First the Patient, Then the IOL

For simultaneous vision lens implantation, the best outcome for patients can only be reached by prioritising their needs, according to Nic J Reus MD, PhD.

“There’s no free lunch in optics,” Dr Reus recalled, quoting Professor Gerd Auffarth’s ESCRS Binkhorst Lecture of 2021. If the depth of field is increased, there are effects on visual quality and dysphotopsias—surgeons cannot have everything.

“You have to match the IOL to the patient,” Dr Reus said. “It is all about equilibrium—look at the depth of field versus visual quality versus dysphotopsias. There is not a question of which lens is the best, but for whom is this trade-off acceptable.”

However, over time, lunch has become less expensive, Dr Reus observed. IOL optics have changed and optical profiles have improved, resulting in fewer dysphotopsias. There is also greater refractive accuracy, due in no small part to accurately performing preoperative biometry. Despite all the developments, sometimes what patients get from the lens does not match with their functional visual needs and expectations. Some of them have unrealistic expectations about the lens’s capabilities in various lighting conditions, which can be the cause of discontent with the surgery.

All aspects of patient life must be carefully considered when choosing the best simultaneous vision lens. Whether they work in dim light, drive at night, or rely on near vision, everything matters.

Dissatisfaction is around the corner, Dr Reus warned, recalling his experience with an unhappy patient with a trifocal lens whose hobby was working on electronics in dim light. The patient had been counselled about the importance of good lighting for near tasks, but the extent to which they worked under such low-light conditions had not been fully appreciated before the surgery and could have made a difference in the outcome.

Patient awareness of lens options also varies, as the 2025 ESCRS Clinical Trends Survey revealed: most surgeons (54%) claimed their patients are aware but not well educated, while some others are educated (26%) or very well educated (12%).

Good counselling about photic phenomena is crucial to prevent dysphotopsias, which may become bothersome for patients. Photic phenomena, such as halos, starbursts, and streaks, can occur with IOLs and may develop into dysphotopsias, leading to patient dissatisfaction.

Dr Reus suggested a four-pillar checklist to keep in mind: First, note the patient’s lifestyle, needs, expectations, and previous visual corrections; second, collect a thorough history of the ocular condition, with contrast sensitivity and comorbidities, the binocular single vision, the stability of the capsular support, or the axial length; third, gather accurate and consistent measurements of the eye and the IOL power, taking astigmatism and, in select cases, angle kappa into account; and, finally, establish the lens strategy.

Prioritising patient needs, customising lens choice, and managing expectations to maximise satisfaction—by balancing spectacle independence with visual acuity and framing photic phenomena as a trade-off rather than a complication—are the key rules to follow when preparing for surgery. A dissatisfied patient may also cause dissatisfaction for the surgeon.

“If there is a mismatch between the lens, the eye, and the expectations, then you will have complaints,” Dr Reus concluded.

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

Nic Reus MD, PhD is an independent ophthalmologist at Amphia Hospital, Breda, Netherlands. nreus@amphia.nl