Toric. Multifocal. Extended depth-of-focus. Accommodative. Light adjustable. The pool of premium intraocular lenses (IOLs) seems to get deeper all the time. While the multiplicity of choices is impressive, it also means that selecting the proper IOL requires surgeons to balance what their patients want with their medical histories, optical characteristics, and the capabilities of the IOLs themselves.

“The reality is that there is no one perfect solution for every patient,” says Mitch Shultz, MD, a cataract surgeon at Shultz Chang Vision in Northridge, California. Other experienced surgeons agree.

“As we all know, there’s no such thing as a perfect lens, and there’s no such thing as a free lunch,” says Dagny Zhu, MD, a cataract surgeon and medical director and partner at NVISION Eye Centers in Rowland Heights, California. “I really don’t like classifying lenses as good, better, best, because you can’t really arrange them that way. Every lens is going to have advantages and disadvantages.”

“If you look at the peer-reviewed literature, no brand has one thing that’s far superior in every lens design over another,” notes Elizabeth Yeu, MD, an assistant professor of ophthalmology at Eastern Virginia Medical School and an ophthalmologist with Virginia Eye Consultants in Norfolk, Virginia. Dr. Yeu is co-author of a peer-reviewed paper on IOL selection.¹

So how should cataract patients be matched to their ideal premium IOL? In most cases, the decision tree begins with the evaluation of three major patient factors: preexisting conditions or prior ocular surgeries, line of sight characteristics of the eye, and the patient’s visual goals and desires for uncorrected vision.

Patient Factors to Consider

Many preexisting conditions are relatively common among cataract patients, including macular pathology, degeneration of the retinal membrane, and glaucoma. The progression of these diseases, especially in patients who are in their 50s or older, must figure prominently into the IOL selection equation.

“Choosing the appropriate IOL is not only about what is good for them at the present moment, it’s also thinking down the line,” says Dr. Shultz. “These patients are likely to live 20 to 30 more years with this technology, so when we see mild macular degeneration, we shouldn’t be putting multifocal and trifocal lenses in these patients. While they’re doing okay right now, 10 years from now their macular degeneration might be worse, and then they’re stuck with a technology that’s not offering them the best vision they could have.”

Similarly, patients who have undergone previous refractive surgery procedures like LASIK, photoreactive keratectomy (PRK), or radial keratotomy (RK) may have corneal spherical aberrations as a result. If not matched with the correct lens, these patients may experience significant glare and halos, which are not necessarily related to the lens technology but to the presence of the aberrations.

“Another factor that I have been a strong believer in is line of sight,” says Dr. Shultz. “Where does the patient’s actual line of sight come through their pupil, and how will that compare against a technology?” He notes that some trifocal lenses have a small central optical region of approximately 1 mm in diameter. “If a patient’s line of sight is half a millimeter away from the center of their pupil, and we think the lens is going to center closer to the center of the pupil, we run the risk of a patient not looking through the appropriate portion of the lens.”

Only after evaluating these factors should a patient’s wants, needs, and even personality come into play. Questions to consider include: Does the patient read mostly printed materials like books or magazines, or read on a phone, tablet, or computer screen? Does the patient often drive at night? Under what circumstances would the patient be willing (or unwilling) to wear eyeglasses? What negative characteristics, such as glare and halos, is the patient willing to live with, and to what degree?

“Those are all the basic things that we look at when we’re counseling patients about the facts of IOLs,” says Dr. Shultz. From there, the decision tree branches out to any number of potential technologies (or combination of technologies) to meet the patient’s wants and needs. For example, many cataract patients look for as much spectacle independence as possible, a desire that must be balanced with considerations like lid margin and ocular surface disease.

Finding the Right Lenses

For those with healthy eyes, Dr. Yeu often recommends the Johnson & Johnson Vision or Alcon families of presbyopia-correcting IOLs. “If they’re looking for the fullest range of vision, then we are fortunate that both the J&J and the Alcon portfolios have very good near-vision lenses, Alcon having the PanOptix trifocal lens and Johnson & Johnson having the Tecnis Synergy hybrid EDOF/multifocal lens,” she says. “Now, we are further fortunate to have a potential portfolio expander with an on-label monovision approach that does not compromise stereopsis but offers the benefits of binocular, monofocal-like quality of vision with the recently approved IC-8 Apthera small-aperture IOL (Bausch + Lomb) in one eye. The Apthera IOL has been a great offering as a presbyopia-correcting option, off-label, for 10 cataract patients with aberrated corneas thus far, such as post-LASIK, post-RK, and irregular astigmatic corneas.

