Patient education is a universal weak link in lens-based surgery. Advances in intraocular lens (IOL) optics, biometry, IOL calculations, and refractive predictability provide a stable foundation for excellent postoperative outcomes, but the variable that most often determines whether a patient is happy after surgery is not refractive accuracy; it is whether patients understand what they are choosing and what trade-offs come with their lens decision. Until recently, eyecare providers lacked a reliable way to give patients an opportunity to experience the vision they could expect with a given IOL. Recent advancements in virtual reality (VR) technology help shrink the gap.

The Importance of Patient Education

In the traditional patient education model, a basic explanation for whether a toric IOL will meaningfully improve the quality of a patient’s vision comes down to words, hand gestures, and a brochure. Further, attempting to explain concepts like dysphotopsia profiles and range of vision (distance, distance plus intermediate, and the full distance-intermediate-near spectrum) in language that helps a patient understand each lens’s unique advantages and disadvantages can be challenging. Patients often become frustrated and confused when they are asked to weigh such advantages and disadvantages without actually experiencing them.

In a series of 50 cases that required the explantation of a multifocal IOL, excessive preoperative patient expectations ranked among the leading reasons for lens removal, alongside reduced contrast sensitivity and photic phenomena.¹ Subsequent series describing neural adaptation failure and IOL exchange support the notion that patient dissatisfaction is less likely the product of a surgical failure and more likely an expectation failure.^2,3 Astigmatism management follows the same logic. In a large database analysis, even 0.50 D of residual cylinder increased the odds of a missed 20/20 uncorrected visual acuity and reduced patient satisfaction.⁴ This is exactly the kind of trade-off patients cannot evaluate from a verbal description alone.

To address the cost of inadequate patient education at my own practice, I have implemented a VR IOL simulator. Among the simulation options currently available, the ones that use VR are InSight VR by GreenMan and the VirtuaLens Immersive IOL Simulator by VirtuaLens; I have been using the latter for the past several months.What follows is not about the device itself but rather what immersive simulation may do for the structure of a premium IOL practice.

Approaches to Previewing Vision

My goal isn’t to upcharge a patient or steer them toward a premium lens if they don’t have any interest in one; it’s to find out what the patient in front of me truly wants regarding their vision. When I know that, I am motivated and better prepared to help them make a confident, well-informed decision that gets us both to a good place before surgery.

There are 2 broad approaches that help patients preview pseudophakic vision: One is the use of adaptive optics to view the real world in the exam lane. The strategy is well validated against real multifocal corrections,^5,6 but it is constrained by the room the patient is sitting in, and no exam lane contains a night-driving scenario, which is precisely where dysphotopsias are most easily noticed.

The second approach, VR IOL simulation, presents a fully synthetic scene with a broader environmental range. With VR technology, a patient may view the outdoors at midday and understand what it feels like to work on a computer or sit at a dinner table. They can also simulate looking down the fairway on a golf course and then directly at their scorecard, and they can see what it looks like to be on a road at night with oncoming headlights and streetlights. Patients narrate their own conclusions from these simulations. An avid golfer can weigh how well they see their ball on the green against the ease with which they read the scorecard, and they can evaluate their range of vision and dysphotopsias such as halos and glare in a night-driving scenario.

How to Help Curate a Patient’s Choice

The VirtuaLens IOL simulator has a self-guide mode that allows a patient to walk through the full spectrum of IOL types.⁷ I do not use it that way, and I would caution any practice against offering too many choices, which can result in choice paralysis.⁸ My strategy for avoiding this dilemma is deliberate: I have an initial conversation with the patient before introducing the VR headset to learn what they do all day and what they care about. Then, I select no more than 3 IOL options for the patient. If they want distance only, they sample a monofocal IOL with and without astigmatism correction, assuming they would benefit from it. That single comparison ends the toric conversation faster and more honestly than anything I could say. If they are interested in range of vision, they sample distance, distance plus intermediate, and the equivalent of a trifocal, which delivers the range but with some starburst and glare around lights, most visible in dark scenarios.

I tell patients explicitly what I am doing. They understand that many IOL options are available, and they are simply sampling the 2 or 3 IOLs that seem best suited to the lifestyles they described to me. Framed that way, most patients decide quickly on the IOL that works best for them. Decision-making styles vary, however, and some patients will deliberate. Usually, selection is straightforward, and most patients leave the office smiling because they know what they chose and why. Importantly, the VR experience makes it so much easier for them to remember their choice, and if they do have some additional questions, the task of answering is much more straightforward when they’re able to reference what they saw in the VR headset.

A Simple Workflow

In my clinic, I have an initial conversation with the patient about their desires, expectations, and concerns in selecting the IOL. With this information, I can direct the tester—a technician, research technician, or fellow—to administer the demonstration for the options I select while the patient’s eyes are dilating. By the time I am ready to enter the examination room again, the technician typically meets me at the door and tells me what IOL the patient has chosen. Sometimes, there are a couple of follow-up questions for me, but gone are the days when I needed to have the long, circular conversations that premium IOL counseling used to require.

