IOLs: What Every Surgeon Needs to Know | Ep. 3: Extended depth of focus IOLs

IOLs: What Every Surgeon Needs to Know is an editorially independent video podcast series from Ophthalmology Times, hosted by Douglas D. Koch, MD, Professor and Allen, Mosbacher, and Law Chair in Ophthalmology at the Cullen Eye Institute, Baylor College of Medicine in Houston, Texas. In this episode, Koch is joined by Julie Schallhorn, MD, MS, Professor of Ophthalmology and Rose B. Williams Endowed Chair in Corneal Research at the University of California, San Francisco.

Together, they discuss what defines an extended depth of focus (EDOF) intraocular lens, some of the various diffractive and refractive design approaches available, and where the category fits as trifocal optics continue to improve.

Defining the EDOF category

Schallhorn frames EDOF as a regulatory classification rather than a description of any single mechanism. “It is totally irrespective of the mechanism [by] which you get to that extended increase in depth of focus,” she says. Per ANSI standards and FDA criteria, a lens qualifies as EDOF based on the amount of defocus it maintains at a 20/30 level around an intermediate distance target—roughly a one-diopter range—which places it in the premium lens billing category regardless of how that range is achieved, she notes.

Diffractive and refractive designs

Several optical approaches are among the options that define the US EDOF market, with diffractive and refractive designs among them, at the time of this recording. Diffractive EDOF lenses (e.g., Tecnis Symphony, Johnson & Johnson Vision) use the same diffractive-ring principle as trifocal and multifocal IOLs, but with wider spacing between rings, producing an intermediate and distance focal point without a distinct near point, she adds. Schallhorn notes the tradeoff: the reduced range of vision comes with a benefit, as the wider ring spacing should theoretically produce less photic phenomena at nighttime and better contrast sensitivity than tighter-spaced diffractive designs.

One refractive design approach in the US market (AcrySof Vivity; Alcon) uses a central zone of increased refractive power—Schallhorn uses the analogy of a donut—that shifts focus toward an intermediate point while the periphery handles distance, rather than relying on diffractive rings. She notes that while this design theoretically produces less ringing around lights, patients on average report somewhat more halos with it than with other EDOF lenses, and its non-uniform refractive power comes with some loss of contrast sensitivity relative to a monofocal control.

Where EDOF lenses fit in practice

Schallhorn is candid about what these lenses do not deliver: true spectacle independence. “These lenses are not going to give you complete spectacle independence,” she says, noting that outcomes vary with patient characteristics and pupil size, and that patients will typically still need readers and more light in certain conditions. A mini-monovision approach—targeting the dominant eye for plano and leaving the nondominant eye mildly under-corrected—has been studied as a way to extend the effective range, though it carries the usual tradeoffs of monovision, including loss of stereopsis past a certain threshold.

In her own practice, Schallhorn says she uses EDOF lenses less than she once did. She still favors a diffractive design for patients with a strong dominant eye who want to minimize photic phenomena, and a refractive design for small-pupil patients who can tolerate a mild monovision approach. More broadly, she credits modern trifocals with narrowing the case for EDOF: “The modern trifocals actually perform really, really well in terms of intermediate and near vision. I think [that's] eating into this EDOF market a little bit.” Koch agrees, noting that today’s trifocal optics no longer carry the quality-of-vision compromises they once did.

More advances in EDOF optics

Schallhorn points to continued innovation in refractive EDOF designs, including a novel device now approved in the US (Tecnis PureSee; Johnson & Johnson Vision), which she says showed defocus curves on optical bench testing that may exceed current EDOF lenses. (Note: The Tecnis PureSee IOL received FDA approval on March 12, 2026, and Johnson & Johnson announced expanded US availability in June 2026.) She also flags a growing “monofocal plus” category—lenses with some EDOF-like characteristics that fall under monofocal reimbursement pathways—as well as ongoing refractive optics work from another manufacturer. “We’re going to see continued growth in this and continued innovation,” she says, “which is good for patients.”

Douglas D. Koch, MD
E: [email protected]
Koch is Professor and Allen, Mosbacher, and Law Chair in Ophthalmology at the Cullen Eye Institute, Baylor College of Medicine in Houston, Texas. Koch consults with Carl Zeiss Meditec, Johnson and Johnson Vision, PerfectLens, and VirtuaLens.

Julie Schallhorn, MD, MS
E: [email protected]
Schallhorn is Professor of Ophthalmology and Rose B. Williams Endowed Chair in Corneal Research at the University of California, San Francisco.

The content presented in this video podcast series is editorially independent. The views and perspectives presented are those of Dr. Koch and Dr. Schallhorn.