Matching Technologies to Presbyopic Patient Needs

With a vast selection of presbyopia-correcting intraocular lenses now on the market, the key to delivering optimal outcomes still lies in clear communication with the patient and matching their needs closely with the most appropriate technology available, according to Gerd Auffarth MD, PhD.

“The latest generation of presbyopia-correcting IOLs allows us to address specific patients’ needs, and we are seeing a paradigm shift regarding non-diffractive IOL technology,” he said. “With a wide choice of lenses available to us, the key to appropriate IOL selection is to understand patients’ needs and their willingness to compromise and to remember there is no such thing as a ‘free lunch’ in optics.”

In terms of optical performance, Professor Auffarth said any attempt to correct presbyopia, a natural but complex process of physiological insufficiency of accommodation associated with the ageing of the eye, needs to take due account of three interrelated concepts: visual quality, depth of field, and dysphotopsia.

“If we want to increase the depth of field, we will reduce visual quality and increase dysphotopsia,” he said. “We have to play with the aberrations of the eye and other factors to maximize visual quality and balance out a certain amount of depth of focus to achieve our goal.”

There are a lot of aspects to consider in determining patients’ needs, said Prof Auffarth, including medical condition, refractive status, hobbies, preferences, profession, and personality.

“Patients are more demanding nowadays and it can be difficult to satisfy them. We are not only looking for the right patient for a premium IOL—we also have to look for the right premium IOL for the patient,” he said. “It gets very confusing when we look at the overwhelming number of monofocal plus, extended depth of focus (EDOF), and trifocal IOLs available.”

The most popular presbyopia-correcting IOLs in the ESCRS 2023 Clinical Trends Survey were trifocal (42%) and EDOF lenses (40%).

“However, the patient satisfaction rates for near/intermediate/distance vision struggle to get over 90% if we combine those who say they were ‘very satisfied’ and ‘somewhat satisfied’ with their IOLs,” he said. “So clearly, there is still room for improvement.”

The typical monofocal-plus patient cannot run the risk of experiencing dysphotopsia—pilots or drivers, for example—but would still benefit from the slightly extended depth of focus for intermediate vision and desire some degree of spectacle independence.

EDOF lenses are a popular choice for patients with an active lifestyle who seek reduced spectacle independence for most activities and require good intermediate vision but are risk averse towards visual disturbances.

Hybrid IOLs, which combine aspects of EDOF and multifocal diffractive IOL design, are good for spectacle independence but Prof Auffarth said they also carry a higher risk of dysphotopsia.

Other technologies, such as the small aperture IOL, may be used in compromised corneas, complex cataract cases, or post-LASIK patients. “They are also an option for patients who have previously been successful with monovision or multifocal contact lenses and want to continue without the need for glasses,” he said.

Light adjustable IOLs can be used for reduced dependence on IOL power calculation, post-refractive surgery eyes, customized monovision, anisometropia, long and short eyes, and astigmatism correction.

Prof Auffarth presented at the 2024 ESCRS Winter Meeting in Frankfurt.

Gerd Auffarth MD, PhD is Chairman of the Department of Ophthalmology at the Heidelberg University Eye Hospital and Head of the David J Apple Center for Vision Research, Germany. Gerd.Auffarth@med.uni-heidelberg.de