During cataract surgery, your cataract is removed and a new clear lens is placed. You and your surgeon will decide which type of intraocular lens (IOL) is best for you. There are many intraocular lenses available on the market. Each lens will have it’s own benefits and drawbacks. The key to key to matching each patient to the best lens for their lifestyle and situation is a both an art and a science.
A monofocal IOL is the basic lens which is covered by insurance. It is important to know that this type of lens provides focus at only one single distance. Most patients with a monofocal IOLs choose to have their vision corrected for distance and rely on glasses to meet their intermediate and near vision needs. You can see the illustration to the left which simulates monofocal vision in which distance is clear, but both near and intermediate vision are blurry. (This simulation demonstrates the vision of someone with little to no astigmatism, see below for the discussion on astigmatism). Patients with monofocal lenses after cataract surgery may prefer to wear bifocal, trifocals, or progressive glasses throughout the day after their cataract surgery. Others may choose to keep readers around the house to take on and off depending on their task at hand. Quality prescription glasses can be quite costly and need to be replaced regularly, so the cost savings in choosing a monofocal IOL evens out with the need for prescription glasses.
Surgeon tip: Is it possible to choose to have good near vision and blurry distance vision? Yes! Once every so often, I will have a patient who is already nearsighted and enjoys reading without glasses and doesn’t mind distance glasses. The patient can stay nearsighted with a lens calculated for near vision clarity, but once again will need glasses for their distance and intermediate vision.
One solution to get around the blurry near vision is to use a technique called monovision. With monovision, your surgeon can select a monofocal IOL correcting each eye to a different power. One eye is corrected to distance and the other eye is corrected for near. When both eyes are open, a patient enjoys a blended vision. Folks who do well in monovision contacts tend to enjoy monovision intraocular lenses as well.
Surgeon tip: Patients that do not have contact lens experience with monovision can find it disorienting to have a power difference between their two eyes. Some people find that monovision compromises the clarity of their distance vision too much. For this reason I only offer this option to my patients who have had prior experience in contact lenses with monovision.
Toric IOLs are a premium type of lens that helps to correct for astigmatism. Astigmatism occurs when the natural shape of the cornea, or front of the eye, is more like an American football rather than a round basketball. Often patients with astigmatism experience blurry vision at all distances. Prior to cataract surgery, the astigmatism can be corrected in glasses and in contact lenses. However, cataract surgery gives an opportune time to correct the astigmatism with a toric IOL. The additional costs for the toric IOL are not covered by insurance, but insurances allow this upgrade to be paid for out of pocket by the patient.
Patients with astigmatism often remark being dependent on their glasses at all times for all distances. In my practice, I recommend toric IOLs to patients with moderate to high astigmatism for the best optical results and to allow clear vision with more spectacle independence.
A multifocal IOL is the most advanced premium lens. Multifocals lenses provide vision across varying distances. These lenses minimize the need for glasses by fixing the problem of presbyopia, which is the need for near-readers with age. When choosing a lens for my mom when doing her cataract surgery in 2019, I knew that she would benefit from a multifocal lens because 1) other than having cataracts, her eyes were otherwise healthy, 2) in her youth she was used to reading without any glasses, and 3) she leads an active lifestyle and found her reliance on glasses to be an annoyance.
Alcon’s PanOptix trifocal lens is one of the leading presbyopia-correcting lenses which offers a crisp focal point at distance, intermediate computer vision, and near reading vision. Patients often comment on the sharpness of their near vision after surgery. The Panoptix can even correct astigmatism. I really like to use this lens for my patients who do a lot of computer and near reading work but also want to enjoy crisp distance vision.
Visit http://www.cataractsurgery.com/ to learn more about the Panoptix and Alcon series of lenses.
Surgeon tip: Post-operative dry eye can be an annoying problem after cataract surgery. I like to warn patients that if they have underlying dry eye, the eyes will be even more dry for the first 3-6 months after cataract surgery. Dry eyes can cause irritation as well as glare and halo around lights. These visual disturbances can be particularly noticeable for patients with multifocal lenses initially when the dry eye is at its worst and improve as the ocular surface returns to its normal state.
Alcon’s Vivity Extended Depth of Focus lens is another leading presbyopia-correcting lens. The non-diffractive technology called X-Wave design allows for elongated focus range. As a result, this lens allows patients to see from distance to intermediate to near as one continual range of focus. The optics are so good, often patients comment on the vivid colors and the crispness of their distance vision after surgery. This lens can also correct astigmatism. I like to use this lens in patients who enjoy crisp distance vision and who like the clarify of reading their phone or labels without glasses but who don’t necessarily spend a lot of time at the computer or reading books.
Surgeon tip: Unfortunately for some patients, due to underlying ocular conditions such as retinal problems or glaucoma, multifocal lenses may not work as well as with a patient without these conditions. Often these underlying conditions can be picked up prior to surgery with advanced diagnostic testing. Sometimes, if the cataract is severe enough, that these conditions cannot be detected until after your cataract surgery because pre-operatively, the view to the back of your eye may be clouded by the cataract. Your surgeon will best be able to guide you to the best lens which matches your lifestyle and vision needs with what will allow you to see your best.
Light Adjustable Lenses
The Light Adjustable Lens from RxSight has changed the way we think about cataract surgery with its adjustability. In traditional cataract surgery, the surgeon chooses a lens prior to surgery. The lens is calculated from preoperative measurements evaluating the shape of the front of the eye and the length of the eye. Although these measurements have become quite exact with our sophisticated biometers, difficulty arises in measuring patients with corneal scars, prior corneal infections, prior LASIK or PRK surgery as well as patients with radial keratectomy. Dense cataracts can also be difficult to measure as can highly far-sighted or near-sighted eyes. Despite all this precision, another aspect that remains challenging is how the lens finally heals and settles in each individual unique eye. How the lens heals and sits affects its effective lens position and thereby its final prescription with the eye.
With the light adjustable lens your surgeon has the capability to change and customize the shape and prescription of the lens noninvasively after surgery. This allows patients to be able to test drive their vision after surgery. It also allows the surgeon to correct astigmatism and account for any far-sightedness or near-sightedness in the eye’s final healed state. Beginning at 18 days after surgery, there can be 2-5 light treatments lasting 90 seconds to reshape the lens. Each light treatment is spaced 3 days apart to allow time for further measurements and for patients to test drive their vision. Watch more about the Light Adjustable lens here.
Surgeon tip: The Light Adjustable Lens was FDA approved in 2017. Initially patients were required to wear UV protecting sunglasses and clear glasses to prevent the lens from inadvertently adjusting post operatively from stray UV light. Since its approval, RXSight has introduced ActivShield™ Technology, a special UV protection layer built into the newly updated Light Adjustable Lens. In effect, this new layer protects the lens from changing shape except during the set postoperative treatments. For additional protection, patients will also be provided with special UV-blocking glasses to wear during this period. These glasses will provide redundant protection until the last treatment is complete.
The topic of IOL choice during cataract surgery can be a complex confusing topic. There are almost too many good options on the table. I have found that the best way to choose a lens is get to know my patients. By understanding what activities you enjoy doing and what tasks require your attention during the day, we will best be able to match the best lens to meet your vision goals. Combined with the state-of-the-art ocular analysis, we can match your vision goals to meet your true visual potential.
This article was originally written on 6/23/2020 by Angelique Pillar, MD and updated on 5/28/23.