My Pick for Patients with Presbyopia

The presbyopic patients who come to Eye Clinic Svjetlost (a large private-pay refractive surgery practice in Zagreb, Croatia) tell us they want to enjoy good vision for work and leisure activities – without the need for glasses. They want to continue to feel young and get the most from life. It has always been challenging to meet these high expectations, but, for me, new IOLs that combine extended depth of focus (EDoF) with diffractive multifocal optics in a hybrid design are making it easier than ever. 

My colleagues and I recently published a paper (1), presenting results on a study conducted on the largest cohort (206 eyes of 103 patients) implanted with one such lens. We found that refractive predictability was excellent, there were statistically significant reductions in sphere and SE from preop to three months, and patient-reported outcome measures (PROMs) were also great. 

However, in addition to the objective results – as those reported in our paper – I also like to ensure that patients don’t have to “hunt” for the best focal points. In my experience, most patients are able to see well from about 30 cm to infinity – with no gaps or blurred zones. And this has reduced the amount of time we need to spend preoperatively asking patients for specific details on how they use their vision or how far away they like to position their mobile phone or computer monitor. Being able to simplify patient education, implant the same lens in both eyes, and still meet all the patient’s visual needs is a big advantage.

In fact, the outcomes have been so impressive that two of the most experienced refractive cataract surgeons in our clinics have already chosen to have the hybrid lenses implanted in their own eyes, including my father, cataract and refractive specialist professor Nikita Gabrić. In 2020, after seeing his patients’ results and their level of satisfaction with the new lenses, he opted to have one implanted in his left eye. 

As with any other premium IOL, careful patient selection and counseling is still required to ensure that patients have realistic expectations. In our practice, we believe that a strong motivation for spectacle independence is essential to success with these lenses. Patients may experience glare, halo, or some loss of distance acuity, especially in low-contrast settings, and may require a little time for neuroadaptation. To accept these risks, they need to see the gain in near vision as a major reward. When patients who still have residual accommodation seek refractive lens exchange, we encourage them to wait a few more years until they are fully presbyopic. 

It is important to avoid implanting presbyopia-correcting IOLs in patients with dry eye disease. These advanced optics demand a stable, healthy tear film for the best visual quality. A patient who is dry before surgery will, even in the best-case scenario, remain so, and may get considerably worse. If the ocular surface problems cannot be treated and improved, it’s best to choose a monofocal IOL.

It is also important to choose candidates without significant (≥0.5 D) astigmatism, or use incisional surgery or the toric version of the lens to correct it. Due to its complex optics, the hybrid IOL is sensitive to any residual astigmatism, and particularly to astigmatism in against-the-rule or oblique axes. In our study, four eyes had residual astigmatism at 3 months; this refractive error had a significant negative impact on their UDVA and near vision under low light or low contrast conditions.

Despite these caveats, we are finding that we don’t need to screen as carefully for this type of lens as we have for other presbyopia-correcting IOLs. We will consider it for low myopes, detail-oriented perfectionists, and even for those who drive at night or work in variable light conditions. 

Just remember that any complications, including residual postoperative error, new or worsening dry eye, or posterior capsular opacification, should be addressed in a timely fashion. After all, we must all be driven to deliver the best results and the absolute highest standard of care.

Relevant disclosure 

The study (1) was supported by a research grant from Johnson & Johnson Vision