Two things are worth underscoring: First, the VR patient education process requires no additional time. It takes place during dilation time while the physician is seeing other patients. Second, the surgeon is not the one spending their time. That combination helps to convert an interval of dead clinic time into a high-yield educational encounter in the entire preoperative pathway.

I’ve also found benefit in introducing the simulator at the first visit rather than a subsequent visit. When a patient returns for their next appointment, they will have likely consulted the internet and talked to friends in the interim, and they come back with far better questions. They have a foundation to explore options intelligently—and usually efficiently—instead of starting over.

Lastly, incorporating a VR IOL simulator has changed the character of my postoperative discussions. If a patient with residual cylinder needs glasses for driving, I can point to the notes in their chart documenting the moment they saw the blur, understood it, and accepted it. If a patient with a trifocal IOL calls about halos, they can be reminded that they saw halos in the simulator and chose the lens knowing the trade-off. In many cases, patients remember these situations on their own, so postoperative surprises are even more uncommon than they were before.

Considerations for Use

There are times when the use of a VR IOL simulator might not be beneficial—for example, in eyes with a dense cataract, where media opacity may prevent the patient from adequately appreciating the simulation, or when simulating monovision or blended vision. Both monovision and blended vision simulations are being integrated and introduced now, which is welcome. Monovision is a common strategy that has historically been hard to preview.

I believe that nearly every patient should be informed about the range of IOLs available, even if they have ocular pathology that, in my view, disqualifies them from getting, for example, a trifocal IOL. This can usually be handled verbally. I explain how an extended depth of focus or trifocal requires the eye to be excellent in every respect; if it is not, quality of vision suffers. I tell them, “I want to give you the sharpest vision possible, and I am trying to protect your vision for the rest of your life.” Patients tend to accept the rationale. However, for those patients wanting to know more, I can use VR as needed to show them the options while letting them know what is best for their eyes. I am in the process of setting up a VR image that will illustrate how ocular pathology will impair the benefit from these IOLs.

Conclusion

The barrier to adoption of VR IOL simulation software is genuinely low. There is no meaningful learning curve for a technician who can already run a lifestyle questionnaire, and it costs no additional clinic time if the demonstration is conducted during the dilation process.

My advice to any practice or administrator on the fence is to simply try it for a week and see the difference it makes.

The reason I like using VR technology for a patient’s IOL selection has less to do with efficiency and more to do with alignment. Cataract surgery is one of the few operations where the patient is the key person qualified to define the vision goal. Immersive simulation finally puts them at the center of the decision with a level of information and understanding that was not available to them before. When the patient has chosen the trade-offs themselves based on what they’ve seen through VR, the entire perioperative process gets easier and more rewarding for both the patient and the care team.

References

1. Kamiya K, Hayashi K, Shimizu K, Negishi K, Sato M, Bissen-Miyajima H. Multifocal intraocular lens explanation: a case series of 50 eyes. Am J Ophthalmol. 2014;158(2):215-220.e1. doi:10.1016/j.ajo.2014.04.010

2. Al-Shymali O, McAlinden C, Alió del Barrio JL, Canto-Cerdán M, Alió JL. Patients’ dissatisfaction with multifocal intraocular lenses managed by exchange with other multifocal lenses of different optical profiles. Eye Vis (Lond). 2022;9(1):8. doi:10.1186/s40662-022-00280-8

3. Al-Shymali O, Canto-Cerdán M, Alió del Barrio JL, McAlinden C, Yebana P, Alió JL. Managing dissatisfaction after multifocal intraocular lens implantation through lens exchange using monofocal or alternative multifocal IOLs. Acta Ophthalmol. 2024;102(7):e1040-e1049. doi:10.1111/aos.16720

4. Schallhorn SC, Hettinger KA, Pelouskova M, et al. Effect of residual astigmatism on uncorrected visual acuity and patient satisfaction in pseudophakic patients. J Cataract Refract Surg. 2021;47(8):991-998. doi:10.1097/j.jcrs.0000000000000560

5. Radhakrishnan A, Pascual D, Marcos S, Dorronsoro C. Vision with different presbyopia corrections simulated with a portable binocular visual simulator. Plos One. 2019;14(8):e0221144. doi:10.1371/journal.pone.0221144

6. Barcala X, Vinas M, Romero M, et al. Multifocal acceptance score to evaluate vision: MAS-2EV. Sci Rep. 2021;11(1):1397. doi:10.1038/s41598-021-81059-0

7. VirtuaLens launches immersive virtual reality IOL simulator, transforming cataract patient education and lens selection. News release. September 3, 2025. Accessed July 27, 2026. https://www.prnewswire.com/news-releases/virtualenstm-launches-immersive-virtual-reality-iol-simulator-transforming-cataract-patient-education-and-lens-selection-302544460.html

8. Jarem L. Practical tips for introducing advanced IOLs to your patients and practice. AAO. May 8, 2025. Accessed July 27, 2026. https://www.aao.org/education/headline/practical-tips-introducing-advanced-iols-to-your-p

Douglas D. Koch, MD, is a professor and the Allen, Mosbacher, and Law Chair in Ophthalmology at the Cullen Eye Institute, Baylor College of Medicine, Houston. He is a clinical advisor to VirtuaLens.