Boosting premium IOL confidence through a mix-and-match approach

Nationally, the proportion of patients who choose premium IOL implantation is considerably lower than the share of those who would benefit from advanced lens technology. Cost is a barrier, but it is not the only nor the primary one. Concerns about an increased risk of glare, halo, or loss of contrast compared with a monofocal IOL are a major reason for the lack of adoption by patients—and by surgeons, as well.¹

Psychologists have long described something called the approach-avoidance conflict, in which a person experiences internal tension between a desirable outcome (spectacle independence, in this case) and an undesirable one (potential adverse effects or complications). The internal conflict can create anxiety and typically leads people to procrastinate or experience decision paralysis. I have found that when this occurs in the context of IOL selection prior to cataract surgery, the result is often to simply choose standard lenses. The patient concludes they will not regret not spending the money to upgrade, but, of course, they also miss the opportunity to optimize their vision and increase spectacle independence.

Lately, I have been taking a mix-and-match approach, slowing the decision to just one eye at a time. This approach “de-risks” the choice for the patient, relieves some of the stress and uncertainty, and helps the patient feel more in control of their visual outcome.

The mix-and-match process

First, I try to determine the patient’s primary concern. If they really want to be spectacle-independent and not have to wear readers after surgery, I anticipate that they will probably want bilateral full visual range (FVR) lenses (sometimes also called full depth of field). I implant my preferred FVR lens (Tecnis Odyssey IOL; Johnson & Johnson Vision)² in the nondominant eye first. At the 1-week follow-up, if the patient is happy with their vision results, I implant the same lens in the dominant fellow eye. If they are in any way displeased with their distance vision, I implant a purely refractive extended depth of focus (EDOF) lens (Tecnis PureSee IOL; Johnson & Johnson Vision)³ in the dominant eye.

On the other hand, if the patient’s primary concern is maintaining good distance vision and they are nervous about potential quality-of-vision issues such as nighttime glare, I will implant the PureSee lens first in the dominant eye and determine at the 1-week follow-up whether I should implant that lens bilaterally or opt for an FVR lens in the nondominant fellow eye to boost the patient’s uncorrected near vision.

I prefer implanting the Tecnis PureSee IOL in the dominant eye because the distance visual acuity, contrast sensitivity, and dysphotopsia profile of this lens have been shown to be similar to that of a monofocal IOL in a prospective, randomized, controlled clinical trial.⁴ For this reason, I am comfortable implanting this lens even in eyes with an epiretinal membrane or other mild macular pathology. However, patients achieve much better intermediate vision than with a monofocal lens, and many of my patients achieve surprisingly good near vision with an EDOF IOL. If I do decide to implant an FVR lens in the fellow eye, pairing an EDOF with an FVR provides patients with better depth perception and intermediate vision than combining a monofocal lens with an FVR lens, in my experience.

Another advantage of postponing a decision on the second eye is that the decision is no longer theoretical. The first eye lens choice is based on what the patient thinks they want. But they are making that choice with vision affected by cataract, which causes glare and quality-of-vision problems. Glare and halo are often the reasons the patient elects to undergo cataract surgery, and the concern that an IOL might not improve existing vision leads them to choose a monofocal implant. It may also be difficult for a patient who has never enjoyed spectacle independence to know what trade-offs they are willing to accept to have good uncorrected vision at all distances. Within a week after the first eye surgery, however, the patient has experienced firsthand whether there is any dysphotopsia with the first IOL and how well they can see at various distances in the operated eye, so they can make a much more informed choice.

A case in point

In a recent case, the patient was an engineer who had spent hours extensively researching different IOLs and was practically paralyzed by indecision. I offered him the opportunity to experience the quantity and quality of vision in his dominant eye with a purely refractive EDOF lens, which proved to be the ideal solution for him. Based on the result in that eye, he felt confident in choosing an FVR lens for the fellow eye and was thrilled with the final binocular outcome.

With the mix-and-match approach, about one-third of my premium lens patients make a choice similar to this patient’s and end up with different IOLs in each eye. Another third each choose bilateral EDOF or bilateral FVR lenses. While I do not yet have hard data on patient outcomes or satisfaction with this approach, anecdotally, it has been successful in my practice at reducing patient stress and indecision.

Looking back, looking ahead

I tried mix-and-match in the past on a limited basis with various other combinations of IOLs (such as the Tecnis Symfony; Johnson & Johnson Vision, and the Clareon Vivity; Alcon), but the current generation of EDOF and FVR lenses feels like a better fit for my patients, with fewer limitations. The biggest challenge in the past has been the risk of quality-of-vision problems with the EDOF lens. If I started with the EDOF lens in the dominant eye and the patient experienced dysphotopsias in that eye, they would often not feel confident in proceeding to the multifocal IOL in the nondominant eye. In that case, they might end up dissatisfied with the lack of near vision and with the quality of their distance vision.

More recently, the only situations in which I have had a patient be unhappy after the second eye when I mix and match the latest-generation IOLs are cases in which I missed the refractive target or the patient had blur caused by untreated ocular surface disease (OSD). In other words, the risks of premium IOL surgery are due less to the limitations of the IOLs themselves and are more likely to be surgeon-induced. It remains important, therefore, for surgeons to treat OSD proactively and to perform careful biometry.

I believe this is a good time to revisit premium IOLs, especially if they have not been a major part of surgeons’ cataract practices in the past. Combining advanced EDOF lenses with FVR lenses creates opportunities for many more patients to benefit from premium IOLs by enabling surgeons to offer advanced options to those who can benefit, elevating the standard of care. Making the decision for each eye separately allows for bilateral implants or mix-and-match, inspiring greater confidence for patients and surgeons alike.

Eric D. Donnenfeld, MD

E: ericdonnenfeld@gmail.com

Donnenfeld is in private practice with Ophthalmic Consultants of Long Island in Garden City, New York. He is a trustee of Dartmouth Medical School and a clinical professor of ophthalmology at New York University Medical Center in New York, New York. He is a consultant for Johnson & Johnson Vision and many other ophthalmic companies.

References

1. Nuijts R. 2022 ESCRS clinical survey highlights: trends in presbyopia correction. EuroTimes IME Supplement. December 2023/January 2024:2-3. Accessed September 17, 2026. https://escrs.org/media/xfijzzyv/dec-jan-2024-supplement.pdf

2. TECNIS Odyssey IOL and TECNIS Odyssey Toric II IOL directions for use. Document 2024PP09064 v9. Johnson & Johnson Surgical Vision, Inc. Accessed September 17, 2026. https://www.jnjvisionpro.com/en-us/products/tecnis-odyssey/

3. TECNIS PureSee IOL, Model DEN00V, directions for use. Document Z312075E rev B. Johnson & Johnson Surgical Vision, Inc. Accessed September 17, 2026. https://www.jnjvisionpro.com/en-us/products/tecnis-puresee/

4. Corbett D, Black D, Roberts TV, et al. Quality of vision clinical outcomes for a new fully-refractive extended depth of focus intraocular lens. Eye (Lond). 2024;38(suppl 1):9-14. doi:10.1038/s41433-024-03039-8