Closing the Presbyopia Gap for Younger Patients

Presbyopia correction with phakic implantable collamer lenses (ICLs) using a monovision approach is safe and efficient, especially for young presbyopic patients, Anas-Alexis Benyoussef MD reported.

Young presbyopic patients, or those between 40 to 55 years old, find themselves in a “presbyopia gap”, a surgical no man’s land.

“They are slowly crossing a bridge, starting with active accommodation, going through an accommodative decline, and finally reaching the total loss of accommodation,” Dr Benyoussef said.

Current standard surgeries like LASIK and refractive lens exchange have limitations: the former can induce ocular surface diseases or higher-order aberrations, while the latter is too invasive for patients who still have partial accommodation, carrying the risk of retinal detachment for those with high myopia.

An additive, reversible solution is needed, and phakic ICLs offer clear potential advantages. They preserve optical quality, maintain corneal integrity for future cataract calculations, and ensure adequate safety thanks to their central port design. However, they are contraindicated in the majority of hyperopic patients due to shallow anterior chambers, which increase the risk of endothelial damage and glaucoma.

How can ophthalmologists create a correct monovision design? According to Dr Benyoussef, the “sweet spot” is between -0.75 D and -1.25 D. In fact, a low target results in poor near vision, while targets above -1.50 D lead to a loss of stereopsis. The optimal target is 1.00 D, which allows patients to maintain a good 3D vision around 60 arcseconds.¹

A 2025 study on 31 patients with an average age of 49 years showed positive clinical results with ICLs, with most patients achieving UDVA better than 20/20 and an even better CDVA, with a near perfect IOL predictability.² Visual gains were significant, with 33 eyes improving by one to two lines, attributed to the magnification effect of ICLs for myopic patients. At three months post-surgery, there were no incidences of cataract development, pupillary block, or IOP spikes, and vault stability was good. The patients’ satisfaction with the surgery was high.

Another study from 2023 compared ICLs with femtosecond LASIK in myopic patients, showing excellent safety and efficacy for both groups.³ Despite having a similar safety index, the efficacy index was significantly better for ICLs. Binocular balance was affected in both groups, with most patients experiencing imbalanced vision at various distances, primarily driven by age-related presbyopia and the anisometropia created by the surgeries.

Dr Benyoussef stressed the importance of establishing a protocol to identify suitable patients and determine the best surgical approach. Sensory dominance testing should replace unreliable motor tests, with the dominant eye corrected for distance vision. Defocus and simulation tests, along with contact lens trials, help assess tolerance before surgery. However, not all patients are suitable, especially those in professions or activities requiring strong depth perception, such as airline pilots, some military personnel, law enforcement agents, firefighters, and certain athletes. But in general, the benefits of ICLs are strong, with a bright future ahead.

“Expand the indication, trust the data, and respect the protocols,” Dr Benyoussef concluded.

Dr Benyoussef spoke at the 2026 ESCRS Winter Meeting in Helsinki.

Anas-Alexis Benyoussef MD, MSc is an ophthalmologist at the University Hospital of Brest, France. anas-alexis.benyoussef@chu-brest.fr

1. Gawęcki M. J Ophthalmol, 2019 May 6; 2019: 2654170. doi:10.1155/2019/2654170

2. Ouchi M. Sci Rep, 2025 Apr 11; 15(1): 12454. doi:10.1038/ s41598-025-96471-z

3. Ye Y, et al. Front Neurosci, 2023 Jun 1; 17: 1204792. doi:10.3389/fnins.2023.1204792