. More often, however, it takes careful listening and questioning to make sure that surgeon and patient have a mutual understanding of near, mid-range, and distance vision. “There’s a wide range of near tasks, so someone telling me that they want to see ‘up close’ may have a totally different concept of what means from anyone else,” she says.

Dr. Scoper relies on his technicians and counselors to screen for suitability for a presbyopic lens. “We do all the testing and counseling before the patient sees the doctor. I’m a big believer in the idea that the doctor should do only what only a doctor can do. So I don’t do things like explaining to a patient what cataracts are, what astigmatism is, or the types of lenses that are available. I’m lucky to have a great staff that does that before the patient comes to me,” he explains.
Dr. Scoper spends a few minutes making sure patients know what to expect once he has confirmed that they are good candidates for the Activefocus IOL. “I have a little speech,” he says, “and it goes like this: ‘I can’t give you everything, but I can give you a lot. Let me tell you what I can do for you and what I cannot do for you. Number one, this lens will give you great distance vision without any glasses. You’ll be able to get up in the morning and not need glasses to watch television and drive. The second thing it will do is bring the distance vision’s clarity in to arm’s-length vision. An example of this would be that when driving, you’ll be able to see street signs and other cars at distance, but you’ll also be able to see the dashboard of the car. You’ll be able to see the kitchen counter when you’re cutting up vegetables. You’ll be able to see the peas on your plate when you’re eating. You’ll be able to see your computer and your desktop. Arm’s-length vision will be very good. What it will not do is allow you to see small print up very close, nor medicine bottles or price tags. If you’re going to read a novel for an hour, you’re going to be more comfortable with a light pair of reading glasses. Does that sound good to you?’ They usually say, ‘I understand. Let’s do it.’ ”

Visual Goals

Although newer presbyopia-correcting IOLs offer satisfactory visual results at more than one focal point, surgeons and their patients still need to prioritize. “I think there’s been a paradigm shift regarding what doctors think is important to patients,” says Dr. Scoper. “Early on, I and other surgeons focused heavily on near vision. With some of the early generations of multifocals, patients’ distance vision wasn’t as clear as it would be with a monofocal lens, but we had never talked about good distance vision and patients just assumed that they would end up with good distance vision. The number one thing that patients want but don’t know to ask for is good distance vision. As surgeons, our primary goal should be good distance vision no matter what. That’s what patients really need and want.”

Multifocal and accommodative lenses emerged and developed roughly in tandem with the growing ubiquity of screens. This has implications for presbyopic IOL selection, according to Dr Loh. “I think for most people mid-range is very important, but still, I’d never assume that. I always ask. You still find some people who never use a computer. I think most people want to see their cell phone and their computer without glasses, though.”

When Dr. Scoper discusses visual goals with his patients, he emphasizes other activities of daily living to clue them into the focal point he deems second in importance to distance vision: arm’s-length vision. “I used to talk mainly about computer vision when I described this to them, but now ‘computer’ is about the fourth or fifth word I use. The first example I give is seeing the dashboard of your car, and then seeing the kitchen counter when you’re cooking and cutting up small vegetables,” he says. “So much of your world is at arm’s length. When you’re sitting and having a conversation with somebody and you can see their face and their eyes, that’s so much more important than being able to read small print. But I also tell patients that if they’re going to sit down and read a book or magazine for an hour, they’ll have to put on a light pair of dollar-store cheaters and turn on some good light to be comfortable.”

Although he is acutely concerned about creating unrealistic expectations, Dr. Scoper says that in some cases he can, in fact, give patients good near vision by putting an Activefocus in the dominant eye, and then a ReSTOR 3.0 in the nondominant eye. “But I don’t promise that,” he stresses. “I don’t even hint. I try to under-promise and over-deliver on that.”

 Dr. Scoper also tries to avoid overwhelming patients with presbyopic lens options. “I think it’s important for a doctor to give one recommendation to the patient. They don’t want five different things to choose from. They just want to know what’s best for them,” he says.

Dr. Loh says that she doesn’t try to limit patients’ IOL options initially. “When I discuss the lenses with them, letting them know the pros and cons of each option, I get a little more feedback from them before I offer my recommendation of what I think would be best, but I still talk to them about everything. I’ve found that everyone has a different idea of what they’ll be getting. You can’t assume anything about people’s expectations,” she says.

Once a patient settles on a presbyopic IOL, Dr. Loh uses her chair time with him or her to manage expectations one more time. She emphasizes that perfect spectacle independence is not assured. “I do tell patients that there is a really high likelihood that they will need light readers. I almost exaggerate that point a little bit, because I find that it’s better to put that out there from the beginning than to let them think that they’re not going to wear glasses,” she says.

