The Art and Science of Presbyopia Correction: Navigating the IOL Patient Journey

Presbyopia-correcting IOLs have undergone a dramatic transformation in recent years. The once-limited options for patients seeking reduced spectacle dependence after cataract surgery have evolved into a diverse and sophisticated array of IOL technologies, including trifocal, extended depth-of-focus (EDOF), small-aperture, light-adjustable, and accommodating lenses. This progress, however, has heightened patient expectations and increased the complexity of clinical decision-making, requiring more nuanced conversations around risk, candidacy, and outcomes.

Today’s patients are not only well informed—many arriving at consultations with anecdotal comparisons and lofty goals—but also diverse in their visual needs, lifestyle demands, and ocular anatomy. At the same time, the availability of advanced diagnostics such as iTrace, OPD-Scan III, and ray-tracing aberrometers has given clinicians a more refined understanding of corneal aberrations, dysfunctional lens indices, and visual performance metrics. This precision enables a more personalized approach to IOL selection but also requires thoughtful integration of biometric data, ocular comorbidities, patient psychology, and even personality traits.

In an in-depth interview with Ophthalmology Times, Zach R. Balest, MD, a staff ophthalmologist at North Georgia Eye Associates, and Lisa K. Feulner, MD, PhD, chief medical officer and founder of Advanced Eye Care & Aesthetics in Bel Air, Maryland, provide a candid look at how leading cataract surgeons approach IOL counseling, manage expectation gaps, and tailor premium lens strategies to the unique anatomy and goals of each patient. From technology utilization to the role of artificial intelligence (AI) to the clinical red flags that influence lens selection, this discussion explores both the art and science of modern presbyopia correction.

This interview has been edited for length and clarity.

Ophthalmology Times: Presbyopia-correcting IOLs have come a long way in recent years. How have patient expectations changed?

Zach R. Balest, MD: Patient expectations with cataract surgery have never been higher. It seems every patient knows someone who has had surgery and no longer needs any correction, and many walk in the door with that expectation. Although this outcome is not realistic for everyone, we have a great deal of technology at our disposal that can help achieve great outcomes with varying levels of spectacle independence. In my experience, the most vital part to ensuring a happy patient is setting realistic expectations prior to surgery based on each patient’s individual case.

Lisa K. Feulner, MD, PhD: Cataract surgery has become more of a refractive procedure these days due to increased patient expectations for spectacle-independence. Presbyopia-correcting IOLs can provide patients with near spectacle-free vision; however, not all patients are ideal candidates for such IOLs. For instance, presbyopia-correcting IOLs are not recommended for patients with coexisting corneal comorbidities due to the increased risk of reduced contrast sensitivity and increased photic phenomena owing to the presence of increased corneal higher-order aberrations (HOAs). Also, inaccurate IOL power calculations due to altered anterior-to-posterior corneal curvature ratio can lead to refractive surprises after cataract surgery. Newer IOL technologies that can extend the depth of focus and reduce the impact of corneal aberrations are now available for patients with compromised corneas.

When you meet a patient interested in lens surgery for presbyopia, what’s your overall approach to evaluating their candidacy and setting the tone for that discussion?

Balest: I start the process with all IOL categories on the table and remove individual options as we go. Given the significant number of IOLs available, it is important to narrow down the options, so the patient is not overwhelmed. I use the exam and preoperative testing, which includes biometry, corneal topography/tomography, and retinal optical coherence tomography, to remove options that will not work well for that individual patient.

Then I have a discussion with the patient, with the goal of narrowing the list down to only a couple of options. I discuss the patient’s hobbies and visual goals for after surgery. I like to know at what distances they are using correction currently and what they are willing to do after surgery. I also determine whether their priority is to achieve the highest-quality vision with less nighttime symptoms or as much spectacle independence as possible. I then present the remaining options to the patient, making sure to explain the pros and cons of each option.

Feulner: Standard monofocal IOLs only restore vision at 1 focal point and can be used in most patients, resulting in excellent vision with or without glasses. To address the limitation of needing glasses for other focal points, newer IOLs utilizing different technologies have been developed to reduce spectacle dependence, extend the depth of focus, and improve uncorrected intermediate and near vision. Previously, patients with comorbid corneal disease have been limited to monofocal options, often resulting in total dependence on spectacle correction, but newer IOL options to improve spectacle independence are now available to a broader subset of these patients.

