The Ophthalmic ASC spoke with 4 ophthalmologists about the criteria they use for choosing monofocal, toric, multifocal, extended depth of focus (EDOF), and/or presbyopia-correcting intraocular lenses (PCIOLs). They also shared unmet needs in current IOL technology, what their ideal IOL would be if they could design one, and more.

IOL Philosophy and Selection

When selecting an IOL for a patient, Dagny Zhu, MD, medical director and partner at HyperSpeed LASIK | NVISION Eye Centers in Rowland Heights, California, says vision quality, range of vision, and longevity of material are all factors that influence her decision. 

For Blake K. Williamson, MD, MPH, MS, of Williamson Eye in Baton Rouge, Louisiana, patient expectations and their visual goals are the first things he considers. “Some patients don’t mind wearing reading glasses; other patients do. So that will put you in a different category,” he explains. “Next, I would say a healthy eye—a clean optical coherence tomography (OCT) scan of the macula that doesn’t show any epiretinal membranes or retinal pathology, and a clean cornea that doesn’t have any irregular cylinder.”

Cathleen M. McCabe, MD, chief medical officer of Eye Health America in Sarasota, Florida, says there are 3 main categories of factors she considers. “The first is the desire of the patient to be spectacle-free and their sensitivity to the compromises necessary in order to achieve spectacle independence. The second is how much astigmatism the patient has, because to receive the best quality of vision, a foundational part of that is good refractive targeting. The third is the health of the eye. I go over that with the patient, especially paying attention to early signs of progressive disease.” 

Brian R. Will, MD, of Will Vision & Laser Centers, a multilocation practice in the Pacific Northwest, notes that key factors he considers include the patient’s desired range of vision, optical quality, contrast sensitivity, tolerance for potential dysphotopsia, overall eye health, prior refractive surgery history, and the predictability of refractive outcomes. “Because the overwhelming majority of our patients seek spectacle independence, we naturally gravitate toward modern presbyopia-correcting platforms whenever the eye is an appropriate candidate,” Dr. Will explains.

Evolving IOL Preferences

Dr. Zhu says she is more likely to implant the full-range-of-vision IOLs because of the improvement in vision quality compared to previous generations. “I’ve recently settled on a mix-and-match approach¹ for my younger or more active patients with a nondiffractive EDOF in the dominant eye and a full-range-of-vision IOL in the nondominant eye, to take advantage of both IOL types,” she explains. 

Regarding premium IOLs, Dr. Williamson says he is currently using the Tecnis Odyssey IOL (Johnson & Johnson) and enVista Envy (Bausch + Lomb). “I’m also using the RayOne EMV (Rayner) for extended depth of focus, and I am looking forward to using the Tecnis PureSee IOL (Johnson & Johnson)—which was approved by the FDA in March—for my increased depth of focus, because different patients have different goals and different willingness to tolerate certain side effects,” he says. “The trifocals keep getting better, and as EDOFs get better, I think it’s important to continuously offer the most up-to-date technology.”

Dr. McCabe says her IOL preferences have changed in recent years as she has become more focused on precision in astigmatism correction and minimizing spherical equivalent in residual refractive error. “Independent vision is tied directly to the amount of refractive error—specifically, the amount of residual astigmatism—which also plays a role,” she notes. “And because different platforms have different ranges of cylinder correction and a different number of steps of that cylinder correction, I have gravitated more toward a platform that has that specificity. I have been using the enVista platform to try to minimize residual astigmatism.”

Dr. McCabe also likes the glistening-free, edge-to-edge optic of the enVista monofocal lens, and the fact that it has that fenestration at the optic haptic junction. “I also care for a lot of patients who have had dislocated lenses, either early or late after surgery, and having a mechanism where I can more easily solve that with scleral fixation is an advantage as well,” she explains.

Dr. Will notes that his team’s IOL preferences have also changed in recent years. “The newest generation of presbyopia-correcting IOLs has improved in 3 key areas: significantly reduced dysphotopsia, better intermediate performance, and improved contrast sensitivity,” he says. “These advances allow us to offer premium lenses to a broader patient population confidently. Today, the vast majority of patients in our practice—approximately 99%—receive premium IOL technology.”

Monofocal IOLs

Dr. Zhu says she uses a variety of platforms based on what’s best suited for each patient. “I prefer an enhanced monofocal like the Tecnis Eyhance IOL (Johnson & Johnson Vision) for most, but will default to the Clareon Monofocal IOL (Alcon) for sicker eyes, and the enVista monofocal (SA neutral) (Bausch + Lomb) for eyes with irregular astigmatism,” she says. 