Regarding the possible need for a postop enhancement, Dr. Loh says, “I do warn patients ahead of time that sometimes it can take more than one surgery to get everything correct.” She adds that it’s not a big topic of conversation, however, except on the rare occasion that a patient is truly unhappy postop.

Dr. Scoper says he will do a touch-up at no charge if necessary, but also emphasizes that it’s a rare occurrence. “I use the expanded version of the Hill RBF formula, and the last time Dr. Hill ran my numbers, the percentage of patients I hit ±0.5 D was 97 percent of all the patients I did. So I don’t even talk about enhancements in advance. The counselors may mention it, but I’m doing very few enhancements.”


Sometimes a patient’s response on a preoperative questionnaire or even the verbal feedback they give in discussion fails to fully clarify what they really want. Both doctors say it’s important to carefully observe patients to spot factors that can strongly affect their satisfaction with presbyopia-correcting lenses.

While interacting with her patients, Dr. Loh is also assessing how their body type may influence their concept of near or intermediate distance. “If someone is really tall and has longer arms, they’re going to have a different focal point than a petite female with shorter arms, for example” she says. “The distance they’ll want to read from is very different, and that is a key point.” Dr. Loh cautions against relying on observations alone or just the patient’s questionnaire answers, however. “You really have to look at the patient, but you also have to ask them where they like to read,” she stresses. “Obviously, you can look at body type and make some assumptions, but you’d still  better ask, because you don’t know people’s true preferences.”

For Dr. Scoper, body type determines whether he can mix and match lenses for a select group of patients, placing a mid-range-power multifocal in the dominant eye and one with a stronger add in the nondominant fellow eye. “I do it if they’re five-foot-zero and their arms are just too short to really be able to use their intermediate vision,” he says. “I can give them more by adding that in.”

Observing the patient’s near reading behavior preoperatively is also key, says Dr. Loh. “Someone who’s already doing monovision naturally or with contact lenses, or who happens to be a moderate to high myope may say, ‘Well, I still take my glasses off to read.’ That really alerts me to the fact that I have to take extra care when offering presbyopic lenses,” she says. “One of the biggest pearls ever taught to me is to find out what the patient’s vision is without their glasses. It sounds kind of simple, but if you can’t make them better than they are now without their glasses, they’re not going to be happy. If someone is a moderate to high myope, if they can already read well without their glasses, say at J2 even with a cataract, if you put in an EDOF or a multifocal lens and then they’re J4, you might think you have a successful case. But they’re going to say, ‘That’s not better! I could see J2 without my glasses!’ So knowing where they’re starting from is critical,” she says.

Dr. Scoper also makes a point of asking his myopic patients when they wear their glasses. “If I’ve got someone who is a -5 D or above, I know that their near focal point is too close to be very practical. I’ll treat them like an emmetrope, like anybody else,” he says. “But if I’ve got someone who’s a -2 D, -2.5 D, or -3 D, the first question I ask them is, ‘Do you wear your glasses all day long and just look at things through your bifocal at near, or do you take your glasses off a lot for near?  If they answer, ‘I leave my glasses on all day long, and I never take them off when I want to look at near,’ then I’m going to go for good distance and maybe intermediate vision. But if as a -2 D, they say, ‘Once I walk into the house, I leave my glasses off the whole time. The only time I put them back on is to watch television or drive,’ I know they really love that uncorrected near vision. They can look across the room and their brain is used to the blur at distance. They just put their glasses on when they have to have good distance vision. If that’s the only time that a -2 D wears his or her glasses, I’m going to leave them at -2 D with a monofocal lens,” he says. “If they’ve got some astigmatism I’ll correct it with a toric or the laser. I’m going to leave them nearsighted, because their brain has gotten used to that uncorrected near vision. I may make one eye -2.25 D and the other eye -1.5 D to -1.75 D and give them a little intermediate blended with near.”

“A lot of these patients who read well without glasses don’t even realize it,” says Dr. Loh. “I know that sounds strange, but they’re just so used to it that they don’t think it’s anything special. They won’t report it to you because they just think it’s normal. You can tell somewhat based on someone’s refraction: If someone’s a hyperope, for example, a +3.50 D, they’re not going to be able to read at all without glasses. But if they’re a myope, you’d better ask them things like, ‘Are you reading without your glasses?’ and ‘Can you take your glasses off and read this card for me?’ Or you may recognize it if they say something like, ‘I’m really lucky. All of my friends have to wear reading glasses, and they’re all jealous of me because I don’t have to.’ I’ve really learned to pay attention to this.”

