New IOLs for presbyopia correction

Why and how practices are recommending these IOL options.

There’s never been a better time — for your cataract patients and your practice — to offer presbyopia-correcting intraocular lenses (IOLs).

“I think the younger among us don’t really think of presbyopia as that big of a deal,” says Ahad Mahootchi, MD, medical director of The Eye Clinic of Florida in Zephyrhills, FL. But a patient who had a presbyopia-correcting IOL implanted changed his mind. “She broke her hip and was hospitalized. She was so thankful to be able to watch TV and read consents and use her iPad without glasses,” says Dr. Mahootchi.

Practices, meanwhile, benefit from happier patients, not to mention the increased revenues that come from these higher-priced premium IOLs. “Economically, these lenses are a real financial boost to the practice,” says Jeffrey Whitman, MD, chief ophthalmologist at Key-Whitman Eye Center in Dallas, TX.

New lenses address astigmatism and presbyopia

In recent years, no fewer than three such IOLs have hit the U.S. market, including the relatively new extended-depth-of-focus (EDOF) lens. These IOLs are aimed at patients who want to achieve as much freedom from glasses as possible.

“We are fortunate to have several presbyopia + astigmatism-correcting implant options available: The EDOF Tecnis Symfony toric (J&J Vision/AMO), the accommodative toric IOL Trulign (Bausch+Lomb), and the AcrySof IQ ReSTOR +3.0D Multifocal Toric IOL (Alcon),” says Cynthia Matossian, MD, FACS, founder and CEO of Matossian Eye Associates in Doylestown, PA. “All of these implants provide excellent distance and intermediate vision, and good, functional near vision.”

Of the three, the AcrySof IQ ReSTOR is the most recent entrant. The +2.5 D received FDA approval in March 2017, while the +3.0 D received FDA approval in December 2016. The Symfony toric entered the market in July 2016 and the Trulign in 2013 (see Presbyopia-correcting IOL options, page 17).

“With the EDOF IOLs, there is less glare and fewer starbursts and halo issues, although, as ophthalmologists, we still need to warn patients about some perceived auras and spider webbing around lights,” Dr. Matossian says. “The lower-add multifocal IOLs provide much better intermediate vision with slightly less power for near reading.”

Dr. Whitman agrees, noting that, “The EDOF lenses have rapidly become our premium lens of choice. (They) offer a great range of vision, including the now all-important intermediate distance (think computer and handhelds) and can correct astigmatism as well.

“Most of our patients are seeing J3 to J1, particularly if the non-dominant eye is overcorrected to -0.5 D, with excellent distance and intermediate vision,” he added. “The lens can be mixed with a multifocal (IOL) as well, if J1 is the goal for near vision. It can be used in post-refractive surgery patients with even moderate corneal coma.”

The EDOF lenses “are much better tolerated by patients” than previous generations of multifocal lenses, says Michael Greenwood, MD, with Vance Thompson Vision in Sioux Falls, SD. “It is still important to eliminate any residual refractive error or astigmatism, but they have been a great addition to our toolbox. Patients have really appreciated the decrease in the positive dysphotopsias with these IOLs while keeping good distance, intermediate, and near vision.”

Benefits of a new generation

By all accounts, today’s emerging premium IOLs improve on previous iterations of multifocals. First approved by the FDA in 2005, the most common complications of early multifocal IOLs included glare, halos, and starbursts around headlights, making driving at nighttime a challenge for many patients.

“The other drawback with the older multifocal models is that they split light into two foci: distance and near,” Dr. Matossian says. “This design necessitated bright light for most reading tasks. With two deliberate foci, the intermediate distance was not clear for our patients who used computers, e-tablets, or cell phones.”

Presbyopia-correcting toric IOL options

AcrySof IQ ReSTOR +2.5 D multifocal toric IOL, Alcon’s newest AcrySof IQ lens, received FDA approval in March 2017. The lens features ACTIVEFOCUS optical design, which produces clear distance vision and a range of vision for patients as well as stability to stay on axis for correcting astigmatism, according to a company press release. The AcrySof IQ ReSTOR is also available in +3.0 D and +4.0 D add powers. Other features include an acrylate/methacrylate copolymer material, overall diameter of 13.0 mm (6.0 mm optic diameter), A-constant of 119.1, and a refractive index at 35°C of 1.55, according to the company’s website.