Dr. Williamson also uses the enVista monofocal, and the LI61AO from Bausch + Lomb. Dr. McCabe says she finds the enVista platform provides an accurate targeting of astigmatism correction. Dr. Will uses the Tecnis Eyhance IOL. “We prefer enhanced monofocal designs because they provide a slightly expanded depth of focus,” he says. “One practical advantage is a more forgiving refractive landing zone. A patient arriving at −0.50 D postoperatively—which might leave them at 20/30 with a conventional monofocal—is more likely to see 20/20 with an enhanced optic. This broader tolerance for small refractive deviations translates directly into real-world outcomes and patient satisfaction.”

Toric IOL Candidacy

Dr. Zhu says WTR 1.5 D and ATR 0.75 D are her minimal thresholds for a T3 toric. “For lower cylinder correction, I prefer the enVista Toric platform as they correct lower than a T3,” she explains.

Dr. Williamson points out that he wants to make sure that they have multiple measurements that are in alignment with both the magnitude and the meridian of cylinder. “Typically, I’ll make sure that we’re looking at a Zeiss IOLMaster 700 reading on biometry and compare that to my OPD-Scan III Wavefront Aberrometer (OPD3; Nidek), along with my Pentacam (Oculus). If all 3 of those diagnostics are telling me that I have a diopter around 90, then I feel pretty confident that that’s where the astigmatism is lying on the cornea,” he says.

Dr. McCabe looks at the topography to assure that there’s no complexity to the cornea or irregular astigmatism. “As long as it’s regular and they have astigmatism within the range that toric lenses will correct, I think that they are a candidate,” she explains. “The only other category would be someone who doesn’t have good potential. For example, I had a patient with a large macular scar in one eye and the patient would not have seen a benefit of toric correction in that eye.” 

Multifocal, EDOF, and Presbyopia-Correcting IOLs

When screening patients, Dr. Zhu uses OCT macula, OCT nerve head, and topography to rule out irregular astigmatism.

Dr. Williamson asks the following questions to see if a patient is a multifocal candidate:

• What are their activities? 

• What do they do for their job?

• What do they do for fun?

• How desirous are they of having freedom from spectacles up close? 

• What is their personality type? 

• How healthy is the eye?

• Does the cornea look clean with no regular astigmatism? 

• Have they had prior refractive surgery such as RK?

• Do they have anything minor going on in the retina, such as subtle epiretinal membranes or early age-related macular degeneration?

“These are all things that I need to look at before I rule in or rule out candidacy for a multifocal,” Dr. Williamson says.

Dr. McCabe looks for regular topography, healthy eyes, no early signs of progressive disease, and a patient who is understanding that they may experience some positive dystopias and are amenable to anything that will need to be done to remediate their symptoms if they develop side effects. “My go-to trifocal is enVista Envy, and I’ve really been impressed with how few patients experience dysphotopsias and with the quality and quantity of range of vision that the patients receive,” she says.

Dr. Will notes that his primary candidacy criteria are patient motivation for spectacle independence and a visual potential of 20/30 or better. “We assess overall ocular health, macular function, and corneal optical quality,” he explains. “Equally important is educating patients about the normal neuroadaptation period that follows lens implantation.” 

Dr. Zhu’s go-to EDOF lens is Vivity (Alcon) and trifocal is Clareon PanOptix Pro Trifocal IOL (Alcon). She also likes the Tecnis Odyssey IOL (Johnson & Johnson) and enVista Envy for specific patients.

Dr. Williamson says that he uses the EDOF, RayOne EMV, and is looking forward to using the Tecnis PureSee when it is available. On the multifocal side, he also uses the Tecnis Odyssey IOL and the enVista Envy. As for PCIOLs, Dr. Will's most commonly used platforms are the Tecnis Odyssey IOL and Clareon PanOptix Pro Trifocal IOL. “Both deliver an excellent range of vision, with distinct optical characteristics that allow us to individualize the choice based on the patient’s lifestyle and visual goals,” he states. “We have largely moved away from standalone EDOF lenses for our patient demographic.” 

Practice and Economic Considerations

For patients with very high expectations, Dr. Zhu is more likely to recommend the Light Adjustable Lens (LAL, RxSight). “It provides high quality of vision with a range of spectacle independence that is determined by the patient. The adjustment process allows patients with high expectations to play a more direct role and take greater responsibility for their outcome.”

Dr. Williamson says patient expectations are the most important thing. “If a patient, for example, does a lot of needle work, sewing or craft work, they’re going to want to see up close,” he points out. “If they’re a big myope and they’ve been used to having very good up close vision their whole life, they may want to see up close without the use of reading glasses. So those are very important things. Expectations are premeditated resentments, as we like to say. So, you want to make sure that you dramatically undersell so that you can dramatically over deliver,” he explains.

