Extending Depth of Satisfaction

The ESCRS Eye Journal Club held a webinar hosted by Artemis Matsou MD, Alfredo Borgia MD, and Victoria Till MD to discuss the paper “Dissatisfaction after implantation of EDOF intraocular lenses,” published in the May 2025 issue of the Journal of Cataract & Refractive Surgery.¹ The panellists were Andreia Rosa MD, PhD and Rudy MMA Nuijts MD, PhD, lead author of the article under discussion.

Providing a summary of the study, Dr Till noted the single-centre retrospective study reviewed medical records of patients who received an extended depth of focus (EDOF) lens at the University Eye Clinic of Maastricht University Medical Center between July 2020 and July 2022. It identified patients reporting dissatisfaction, the aetiology of the dissatisfaction, treatment responses, and final outcomes.

All patients underwent implantation of the AcrySof IQ Vivity (Alcon) single-piece foldable non-diffractive EDOF IOL. The lens is made from a hydrophobic acrylate/methacrylate copolymer material. It features a biconvex optic with an aspheric anterior surface and a spherical posterior surface, designed to provide a continuous range of focus from distant to intermediate vision as well as functional near visual acuity.

The target refraction was either bilateral emmetropia or minimonovision, with the dominant eye targeted for emmetropia and the non-dominant eye for residual myopia between -0.25 D and -0.75 D, aiming for a difference of 0.50 D between the two eyes. Eyes with an expected postoperative astigmatism greater than 1.00 D received toric IOLs.

Among 354 eyes of 202 patients, 52 patients reported dissatisfaction regarding 83 eyes (22.8%). They included 53 eyes (64%) that received a non-toric Vivity IOL and 30 eyes (36%) that received the toric version. The refractive target was minimonovision in 43 patients and emmetropia in 9 patients. Patients reported blurred vision in 78 eyes (94%), photic phenomena in 21 eyes (25.3%), and both conditions in 16 eyes (19%).

The primary causes of dissatisfaction were residual ametropia (51.8%), dry eye disease (DED, 26.5%), and posterior capsular opacification (12.0%). Additionally, 4 patients experienced expectation mismatches, with their dissatisfaction mainly attributed to their uncorrected near visual acuity (UNVA). Treatments were administered to 85.5% of the eyes, including interventions such as artificial tears, spectacles, or refractive surgery enhancement.

Treatment was successful in 57 of 83 eyes (68.7%) among 35 patients. However, 12 patients (21 eyes, 25.3%) remained dissatisfied despite treatment, and 5 patients were lost to follow-up. The main causes of dissatisfaction after unsuccessful treatment were waxy vision syndrome (6 eyes), DED (6 eyes), and expectation mismatch (4 eyes). Two patients had pre-existing ocular conditions, with one patient having age-related macular degeneration in both eyes and another having a history of retinal detachment in one eye.

Best for minimonovision?

In the discussion that followed, Dr Matsou noted that the minimonovision patients made up the highest proportion of dissatisfied patients. She asked the panel if the results challenged the practice of using EDOF IOLS in a minimonovision strategy, on the basis that they would be a safer option than multifocal lenses.

Professor Nuijts said that the dissatisfaction among minimonovision patients is usually due to poor distance vision. His treatment in such cases involves leaving the dominant eye slightly myopic and using laser-assisted sub-epithelial keratectomy (LASEK) on the non-dominant eye to target emmetropia. Patients often report significantly higher satisfaction with their vision in these cases with only slight refractive adjustments.

“If you implant these types of lenses, or even monofocal IOLs, it can really become a problem if you don’t have access to excimer laser surgery,” he said. “You can improve the satisfaction of these patients really dramatically by doing it.”

Dry eye considerations

Prof Nuijts also pointed out that the eyes in the study represented a complete case series of patients and included all causes of dissatisfaction. Similar rates of dry eye after cataract surgery were found in other studies where patients were proactively asked to report complaints, such as the PREMED study.

“The dry eye complaint [seen] here is, therefore, probably not really different from a control situation with a normal lens,” he said. “But the effect of the dry eye is probably different in this particular situation where you have an advanced technology IOL—in this case, an EDOF lens—because the condition causes more problems in the quality of vision domain.”

Dr Matsou asked the panel if they take any specific measures when implanting an EDOF lens to avoid postoperative dry eye and the resulting dissatisfaction.

Prof Rosa said she will not treat asymptomatic patients pre-emptively but will treat blepharitis when it is present. As with all cataract surgery, she will take all necessary measures to ensure a normal ocular surface with good tear break-up times and without any punctate keratopathy. Postoperative management of dry eye is also crucial due to the disruption of the ocular surface induced by factors such as povidone iodine, corneal incisions, and NSAID eye drops.

“It’s important to tell patients they may need some sort of lubrication afterwards, to think about which drops they really need, and avoid over-medication, because it can also disrupt the ocular surface,” she added.

EDOF and ocular comorbidities

Dr Borgia asked whether persisting ocular conditions—such as previous corneal refractive surgery, macular atrophy, and epiretinal membrane—should be considered contraindications for an EDOF IOL.

Prof Nuijts said he would generally not consider patients with significant ocular comorbidities as candidates for EDOF IOLs, citing a UK registry study that showed eyes with epiretinal membranes had an incidence of CME after cataract surgery six times that of eyes without the condition.² On the other hand, patients with primary open-angle glaucoma and those undergoing phacovitrectomy for epiretinal membrane reported very satisfactory outcomes with the Vivity EDOF lens in studies presented at the 2024 ESCRS Congress in Barcelona, he pointed out.^3,4

Artemis Matsou MD, MRCP(UK), FEBOS-CR, FEBO, PgDip CRS is a consultant ophthalmologist and cataract lead at Queen Victoria Hospital, East Grinstead, UK. art.matsou@gmail.com

Alfredo Borgia MD, FEBO is a cornea, cataract, and refractive surgery consultant at “Mons. Dimiccoli” Teaching Hospital, Barletta, Italy. alfr.borgia@gmail.com

Victoria Till MD is based at Hanusch Hospital, Vienna, Austria. victoria.kauer@gmx.at

Rudy MMA Nuijts MD, PhD is Full Professor of Ophthalmology and Director of the Cornea Clinic and the Center for Refractive Surgery at the Department of Ophthalmology, University of Maastricht, Netherlands. rudy.nuijts@mumc.nl

Andreia Rosa MD, PhD is Assistant Professor of Ophthalmology at the Faculty of Medicine of the University of Coimbra, Portugal.

1. Wanten JC, et al. “Dissatisfaction after implantation of EDOF intraocular lenses,” J Cataract Refract Surg, 2025 May; 51(5): 399–405.

2. Hardin JS, et al. “Cataract Surgery Outcomes in Eyes with Primary Epiretinal Membrane,” JAMA Ophthalmol, 2018; 136(2): 148–154.

3. Urcola JA, et al. “Evaluation of visual outcomes after implantation of an extended depth-of-focus intraocular lens in patients with mild glaucoma,” presented at the European Society of Cataract and Refractive Surgeons Annual Meeting, 6–10 Sept 2024, Barcelona, Spain.

4. Sararols L. “A prospective study of the bilateral implantation of an extended depth-of-focus intraocular lens in patients undergoing phacoemulsification in one eye and phacovitrectomy for epiretinal membrane in the fellow eye,” presented at the European Society of Cataract and Refractive Surgeons Annual Meeting, 6–10 Sept 2024, Barcelona, Spain.