Maximising Success While Minimising Dissatisfaction

Presbyopia is a common life experience. What changes are patient needs and expectations when they ask for presbyopia correction, according to Hrvoje Kovacic MD.

“Historically, the majority of daily tasks were distance-oriented,” Dr Kovacic explained. “Now it has changed to near work with laptops, tablets, and smartphones. We went from restoring vision to optimising it, where spectacle independence is increasingly expected.”

This evolution makes the life of an ophthalmologist a little more difficult, but luckily technology is answering the call, Dr Kovacic said.

Monovision with monofocal-plus IOLs is one option. The dominant eye is targeted for emmetropia and the non-dominant eye for myopia (-0.75 D to -2.00 D) to provide a functional range of vision without optical disturbances. These lenses show a good spectacle independence rate (90%) and high patient satisfaction. Suitable patients are those who had contact lens monovision and those who are intolerant of glares and halos.

Monofocal-plus IOLs have been shown to improve intermediate visual acuity compared to standard monofocals without the trade-off of simultaneous vision IOLs. Eligible patients prioritise distance clarity, with a small bonus at intermediate distances. Candidates for this approach include those not suitable for extended depth of focus or multifocal IOLs and patients seeking monofocal-like vision with high contrast sensitivity and minimal photic phenomena.

Extended depth of focus IOLs create a continuous range of vision through an elongated focal zone, with the advantage of excellent distance vision, good intermediate vision, fewer halos and glares, and higher contrast sensitivity compared to multifocal IOLs. However, near vision remains limited, typically requiring glasses, and some photic phenomena may occur.

Multifocal lenses are another option, and many improvements have been made since the US FDA first approved them in 1997. Dr Kovacic highlighted the ReSTOR (AcrySof) from 2005 as an example, with its apodised diffractive design. It showed good results, but with a major downside related to dysphotopic phenomena. Trifocal IOLs rose as a popular option in the 2010s. A study comparing the PanOptix (Clareon) and Synergy (TECNIS) intraocular lenses showed good distance and intermediate uncorrected visual acuity, with slightly less near vision and fewer dysphotopsia.¹ Patients reported no need for spectacles in 80% of cases, with 90% never or rarely needing them.

Suitable candidates for trifocal IOLs include patients with multiple visual demands, especially for near vision, and a strong desire for spectacle independence. Dr Kovacic said these patients should have realistic expectations, including the possibility of halos and glares. Trifocal IOLs are not suitable in patients with severe dry eye, retinal and corneal pathologies, and glaucoma.

Dr Kovacic also suggested different IOL combinations, including mix-and-match strategies or monovision, as options for reducing spectacle dependence while minimising visual disturbances from photic phenomena. He further emphasised the importance of carefully evaluating the type of patients sitting in the ophthalmologist’s waiting room.

“Careful patient selection and appropriate IOL matching are crucial to successful outcomes,” Dr Kovacic said. “[It’s vital to] manage expectations to minimise postoperative dissatisfaction.”

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

Hrvoje Kovacic MD is an ophthalmologist at Het Oogziekenhuis Rotterdam and Franciscus Gasthuis and Vlietland, Netherlands. h.kovacic@oogziekenhuis.nl

1. Modi SS, et al. J Cataract Refract Surg, 2025; 51(8): 695–702.