Evolving Lenses

Dr. Loh doesn’t rule out presbyopia-correcting IOLs for patients who’ve been happy with monovision, but she does caution them about attempting to fix what’s not broken. “I get patients that use contacts for monovision, and they’ve done this for 20 years and they love it. When I hear that, I usually tell them that I think we should recreate that surgically. They like it, they’re used to it, and I’ve found that changing it can be a problem. So in that case, I’ll usually say, ‘Look. There are these other lenses out there, multifocals or EDOF, that will give good distance and intermediate vision and some near vision binocularly, and that may be beneficial to you, but you’re really used to your monovision and you seem very happy with it. I think keeping it would be in your best interest.’ So sometimes I’ll steer people away from the multifocal or EDOF lenses because of that. But if they want to try them, that’s fine. It’s important to really make them understand the pros and cons of each situation.”

Dr. Scoper will try placing a presbyopic IOL in the dominant eye to give good distance and intermediate, with a monofocal targeted for near vision in the nondominant eye in those patients who are well-adapted to monovision. “In their nondominant eye, I’ll place a monofocal lens focused exactly to where they’re used to, whether it’s -2 D, -2.25 D or -2.5 D,” he explains. “We’re then able to give t
A 2013 study4 comparing the visual acuity of patients bilaterally implanted with ReSTOR 2.5 IOLs to patients with a ReSTOR 2.5 in the dominant eye and a ReSTOR 3.0 in the nondominant eye at six months showed that the blended-vision patients gained significantly greater near UCVA, with only slightly lower intermediate and distance UCVA.
hem more with intermediate vision in the dominant eye, and they love that,” he reports.

 Studies suggest that one way to improve near vision and thereby increase patient satisfaction with EDOF lenses like the Tecnis Symfony is to employ a blended-vision approach by targeting the dominant eye for emmetropia and the nondominant for slight myopia.2,3

Both doctors say their presbyopic lens patients have few complaints about night vision. “I usually don’t get too many complaints about it, but I do warn them ahead of time,” says Dr. Loh. “I have had some patients who’ve had some glare and halos: Luckily, I haven’t had anyone tell me it’s been horrible or debilitating. But they’ll comment on it sometimes.”

Dr. Scoper reports essentially the same thing. “I may hear just a comment or an observation that rings and halos and glare are present, but it’s really not a problem,” he says. He also advises his patients to expect some postoperative nighttime visual symptoms. “I tell them that they’ll see some glare and rings around headlights and streetlights at night, simply because the implant actually has rings in it. But I also tell them that it gets better within three or four months to the point that usually, they’ll hardly notice it,” he adds.

Dr. Scoper notes many patients experienced troubling nighttime symptoms and blurry distance vision with earlier generations of multifocal IOLs, and notes that visual outcomes are improving as the technology evolves. “I think that many surgeons felt like they were burned with some of the original multifocals because there was a small group of patients who really didn’t do well,” he says.

“I have the most familiarity right now with the Symfony (Johnson & Johnson Vision; Santa Ana, Calif.) and I have used the new Activefocus from Alcon as well,” says Dr. Loh. “Both feature improvements over the earlier presbyopic lenses in that they give more intermediate vision, which is becoming more important to a growing number of patients than the reading of fine print. They do that at a cost sometimes to book-reading near vision and other up-close reading, though.” Dr. Loh adds that as the lenses improve to provide better vision across a wider range of vision, talking to your patients remains critical to their satisfaction. “What I’ve learned is that everyone has a different idea of great vision, and I think that in order to really make someone happy, you have to find out what they really want,” she says.  REVIEW
Dr. Loh is a consultant for Johnson & Johnson Vision, Allergan and Sun Ophthalmics, and a speaker for Shire. Dr. Scoper is on the speakers’ bureau and consults for Alcon, and is on the speakers’ bureau of its parent company, Novartis.

1. International Society of Refractive Surgery. ISRS 2015 U.S. trends survey. Accessed 6 December 2017.
2. Cochener B, Concerto Study Group. Clinical outcomes of a new extended range of vision intraocular lens: International multicenter Concerto Study. J Cataract Refract Surg 2016;42;9:1268-1275.
3. Breyer DRH, Kaymak H, Ax T, et al. Multifocal intraocular lenses and extended depth of focus intraocular lenses. Asia-Pacific J Ophthalmol 2017;6;4:339-349.
4. Carones, F. (2013 October). Six-month results from an aspheric apodized diffractive multifocal IOL with a +2.5 D add power. Poster presented at the 31st Congress of the European Society of Cataract and Refractive Surgeons, Amsterdam, the Netherlands.