I start with a standard lifestyle questionnaire, which I review prior to meeting the patient. The questionnaire gives me clues to the patient’s visual difficulties, lifestyle, and expectations before I enter the room. It’s important to assess the patient’s personality, visual goals, health and ocular history, and exam to match the right lens choice to the patient. Based on this, I am already considering whether the patient would be best suited for a monofocal with distance or near, monovision with an enhanced monofocal, or mini-monovision. Are they suited for a multifocal, trifocal, or EDOF for more spectacle independence, or do they have a history of prior refractive surgery or corneal abnormalities that make them a better candidate for a small-aperture IOL or a light-adjustable lens?

Advanced technology lenses work best in pristine eyes. Problems with ocular alignment, pupil size, ocular surface disease, irregular astigmatism, corneal dystrophies, scarring, and diseases of the retina and optic nerve limit successful utilization of these technologies

Once I have reviewed the lifestyle questionnaire, past medical history, and ocular history, I review the data collected by an OPD-Scan III and an iTrace. Both technologies help me quickly assess a patient’s candidacy for a lens beyond a monofocal. I work off an iPad and often review this data quickly before I enter the room. With the OPD III I’m looking at:

• Placido rings: clear, sharp, concentric
• Corneal total coma HOA: < 0.32
• Astigmatism: regular vs irregular
• Angle κ (the angular distance between the pupillary axis and visual axis): < 0.6
• Chord mu (the 2-dimensional linear distance between the center of the pupil and the cornel light reflex; often used to approximate angle κ)
• Angle α (the angle between the visual axis and the optical center, ie, how much the visual axis is offset from the geometric center): < 0.5
• Photopic and mesopic pupils: > 3 mm photopic and < 6 mm mesopic
• Root mean square value: higher than .43 at the 3-mm zone (ie, HOAs are influencing the visual system)

The iTrace lets me evaluate their corneal quality (corneal performance index) both in photopic and mesopic settings and the impact of their cataract (illustrated by the dysfunctional lens index), and then it concisely combines the two to give me a Quality of Vision Index score. This is helpful to quickly determine whether the degree of cataract is consistent with their visual complaints and visual acuity or whether I should be looking for other pathologies. The iTrace also gives me an excellent evaluation of their tear film and ocular surface. I can evaluate the data generated by these 2 technologies in less than a minute. This really cuts down on the time I spend with patients discussing lenses that they are not candidates for while giving me an opportunity to visually show the patient how different IOLs can meet their expectations. Then, of course, I examine the patient and evaluate the ocular surface, cornea, optic nerve, and retina.

How do you explain the differences between monofocal, multifocal, EDOF, light-adjustable, accommodating, and small-aperture IOLs to patients?

Balest: For patients with lower amounts of corneal astigmatism, I let them know that a monofocal IOL provides very high-quality vision at 1 distance but that it has the least amount of range out of our options. I tell them that the trifocal is going to provide the greatest range of vision but that it does come with some trade-offs such as halos/glare at night and the potential of slightly reduced quality of vision. I like to describe EDOF lenses as hybrid lenses that provide some extra range of vision but with adverse effects similar to a monofocal; I also let them know that the near vision is a little less predictable in that category, with some patients having better near than others.

More recently, we have had the benefit of small-aperture IOLs, which I explain work differently and are able to provide a good range of vision, with the downside being some patients notice dimness in the treated eye compared with the other eye. I also utilize a lot of blended/mini-monovision in my practice and discuss that option when warranted.

Feulner: I have a similar conversation with my patients although I don’t use the term reduced quality of vision. I say that multifocal and trifocal lenses can give them an extended range of vision but that like all the options, there are compromises to consider. If they do a lot of up-close work, they may still need to wear readers; they may see circles around lights at night, but many people adjust to this over time; and they must commit to maintaining their ocular surface to ensure good-quality vision for a lifetime.

For EDOF IOLs, I explain that they will have good functional intermediate and distance vision but a more limited range of vision. Choosing to leave them a little minus helps, but they may still need glasses for some near tasks. However, they are unlikely to have nighttime dysphotopsias associated with the other lenses.