“Regarding diffractive presbyopia-correcting IOLs, there is no one-size-fits-all. I feel fortunate to have access to a consignment of both portfolios, and it is a balance between personality type, range of vision, and patient aversion to positive dysphotopsias.” Dr. Yeu continues. “These are all considerations that I take into account as I am looking at the lenses.”

Dr. Shultz and Dr. Zhu also give the PanOptix lenses high grades for versatility.

“I certainly feel that the PanOptix kind of stands out as the lens of choice for those types of patients, but I’m constantly making patients understand the potential for glare and halos, and it can take a couple months for the brain to adapt to that,” Dr. Shultz says.

Dr. Zhu describes the PanOptix trifocals as her “go-to” premium IOLs, owing to her opinion that “it provides the greatest range of vision without the need for spectacles and with the least likelihood of side effects in my experience.” On the other hand, she points out that, like most diffractive presbyopia-correcting lenses, the PanOptix is not going to be the best choice for everyone. For patients who prioritize nighttime driving, she finds the non-diffractive Clareon Vivity IOL (Alcon) ideal, owing to its low tendency toward halos, glare, and starbursts while also providing high-quality near vision.

“That lens works great for patients who really value their nighttime driving, distance, and they’re okay with using readers once in a while for fine print,” she says. “And so the PanOptix and Vivity pretty much cover the majority of the patients in my practice who are looking for a premium lens and some level of spectacle independence.”

An Adjustable Option

For cataract patients who have undergone previous refractive surgeries, Dr. Shultz is increasingly recommending the Light Adjustable Lens (LAL) from RxSight.

“Anyone who is looking for perfection in their vision with minimal night vision halos and glare, I feel that the Light Adjustable Lens is the technology that can achieve LASIK-like postoperative outcomes,” Dr. Schultz says. He adds, however, that patience is necessary, because LALs require three or more additional postoperative visits to tweak and fine tune the LAL for optimal vision. “Patients need to understand that it’s going to take a month to two months to achieve their final outcomes,” he says.

“The LAL requires a bit of time sacrifice for both the patient and surgeon because you’re doing all the light adjustments after surgery,” agrees Dr. Zhu. “The patient comes in a minimum of three times postoperatively, but each adjustment allows you to fine tune the outcome of an otherwise unpredictable case with great accuracy and precision.”

Other Considerations

While every premium IOL choice must be made with the best interests of the patient in mind, several indirect factors must often also be considered. For example, Dr. Zhu looks at predictability of refracted outcome.

“These days, most of the major companies make lenses that are pretty predictable, but there are still small nuances in terms of how often the manufacturer is actually hitting a particular target for whatever power they’re labeling a lens. There’s some standard deviation, and it’s not always that tight. It’s surprising to know that if you’re off target, some of that actually goes back to the manufacturer and the fact that they cannot nail that power every single time. For example, most lenses come in half-diopter power increments, but the Lenstec family of lenses offers greater precision by coming in quarter-diopter powers.”

Dr. Zhu also looks at long-term stability, a quality dictated largely by the nature of lens materials. Some hydrophobic acrylic lenses, she says, are prone to developing glistenings or subsurface nanoglistenings that can affect the quality of vision over time. Hydrophilic lenses can eventually calcify and increase the risk of capsular contracture, causing IOL tilt or shift. She says manufacturers are making improvements to both types of lenses. For example, Alcon’s Clareon lenses are made from a proprietary new material the company labels as nonglistening.

Dr. Yeu believes that leaving presurgical myopes near-sighted after surgery should be considered. Depending on how potentially neurotic a patient’s personality type is, how much very near work they are doing or how much they enjoy reading under ambient lighting without the use of spectacles may dictate the use of a monofocal or an enhanced monofocal IOL with a near target. Also, different monofocal IOLs have varying levels of spherical aberration correction, and this can be a consideration for various corneas. While she has a go-to monofocal IOL for all average, naïve corneas, for any corneas that have undergone hyperopic LASIK or have keratoconus, Dr. Yeu recommends a zero sphericity monofocal IOL, like Bausch + Lomb’s Envista IOL, which she says is a very common one to house in consignment.

Meeting in the Middle

Ultimately, choosing the right premium IOL is a matter of juggling priorities—both the patient’s and the physician’s. There is no such thing as one-size-fits-all, and every premium IOL technology has its place in refractive surgery.

“The takeaway is that there’s no perfect IOL. Every one will have advantages and disadvantages,” says Dr. Zhu. “There are many criteria in IOL design that affect the final outcomes, so you must choose what works best for you and the patient. Most of the time it’s somewhere in the middle.” ■

REFERENCES

1. Yeu E, Cuozzo S. Matching the patient to the intraocular lens: preoperative considerations to optimize surgical outcomes. Ophthalmology. 2021;128(11):e132-e141. doi:10.1016/j.ophtha.2020.08.025