Tecnis Symfony IOL (J&J Vision/AMO) received FDA approval in July 2016. In clinical studies, the Symfony lens demonstrated seamless day-to-night vision and low incidence of halos and glare. Also, it is engineered to correct chromatic aberration and spherical aberration, according to a company press release. Symfony is available in powers +5.0 D to +34.0 D in 0.5 D steps. Other features include a soft, foldable, UV-blocking hydrophobic acrylic material, overall diameter of 13.0 mm (6.0 mm optic diameter), A-constant of 118.9 for contact ultrasound (119.3 optical), and a refractive index at 35°C of 1.47, according to the company’s website.

Trulign Toric IOL (Bausch + Lomb), which received FDA approval in May 2013, was the first toric IOL to correct for astigmatism and offer improved vision across a range of focus. During the FDA clinical trial, its haptic design provided rotational stability — 96.1% of the lenses rotated less than five degrees from the day of surgery to four-to-six months post-op, according to a company press release. Trulign is available in powers +4.0 D to +10.0 D in 1.0 D steps and +10.5 D to +33.0 D in 0.5 D steps. Other features include silicone material with enhanced UV protection and 10% UV cutoff at 400 nm (body and plates) and polyimide material (haptics), overall diameter of 11.5 mm (5.0 mm optic diameter), A-constant of 119.1, and a refractive index at 35°C of 1.43, according to the company’s website.

Patient education is vital

As good as today’s new premium IOLs may be, ophthalmic practices must overcome the old multifocals’ reputation, as well as the fact that insurance doesn’t cover the cost of premium lenses. To do so, it takes a solid game plan with respect to patient education.

“The most important thing about … using premium IOLs is to educate the patient on their options … and then deliver them with confidence,” Dr. Greenwood says.

Here are some tips to improve your efforts at educating your cataract surgery patients on their premium IOL options:

  • Set realistic expectations. Educating patients on the limitations of premium lenses is important; they may need to wear glasses in some situations, Dr. Greenwood says. Inform patients they may experience positive dysphotopsia early on that usually fades over time or becomes less bothersome. Dr. Whitman agreed. “Let patients know that, even though aberrations are low statistically, they can still get halos, etc.,” he says.
  • Avoid choice overload. “Minimize the number of choices a patient has to make; the more choices, the less likely they will choose any option,” Dr. Greenwood says.
  • Leverage technology. “It is ideal to educate the patient via a video or tablet,” says Janine Disanti, OD, with Matossian Eye Associates. “Checked Up is a program we use that seems to work well. Then, we offer them a questionnaire on their lifestyle and day-to-day tasks. A conversation can then be had in which the patient will realize how many of their everyday tasks will still rely on glasses without presbyopia-correcting lenses.”
  • Repeat the message. “Repetition is the key to learning. The more premium IOLs are discussed with patients, the more they will learn and retain knowledge regarding the benefits of premium IOLs,” Dr. Greenwood says. “Our patients receive a mailing prior to their appointment, they watch videos while they are in the reception area and in the exam rooms, and then the surgeons discuss it with them.”
  • Show patients the money. Don’t be afraid to talk about the cost of the lenses, and give patients a price that includes post-surgical costs, Dr. Greenwood says. “Bundle it up front. Patients will understand, and you won’t feel guilty about recommending a fine tune.”
  • Emphasize the permanence of their selection. “As happy as monofocal patients are in year one, 50% come back in three years wishing they didn’t have to wear readers all the time,” Dr. Mahootchi says. “I tell patients it’s cheaper and more effective to do the fix with the original surgery than years later.”
  • Match the lens to the patient. Clinicians should not only survey patients to measure their motivations for becoming less reliant on spectacles, but also review their lifestyle habits.


With proper education, your patients will better understand premium IOLs and their potential benefits.

“Our patients feel ‘old’ when they wear their reading glasses around their neck, push them on top of their heads as tiaras, or slide their readers down their nose to engage someone in conversation,” Dr. Matossian says. “By educating the patient, we can empower them to make decisions more confidently about their implant choice to decrease their reliance on spectacles.”

Dr. Greenwood agrees. “Premium IOLs have never been better, and, in the very near future, we will have more options at our fingertips. If you use the technology to make sure the patient is a good candidate, do good surgery, and take care of residual refractive errors, the patients will be happy, and the ODs will be happy. And that makes you happy.” OP

Dr. Greenwood is a speaker for Alcon. Dr. Whitman is a consultant to Alcon, Johnson & Johnson Vision/AMO, and Bausch + Lomb. Dr. Matossian is a consultant and/or speaker to Alcon, Bausch + Lomb, and Johnson & Johnson Vision/AMO. Dr. Mahootchi revealed no relevant financial disclosures.

Joseph F. Jalkiewicz is a medical writer based in Marlton, NJ.