I explain to patients who previously wore monovision contact lenses or are post LASIK/photorefractive keratectomy (PRK) that they will get “monovision plus” with the small-aperture IOL—that instead of 1 eye with 1 near focal point and 1 eye with a distance focal point (which can impact depth of vision and night driving), they will have a full range of intermediate to distance vision in 1 eye without compromising their stereo vision at distance. I also talk about the “dimming effect” in low light (a characteristic of small-aperture IOLs) but haven’t found it to be much of a problem in patients who are not candidates for a trifocal/multifocal because of concerns about dysphotopsias or who have high HOAs, irregular astigmatism, or peripheral corneal abnormalities. Small-aperture IOL gives these patients a presbyopic solution that they otherwise would not have.

Where does each IOL shine based on your experience in the clinic?

Balest: Each category of IOL has its place where it shines. I utilize all categories of IOLs as well as multiple different manufacturers, and I believe that we have to try to match each individual patient to the right IOL for them. I tell patients all the time that there is no “best lens.”

The trifocal is a great option for patients with healthy eyes, a desire for near-vision spectacle independence, and a willingness to accept the potential nighttime symptoms and possibility of less-than-perfect vision due to decreased contrast. The EDOF lenses, especially when utilizing a blended vision approach, work well for those who are not good candidates for trifocal IOLs but want increased range of vision. The small-aperture IOLs have opened the door to patients who previously would not have been good candidates for presbyopia correction. The Bausch and Lomb IC-8 Apthera IOL provides good distance, excellent intermediate, and functional near vision. It works well in less-than-ideal corneas and has the benefit of correcting up to 1.5 diopters of corneal astigmatism without having to worry about cylinder orientation. Since this lens is only utilized in the nondominant eye, it is a good option for patients who may not be a candidate or able to afford a premium IOL in both eyes.

Feulner: I have a very similar discussion, but I wouldn’t put affordability as a determining factor because I often (off label) put this in both eyes of patients with radial keratotomy or keratoconus or post LASIK. Also, sometimes these patients need a toric lens in the distant dominant eye.

How does the patient’s anatomy, lifestyle, and budget factor into determining the right IOL? Are there IOL types that carry higher rates of certain issues?

Balest: As mentioned earlier, the first step is to eliminate options based on the patient’s anatomy and testing. After that, the patient’s hobbies/activities and preferences for spectacle wear are considered to narrow down to the best fit for that patient. All of our latest IOLs have better adverse effect profiles than previous generations, but trifocals still carry a higher risk of positive dysphotopsias than other IOL categories

Feulner: Offering too many choices without a clear recommendation from the surgeon often leads to greater confusion and stress for patients. Diagnostic tests, such as corneal topography, biometry, and optical coherence tomography, in addition to a dilated exam and refraction give clinicians an idea of the patient’s lens options before lifestyle factors help narrow the options.

What are the clinical or behavioral red flags that tell you a patient may not be a good candidate for a presbyopia-correcting IOL, even if the eye looks suitable?

Balest: Historically, it was common practice to avoid multifocal/trifocal IOLs in patients with type A personalities as they were less likely to tolerate the compromises associated with this category of lenses. As technology and the performance of these lenses have improved, the door has opened to some patients who would have previously been excluded. I am still cautious with patients who are demanding perfect vision at all ranges—“I never want to wear glasses again”—or have required multiple remakes of glasses in the past, but I am more open to placing current-generation IOLs once the patient is fully informed of the nuances of presbyopia-correcting IOLs and still desires this option.

Feulner: I agree with Zach. I usually have a dialogue that is something like this: “Most patients see clear circles around headlights at night; however, the majority of patients don’t notice them after about 6 months. Some patients still see the circles after 6 months but aren’t bothered by them because they are happy to be spectacle free most of the time. But there are a small percentage of patients who still see them at 6 months and find them distracting. If you feel that you would find them distracting or seeing them would make you unhappy, don’t choose this option.”

That dialogue seems to weed out the people less likely to be successful with these lenses a majority of the time.

How do you address patients who come in with anecdotal evidence—“My friend got this lens and loves it”—without undermining trust?

Balest: The main point I stress is that every eye and surgery is different and that outcomes will vary due to this. I emphasize that I will utilize all available options to produce the best outcome for them based on their individual anatomy and measurements.