For Dr. McCabe, the single most important means of avoiding unhappy patients is in setting realistic expectations. “In many ways, we are setting expectations for the usual postoperative course, including worsening of dry eye signs and symptoms, time needed for neuroadaptation, the likelihood of rings around lights with diffractive IOLs in the early postoperative period, and the need for readers in dim light,” she explains. “With patients who are moderate myopes, it is important to let them know that they may have essentially a natural magnifier at near with their uncorrected vision and that, in exchange for ‘normal’ near magnification, they will not need distance glasses. There are patients who really don’t want to make that trade, and we need to know that in advance.”

Building Premium Packages

Dr. Zhu explains that her practice does not take insurance. “Because of that, there is only a small difference between our monofocal and premium IOL packages,” she says. “We only perform femtosecond laser-assisted cataract surgery and so bundle that cost in all our packages.”

Dr. Williamson says his practice has basic, better, and best. “Basic is monofocal manual surgery. Better is femto with astigmatism correction or toric lens. And then best is femto with the multifocal or EDOF, and it includes a free LASIK touchup within a year if needed,” he explains.

Dr. McCabe says her practice really concentrates on an outcomes-focused discussion that considers primarily how much of the time the patient is willing to wear glasses, in conjunction with the appropriate choices within a category based on the health of the eye. “The choices are either glasses all the time, glasses for distance or near (or monovision), or the least dependence on glasses,” she explains. “The fee in each bucket includes testing and the technology needed to reach that visual goal along with astigmatism management and femtosecond laser in the buckets with refractive endpoints.”

Dr. Will's practice uses a flat-fee model that covers the premium lens, advanced diagnostic testing, and one enhancement within the first year of surgery. “This allows patients to pursue spectacle independence with confidence, knowing that refinement is included if needed,” he points out. 

Unmet Needs in IOL Technology

Dr. Zhu says that improvements in contrast sensitivity and nighttime dysphotopsias are still needed, as are designs that reduce the incidence of negative dysphotopsia, which remains a common cause of postoperative dissatisfaction.

For Dr. Williamson, an unmet need is “a lens that gives you J1 vision up close and 100% contrast sensitivity similar to a monofocal lens and doesn’t have any dysphotopsias at all.”

Dr. McCabe says, “Although current available technology is wonderful and has made great strides in improving quality and range of vision, there are some advances that we are still hoping for in the future. The ultimate solution would provide excellent contrast sensitivity, offer a smooth range of focus from very near to infinity, be infinitely adjustable over the life of the patient, and be appropriate for all patients, independent of the health of the eye.” 

Dr. Will says a real unmet need lies in the patient journey—specifically, in how lens companies market their products. “Surgeons are currently expected to shoulder the entire burden of patient education and awareness of premium lenses,” he claims. “Yet, medical device companies have both the right and the resources to advertise their products directly to consumers. A more robust direct-to-patient marketing strategy from manufacturers would meaningfully expand the premium IOL market, benefiting patients and practitioners.”

Designing an Ideal IOL

Dr. Zhu says she would design a large optic to minimize negative dysphotopsia, full range of vision while preserving vision quality (a truly accommodating lens), lifelong adjustability, and long-lasting material that stays clear. 

Dr. Williamson says his ideal IOL wouldn’t have diffractive rings in it, and it wouldn’t cause any nighttime halo, glare, or starburst. “It would not decrease contrast sensitivity and it would allow people to see 20/20 at distance with no loss of contrast and J1 up close with no need for reading glasses. So almost like a perfectly designed human lens in a very healthy 20 year old,” he explains.

Dr. McCabe says her ideal lens would be appropriate for all patients, would not split light, would focus from distance to very near, have forgiving targeting, be customizable for individual patients, and adjustable for the lifetime of the patient. “I would also love to see on-demand IOL production to limit waste due to the shelf life of IOLs,” she adds. 

Dr. Will adds that his ideal IOL is a postoperatively adjustable optic. “Not unlike the Light Adjustable Lens, but simpler in execution,” he explains. “In addition to altering the sphere and cylinder postoperatively, we need to be able to correct higher-order aberrations in the optical system by manipulating the IOL macromers. A way to postoperatively correct tilt or decentration would also be a significant technical advance.”

REFERENCE

Zhou IS, Zhu DC. Clinical and patient-reported outcomes after mix-and-match implantation of a trifocal and non-diffractive extended depth of focus IOL. Clin Ophthalmol. 2025;19:2625-2635. doi:10.2147/OPTH.S533091

DISCLOSURES

Dr. Zhu is a consultant for Alcon, Bausch + Lomb, and Johnson & Johnson.

Dr. Williamson is a consultant for Bausch + Lomb, Johnson & Johnson, and Rayner. 

Dr. McCabe is a consultant for Alcon, Bausch + Lomb, BVI, Rayner, and Zeiss.

Dr. Will reports no relevant disclosures.