So Near, Yet So Far

Accommodation is a complex process involving a sophisticated interaction between the crystalline lens, capsular bag, ciliary body, and zonular fibres. The average human starts life with more than 30 D of accommodation, which drops to perhaps 1 D by age 50.

“Presbyopia, the loss of elasticity, is the first evidence of human decay in life, the first function that decays as a matter of ageing before any other function,” notes Jorge L Alió MD, PhD.

Diverse theories of accommodation led to many investigative treatments that ultimately proved unsuccessful, including approaches targeting the ciliary process or relaxing the sclera through surgical incisions, as well as early attempts at accommodative lenses. Ceaseless efforts to offer solutions for presbyopia have led to options including simultaneous vision IOLs, presbyLASIK, and miotic eye drops.

While simultaneous vision IOLs are now able to provide good vision at more than one distance, they do not restore true accommodation, with some patients experiencing postoperative issues such as dysphotopsia.

However, several IOLs now in clinical trials do appear to offer some level of accommodation. (see table). The furthest along of these candidates is the Lumina IOL (Akkolens). Developed by Professor Alió and colleagues, this lens received the CE Mark in 2026 and is now available on a limited basis in the EU.

According to Prof Alió, the failure of previous generations of accommodative IOLs can be attributed to a basic design flaw: they were intended for implantation in the capsular bag. The capsular bag, a basal membrane of the lens epithelium, becomes fibrotic after removing the natural lens, effectively turning into dead fibroblastic tissue and rendering it inelastic, he explained.

This flaw served as the key to success for the Lumina lens, which is implanted in the sulcus—away from the capsular bag—and relies on the ciliary body, rather than the zonular fibres, for accommodation. Thanks to specially designed haptics, the lens harnesses ciliary body forces to move two varifocal optical parts that slide over one another, inducing a continuous change in power according to distance, based on the optical principles of Nobel Prize winner Luis Walter Alvarez. “This is real accommodation,” Prof Alió said.

In clinical studies, the Lumina lens provided up to 2 D of objectively measured accommodation, with many patients reporting good vision at all distances at one year follow-up. Complication rates were low.^1,2

Another successful idea

Pioneering surgeon Ioannis Pallikaris MD, PhD, best known for performing the first LASIK surgery, has also maintained a strong interest in IOL development.

He recalled the anticipation from two decades ago, when the field was excited to know which accommodative lens would next reach the market; by 2007, at least 10 distinctive designs were waiting for regulatory approval. Now, patients and surgeons are happier with available pseudophakic technologies, making it harder for new accommodation designs to find a spot in the same market, Prof Pallikaris said.

The first product labelled as an accommodative IOL was the Crystalens (Bausch + Lomb), which received FDA approval in 2003 and updates in 2008. The Trulign toric IOL (Bausch + Lomb), which was based on the Crystalens design, received approval in 2013.

Although the Crystalens initially generated a lot of excitement, enthusiasm waned once it became clear the lens did not provide complete accommodation, Prof Pallikaris recalled. This kind of lens had a problem with tilt and capsular fibrosis, eventually becoming ineffective, he said.

Agreeing with Prof Alió that fibrosis of the capsule is unavoidable, Prof Pallikaris said overcoming this limitation is essential for the evolution of accommodating IOLs.

“We are not so far from a functional accommodative IOL,” Prof Pallikaris said. “There are other problems, starting from capsulorhexis, lens design, binocular summation, and the lack of a centration system, but solving fibrosis is essential for obtaining a functional accommodation.”

One of the solutions he proposed for addressing the fibrosis issue is fixOflex™ (EYE PCR), an endocapsular device specifically designed to avoid posterior capsule opacification (PCO) formation. The device is implanted in the sulcus before phacoemulsification protects the IOL from fibrosis, potentially providing some accommodative power.

“When dealing with accommodative IOLs, reconstructing a normal capsule shape makes sense,” Prof Pallikaris explained. “FixOflex has some degree of elasticity and, with some small design changes on the way, may adapt a certain design with accommodation.”

In a prospective study involving 121 patients, those receiving the fixOflex device had a PCO rate of 0.83% at one year compared with 13.0% in controls, with no patients requiring Nd:YAG capsulotomies.³ Another study suggested the device had the potential to all but eliminate dysphotopsia.⁴

As Gerd Auffarth MD famously titled his 2021 Binkhorst Lecture, there is no free lunch in optics⁵—especially for accommodative lenses. According to Prof Alió, the final limitation in restoring physiological capability in lieu of the natural lens is variability among patients’ eyes. Additional challenges include improving accommodation measurement, increasing dioptric change, and maintaining optical quality.

“We still have better systems today, and we are working on the potential of binocular summation. I do not think we have to stick to a very precise accommodative system, because our brains are very forgiving and can accept a high degree of compromise on the precision of the optics,” Prof Pallikaris concluded.

Jorge L Alió MD, PhD is Professor of Ophthalmology at the Miguel Hernández University in Alicante, Spain, and founder of Vissum Miranza, Alicante, Spain. Jlalio@vissum.com

Ioannis Pallikaris MD, PhD is Professor of Ophthalmology, Rector University of Crete, Greece; Founder and Director of the Institute of Vision and Optics, University of Crete, Greece; and Founder of EYE PCR, Greece. pallikar@gmail.com

1. Alió J, et al. Am J Ophthal, 2016; 164: 37–48.

2. Alió J, et al. J Refract Surg, 2025; 41(4): e374–e381.

3. Pallikaris I, et al. Transl Vis Sci Technol, 2026; 15(2): 8.

4. Pallikaris I, et al. Invest Ophthalmol Vis Sci, 2025 June; 66: 2233.

5. McGrath D. EuroTimes, 2021 Dec; 26(11): 9. www.escrs.org/eurotimes/no-free-lunch-in-optics.