Feulner: I agree with Zach. However, I find the opposite situation is more common. Many more patients come in complaining that a friend had the lens and hates it. I say something similar to Zach but also state that, as they will see, we will spend a lot of time ensuring that they are the right candidate and use multiple technologies to ensure that our measurements for the correct IOL are as precise as possible.

How do you utilize technology and visual examples to help explain ocular aberrations and potential outcomes to patients when having these treatment discussions?

Balest: We have brochures and digital methods of demonstrating astigmatism correction and presbyopia correction, but one of the most effective methods I have found is the Prime Dashboard on iTrace. This allows the patient to easily visualize the difference that astigmatism correction will make in their particular case. In the future, I expect virtual reality to become a common method of allowing patients to experience their options firsthand.

Feulner: We also use the iTrace to simulate the improvement that a small-aperture IOL can make as well as a toric IOL. Both the iTrace and OPD III have great visual simulations to help show patients the impact of the corneal surface, astigmatism, etc. We also use topography and placido rings to show astigmatism and ocular surface disease to help drive home the message that we need to prepare the ocular surface before we do biometry. We show videos that discuss and demonstrate the outcomes of each option. We now send out emails ahead of time with links to the information so that patients are prepared and educated when they come in for the evaluation.

Educating and showing patients the impact of HOAs continues to be challenging.

Where do you see the biggest education or expectation gaps in a typical patient’s premium-IOL journey?

Balest: It’s unfortunate that patients often present to their surgical evaluation with no prior education about IOL technologies from their primary eye care provider. As a field, we could provide better education to patients ahead of time so they can come to their appointments well informed and prepared with questions specific to their situation.

Feulner: I find that patients are increasingly more educated than they have ever been. There is a lot of information on social media and through internet searches, so patients are investigating, in many cases, before they get to the office. The biggest gap in education from my standpoint is, as mentioned earlier, that every patient is different and that even though a friend may be spectacle free after surgery with a basic implant, we can’t be sure of their uncorrected visual acuity or refractive error. I find the discussion with patients about their family and friends’ outcomes the most difficult to address. More disease-state awareness would help.

How do you counsel patients about potential surgical risks or the need for enhancements?

Feulner: I discuss the possibility for a refractive touch-up at the end of my risks-benefits-alternatives discussion. We don’t charge ahead of time because it’s not a common problem, so I tell them that there may be a fee if we need to that after surgery.

Once a patient commits to a premium IOL, how do you maintain their confidence and prevent buyer’s remorse before surgery?

Feulner: I tell patients that I’m putting the equivalent of a Porsche in their eye and that they will need to maintain their eyes with treatment of the ocular surface and regular follow-ups to ensure the lens is optimally performing—just like they would have to maintain air in the tires, oil changes, and tune-ups for optimal performance of a Porsche. This seems to help them understand what they are purchasing, and truly committed patients go into it with full knowledge.

What do you tell patients who are dissatisfied after surgery?

Balest: Being very up-front and discussing the potential complications prior to surgery make these conversations easier to have should they occur. Thankfully, we are able to correct many of the most common issues patients have following surgery. I make sure to give the patient the time they need to fully explain the issues they are experiencing, express understanding, and then let know we will work together to come to the best solution we can.

Feulner: Dissatisfaction post-op is so open-ended. There are many reasons for dissatisfaction: Some are lens/surgery based, some are ocular surface or posterior capsular opacification based, and some are imagined. Determining the reason is most important. Usually, the first 2 issues have manageable solutions. The latter can present the most frustrating and difficult dilemma to solve. Usually in these patients I offer to take the lens out.

Where do you see AI enhancing the cataract- or presbyopia-correction process?

Balest: In the near future, I expect AI to be integrated into IOL formulas to increase the accuracy of refractive outcomes.

Feulner: AI will help us technically be more precises as Zach said but also will help patients and doctors decide which choice is the best for an individual by incorporating personality, hobbies, career, and eye findings.

What barriers could slow AI adoption in cataract and refractive practice, and how can clinicians stay ahead?

Balest: Anytime you incorporate new technology into clinic workflows, it can lead to inefficiency while working out the kinks. Sometimes knowing this can make it tough to take the leap. Making sure everything is streamlined to minimize disruption will be vital to widespread adoption.